00:01
Then we come to, what I would say, is the majority of patients.
00:06
They don't remember having a chancre,
and they've got a positive serologic test for syphilis.
00:14
But they have no recollection of any illness,
and so they have no clinical manifestations.
00:21
But the point that this disease is not quiescent.
00:27
There's something going on.
00:29
So all they've got to show for it is a positive serologic test for syphilis.
00:34
Here we're showing you the classic positive rapid plasma reagin or RPR.
00:42
Furthermore, the disease can relapse,
and when it relapses with inadequate therapy,
it is also possible to transmit the disease
because these lesions are highly contagious.
01:01
It's less florid than secondary syphilis.
01:04
You find the mouth and the genital areas affected most frequently,
and sometimes the lesions are sort of rounded or annular.
01:17
And then the worst possible manifestation
and these are obviously old photographs,
are the lesions of tertiary syphilis,
which is a slowly progressive destructive inflammatory process.
01:33
It can involve any organ in the body
and usually doesn't occur till at least
5 but up to 30 plus years after the initial infection.
01:44
So as I mentioned, this disease is not quiescent - it's ongoing.
01:54
So let's talk for a minute about neurosyphilis,
and first talk about asymptomatic neurosyphilis.
02:02
That can be expected in about 10% of individuals
who contract syphilis in the first place.
02:12
And so they're asymptomic,
they have a positive serology,
and they often undergo analysis of the cerebrospinal fluid
because of their positive serology.
02:28
What's found is a pleocytosis --
a mixture of round cells and neutrophils,
an elevated protein in almost everybody,
and a positive CSF VDRL.
02:47
But they have no neurologic signs or symptoms.
02:52
So they usually have one or more of those findings in the CSF,
but they have no neurologic findings of any kind,
no symptoms and no signs.
03:03
Now the ones who become symptomatic,
all of them had preceding asymptomatic neurosyphilis.
03:12
So if a patient presents with asymptomatic neurosyphilis
unless you treat them,
they're going very likely to develop symptomatic neurosyphilis.
03:30
And that brings us to a discussion of syphilitic meningitis.
03:35
About 50% or more recall having had a chancre
or some kind of rash that was consistent with secondary syphilis,
or they may have had both.
03:47
The classic findings are signs of increased intracranial pressure
such as nausea, vomiting, headache.
03:55
And sometimes the vomiting is projectile,
sort of effortless vomiting.
04:02
That's a sign of increased intracranial pressure.
04:06
Or they may have acute hydrocephalus without any focal signs.
04:11
And some patients may have meningitis
and it tends to involve the meninges of the vertex of the top of the head.
04:20
Many of these patients will present for the first time with a seizure,
or with a focal neurologic deficit,
such as hemiplegia, aphasia, or some altered consciousness.
04:34
Syphilis can also infect the base of the brain where the cranial nerves are,
and give craniel nerve dysfunction.
04:41
For example, III, VI, VII, and VIII can be infected.
04:45
And it can be unilateral or bilateral in nature.
04:49
Now meningovascular syphilis implies involvement of the blood vessels.
04:55
And so when you involve the blood vessels,
sometimes you get clots.
05:02
And when these blood vessels are occluded,
you get stroke.
05:09
Now this usually occurs later than most manifestations of neurosyphilis.
05:15
And so what happens because the middle celebral artery
and its tributaries are involved,
you get a contralateral hemiparesis,
you may get homonymous hemianopsia or aphasia.
05:34
And a little pearl is, young people don't get strokes.
05:39
So if a physician encounters stroke in a very young person
who's had no history of hypertension or any other predisposing factor,
you ought to think of syphilis as one of the causes of that stroke.