Tertiary syphilis: late symptoms and treatment

Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum. It develops in stages. Primary syphilis brings a painless sore. Secondary syphilis brings a rash and other general symptoms. After that comes a latent period with no symptoms, which can last years.

Tertiary syphilis is the stage some people reach if the infection is never treated. Patient.info says that studies of untreated people suggest symptomatic late syphilis is found in up to 40% of those with late infection. It divides late disease into gummatous disease (15%), cardiovascular disease (10%) and late neurological complications (7%).

These figures come from studies of untreated people in the past. Today most people are diagnosed and treated long before this stage.

Cardiovascular syphilis is inflammation of the aorta, the main artery from the heart. Patient.info says the most frequent effects are aortic regurgitation, aortic aneurysm and angina. The British Heart Foundation lists untreated syphilis as a rare cause of thoracic aortic aneurysm.

Neurosyphilis affects the brain, spinal cord or their coverings. Patient.info lists loss of position sense in the spinal cord (tabes dorsalis), dementia and meningovascular involvement as common presentations. Tabes dorsalis is characterised by unsteady walking from lost sensation and shooting pains. About half of people with neurosyphilis also have HIV, so HIV testing is part of the assessment.

Gummatous syphilis produces gummata, which are inflammatory nodules or plaques that can be locally destructive. Patient.info says they can occur in any organ but most commonly affect bone and skin.

The NHS lists possible complications of untreated syphilis: heart problems like angina, aortic aneurysm and heart failure; brain problems like fits, memory problems, personality changes and dementia; nerve problems like shooting pains, pins and needles and gradual damage to the joints; and problems with the skin, bones, testicles, liver and other organs. Muscle weakness and sight and hearing problems are also listed.

None of these symptoms is specific to syphilis. Patient.info says syphilis should be considered in anyone presenting with cardiac or neurological signs or symptoms, because the picture is so variable. The history, including past exposure, helps guide this.

Diagnosis begins with blood tests for syphilis antibodies. Patient.info describes treponemal tests such as EIA or CLIA and TPPA, plus a non-treponemal test such as RPR or VDRL that gives a measure of disease activity. Positive tests are confirmed with a different test. A full screen for other sexually transmitted infections, including HIV, is advised.

Further tests depend on symptoms. Patient.info says anyone with neurological signs or symptoms, and those who fail treatment, should have a lumbar puncture, and that neurological imaging may be appropriate. Cardiac investigations such as an ECG and echocardiogram may also be needed. Specialists in sexual health, infectious diseases, neurology or cardiology are often involved.

The NHS says syphilis is treated with antibiotics, which may be injections, tablets or capsules, and that the length of treatment depends on the stage. Patient.info says treatment should take place within a sexual health clinic. It lists penicillin-based regimens for late disease, with a different, longer course for neurosyphilis than for early infection. The exact drugs, doses and durations are set by the specialist team following the BASHH guideline.

Some people get a short flu-like reaction after the first dose. The NHS says this usually happens within the first 24 hours. Patient.info calls it the Jarisch-Herxheimer reaction and says it is uncommon in late syphilis but can be serious, so treatment is planned with care.

Antibiotics stop the infection from progressing, but they cannot undo damage that has already happened. Heart or aortic problems may need cardiology review, and neurological damage may need ongoing support. The NHS says you will need to return to the clinic several times in the first 12 months for repeat testing. Partners are offered testing too, and the clinic can contact them without naming you.

The outlook depends on how much damage was done before treatment. Treatment halts the infection. Tests are repeated to confirm that antibody levels are falling as expected. Where the aorta, nerves or brain are involved, ongoing specialist care is usual.

The best outcome by far comes from earlier treatment. Because syphilis can be silent for years, the only way to know is to test after a possible exposure. The NHS also advises waiting until 2 weeks after you and your partner have finished treatment before any sexual contact.

Go to a sexual health clinic or see a GP if you or a sexual partner have symptoms of syphilis, a partner has told you they have syphilis or another STI, you recently had sex with a new partner without a condom, you are pregnant or planning pregnancy and think you might have syphilis, or you injected drugs with a needle that may have been shared. The NHS says a test is the only way to confirm it.

New confusion, fits, sudden weakness, chest pain or breathlessness need emergency care. Call 999 for these, whatever the cause. Do not wait for sexual health clinic appointments in an emergency.

NHS sexual health clinics test and treat syphilis free of charge, and you do not need a GP referral. Pregnant women are offered syphilis screening in antenatal care. Self-test kits are available through local NHS services and pharmacies.

Private clinics also offer testing, but late syphilis with heart or brain involvement needs a multidisciplinary team, which is usually coordinated through hospital services. If you pay privately, ask who will manage partner notification and repeat testing.