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1° Syphilis: indurated, nontender ulcerative lesion accompanied by nontender, nonsuppurative regional LAN
2° Syphilis = spirochetemia: fever, malaise, diffuse LAN; patchy alopecia; HA; hyperpgimented maculopapular rash on palms/soles
Latent Syphilis: recognized only by reactivity on serologic testing; no clinical findings; variable course
3° Syphilis: neurosyphiliis, CV, gummatous; pathophysiology is mainly endarteritis

3° Syphilis
neurosyphilis: to be discussed below
CV syphilis:
endarteritis of vasavasorum  progressive necrosis and loss of elastic tissue  dilatation  aneurysm;
esp of aortic arch and proximal thoracic aorta; rarely dissect;
cause symptoms by encroachment/erode chest wall, SVC, recurrent laryngeal nerve, trachea and bronchi
Gummatous syphilis: indolent, destructive granulomatous lesions of soft tissue/bone scarring and disfigurement [BENIGN??]

So How to Dx?
Exams of the lesions/chancre
 ulcer itself not adequate
 Dark field microscopy of exudate
  Corkscrew morphology
  Time and Tx sensitive
 Direct flourescent Ab [DFA-TB] applied to exudate
Serology: 2 stages
Non Treponemal Serolgoic Tests: VDRL, RPR, etc.
 Quantitative results 2/2 dilution
 Need fourfold decrease for clinical significance
Treponemal Specific Tests: not quantitative
 FTA-ABS (fluorescent treponemal antibody absorption)
 TP-PA (T. pallidum particle agglutination

Clinical Syndromes of Neurosyphilis
Asymptomatic: continuation of disease within CNS and absence of ANY CNS symptom
Meningovascular: endarteritis with infarction; same as any other CVA; anywhere within CNS; takes 5-12 years at minimum
Parenchymal: direct invasion of CNS parenchyma; pathology: fibrosis and atrophy
  General paresis
  Tabes dorsalis

Symptomatic Meningitis
Typically w/in first year of infection
HA, confusion, N/V, stiff neck
Cranial neuropathies, esp II, VII, VIII
Less likely is myelitis

Meningovascular Syphilis
Average presentation in 7 years, but can occur months after primary infection
Infectious endarteritis of CNS vasculature
Prodrome: HA, dizzy, personality changes preceding stroke (2/2 meningitis?)
Can affect any vessel, but MCA and branches most common
Think of it in CVA with young person, STI exposures

Tabes Dorsalis
A disease of posterior columns and dorsal roots
Lancinating pains: sudden, brief, severe stabs of pain affecting limbs/back/face lasting minutes/days
Gastric crises: recurrent attacks of severe epigastric pain, nausea, vomiting
Pupillary irregularities: ½ Argyll-Robertson
Absent LE reflexes, impaired vibratory/position sense

The Argyll Robertson Pupil
Small, nonresponsive to light, contracts normally to accommodation and convergence, dilates imperfectly to mydriatics, does not dilate to painful stimuli..

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