What is tertiary syphilis?

- The last stage of syphilis is referred to as tertiary syphilis. This occurs three years after the initial infection, and has its own set of characteristics, signs, and symptoms. I don't have space to write it down here, so, instead, I'll write up here that tertiary syphilis is not contagious. There are three main sets of symptoms you'll have with tertiary syphilis. The first occurs across the body and can appear anywhere, but seems to occur most commonly in these three places. That is the development of what are called gummas. A gumma just refers to a large bump that appears where it's not supposed to. That means if syphilis spreads into your liver from the bloodstream, you'll get these bumps on the liver that may have the same color and consistency as the standard, normal liver tissue that I have right underneath here, but this is mainly the result of the syphilis treponemes fighting white blood cells over a long period of time, three years. You can see the same thing when syphilis spreads to your bones. I'll show this big deformity of the femur right here, all due to the syphilis treponeme. If this treponeme, or this spirochete, spreads up to your skin, and attacks the blood vessels that live there, you'll start to see bumps from the battle of syphilis and white blood cells as well. These gummas can be so deforming, that you can have a result like this here. This is a bust of a patient that had tertiary syphilis, that has these very striking deformities. One right here, I can see another there, the nose, and maybe one over here as well. If you ever visit the Musee, or Museum, de, or of, l'Homme, or the Museum of Man in Paris, you can see this bust of this patient with tertiary syphilis as well. In addition to gummas, a patient can also have what's referred to as neurosyphilis, which, exactly as you might expect from the name, is the invasion of the central nervous system by syphilis. Down here, you can see this is a cross-section of the spinal cord, so I've cut it in half, like if I had put a samurai sword through this patients' spinal cord, going this way to that. You should notice that there are two blood vessels that supply the spinal cord in the back, or on the posterior aspect, and there's one main blood vessel that supplies the spinal cord to the front, or the anterior aspect. Now, remember that syphilis, specifically, likes to invade the walls of the blood vessels, and sets up shop in the endothelial cells that line them, so you'll see some characteristic symptoms that occur because syphilis will invade the blood vessel wall that's supposed to supply oxygen and nutrients to the spinal cord, so if the treponeme goes and infiltrates the endothelial cells that line the blood vessels on the back or the posterior aspect of the spinal cord, you can develop symptoms that are grouped together and referred to as tabes dorsalis, which is just Latin for decay in the back, or on the dorsal aspect, so decay in the back of the spinal cord. I don't wanna go into too much detail about the anatomy of the spinal cord, but just know that there are specific tracks that are bundled, so if we deprive the back of the spinal cord of oxygen and nutrients, you'll see a different set of symptoms than if we do that in the front, so if we have a decay in the back, you can have a loss of vibration sense. The other thing the back of the spinal cord is responsible for is position sense, which lets you know where your body parts, like your hands and your arms are, relative to space. Another term for that is proprioception, so you'll also lose your proprioception as well. If syphilis invades the endothelial cells that line the blood vessels in the front of the spinal cord, you'll get a different set of symptoms that are grouped together and referred to as general paresis. Paresis is just a fancy word for paralysis. The paralysis that we have here is, classically, localized in the legs, so you can have a loss of sensation, so if someone touches your leg, you won't even notice that, and you may not even be able to move them, so you could lose motor function. The last thing I'll mention here about general paresis, sometimes, this is also referred to as general paresis of the insane because, in addition to the spinal cord, syphilis can also spread up to the brain to cause mental disorders as well. Another classic symptom that you can have, as part of neurosyphilis, is referred to as having Argyll Robertson pupils. I've drawn this set of eyes down here, and here are the pupils in brown. Now, what the pupils let us do is regulate the amount of light that we're perceiving. I'm gonna draw this tree here cuz we're taking a look on a nice, bright, sunny day, and we see this tree. If it's a really sunny day outside, we might have some trouble seeing this tree, just like how a camera would have trouble taking a picture with very high exposure. In order to make a better image for our brain to process, our pupils will constrict. I'll draw this pupil narrowing, and I'll do the same on this side. These pupils will constrict to limit the amount of light that enters and is processed by the retina, or the back of the eye. The same thing happens if we take this tree, and we move it closer to the eyes. The way you can think of it is that the light that the tree bounces off and gives off a green color of the leaves and a brown color of the trunk, is still light that may be too much for the eyes to process if it's too close, so the pupils will constrict as well, when they try to focus on a nearby object. That process is called accommodation. I'll just write here accommodate. These pupils are able to accommodate. The interesting thing about having Argyll Robertson pupils, is that we're able to accommodate, so someone with tertiary syphilis can accommodate, I'll put a check mark right there, but they can't react to light, so I'll cross out the light source over here. The reason why this happens is that there are two different nerves that process this. There's a separate nerve that allows the eyes to accommodate when focusing on a nearer object, and there's a different nerve that causes the pupils to constrict in response to just light. Syphilis will preferentially attack the blood vessels that supply the nerve that help us react to light. Finally, the last type of symptom we can get, associated with tertiary syphilis, is what's referred to as cardio syphilis. Just as the name suggests, and I'll draw down here, that involves an infection related to the cardiovascular system. I'll draw the heart first and the blood vessels that come off of it. I mentioned earlier that syphilis likes to attack our blood vessels, so it only makes sense that syphilis, in its final stages, will finally reach and attack the largest blood vessel in our body. That's the aorta, and an infection of the aorta is referred to as aortitis, so you can get syphilitic aortitis when you get syphilis, or this treponeme, to infiltrate the endothelial cells that line this giant blood vessel, which will lead to widening of the aorta. I'm drawing it wider over here, so it's going to become a lot bigger than it's supposed to be, so, as the aorta widens, it will cause the heart to work much harder to get the same amount of blood out to the rest of the body. On top of that, the walls of the aorta will even become thinner, up until a point when the aorta, which is now turned into an aneurysm over here, will pop. Again, we refer to this dilation as an aortic aneurysm, where an aneurysm is just a dilation or a widening, which will continue to a point when the walls are just too weak to hold the blood in, then all of a sudden, you'll get a rupture, and bleed out, which can either be closed, and, in which case, you're pumping blood not to the rest of the aorta, but within the walls of the aorta. You can have a closed rupture or you can tear through all the walls of the aorta, and have what's referred to as an open rupture, which will bleed out into the chest and cause a person to die within seconds to minutes. which is why it's important to catch syphilis and start treating it earlier on, before all of these symptoms can manifest.