Syphilis progresses through three phases with distinct clinical presentations.

• Primary syphilis: A chancre at the site of inoculation (penis, rectum or anal canal, mouth, cervix, labia) is characteristic but often goes unnoticed. See Table 83-1 for clinical details. Regional adenopathy can persist long after the chancre heals.
• Secondary syphilis: The protean manifestations of the secondary stage usually include mucocutaneous lesions and generalized nontender lymphadenopathy.
  • - Skin lesions can be subtle but are often pale red or pink, nonpruritic macules that are widely distributed over the trunk and extremities, including the palms and soles.
  • - In moist intertriginous areas, papules can enlarge and erode to produce broad, highly infectious lesions called condylomata lata.
  • - Superficial mucosal erosions (mucous patches) and constitutional symptoms (e.g., sore throat, fever, malaise) can occur.
  • - Less common findings include hepatitis, nephropathy, arthritis, and ocular findings (e.g., optic neuritis, anterior uveitis, iritis).
• Latent syphilis: Pts without clinical manifestations but with positive syphilis serology have latent disease. Early latent syphilis is limited to the first year after infection, whereas late latent syphilis is defined as that of ≥1 year's (or unknown) duration.
• Tertiary syphilis: The classic forms of tertiary syphilis include neurosyphilis, cardiovascular syphilis, and gummas.
  • - Neurosyphilis represents a continuum, with asymptomatic disease occurring early after infection and potentially progressing to general paresis and tabes dorsalis. Symptomatic disease has three main presentations, all of which are now rare (except in pts with advanced HIV infection). Meningeal syphilis presents as headache, nausea, vomiting, neck stiffness, cranial nerve involvement, seizures, and changes in mental status within 1 year of infection. Meningovascular syphilis presents up to 10 years after infection as a subacute encephalitic prodrome followed by a gradually progressive vascular syndrome. Parenchymatous involvement presents at 20 years for general paresis and 25-30 years for tabes dorsalis. A general mnemonic for paresis is personality, affect, reflexes (hyperactive), eye (Argyll Robertson pupils, which react to accommodation but not to light), sensorium (illusions, delusions, hallucinations), intellect (decrease in recent memory and orientation, judgment, calculations, insight), and speech. Tabes dorsalis is a demyelination of posterior columns, dorsal roots, and dorsal root ganglia, with ataxic, wide-based gait and footslap; paresthesia; bladder disturbances; impotence; areflexia; and loss of position, deep pain, and temperature sensations.
  • - Cardiovascular syphilis develops in ~10% of untreated pts 10-40 years after infection. Endarteritis obliterans of the vasa vasorum providing the blood supply to large vessels results in aortitis, aortic regurgitation, saccular aneurysm, and coronary ostial stenosis.
  • - Gummas are usually solitary lesions showing granulomatous inflammation with central necrosis. Common sites include the skin and skeletal system; however, any organ (including the brain) may be involved.
• Congenital syphilis: Syphilis can be transmitted throughout pregnancy, but fetal disease does not become manifest until after the fourth month of gestation. All pregnant women should be tested for syphilis early in pregnancy.