Latent Syphilis, Tertiary Syphilis, Syphilitic Meningitis & Meningovascular Syphilis

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.