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Tertiary syphilis
Other Resources UpToDate PubMed

Tertiary syphilis

Contributors: David O'Connell MD, Belinda Tan MD, PhD, Marvin Turck MD, Susan Burgin MD
Other Resources UpToDate PubMed


Syphilis is a chronic systemic disease with multiple clinical presentations, caused by the spirochete Treponema pallidum. Disease is characterized by 3 stages of active disease (primary, secondary, and tertiary) interrupted by latent periods. Disease is acquired via intimate contact with infected lesions (usually sexual contact), by blood transfusion, or transplacentally to the fetus. After the advent of antibiotics, the long-term sequelae of infection with the treponeme (neurosyphilis, cardiovascular syphilis, and gummas) have become uncommon. In untreated syphilis, 15% of patients develop benign late syphilis with skin (70%), bone (10%), and/or mucous membranes (10%). About 16% of untreated patients will develop either neurosyphilis or cardiovascular syphilis.

Gummas are locally destructive lesions of skin, bone, or involved organs, which may heal spontaneously with scarring but often recur. The term "gumma" is derived from the appearance of slimy central necrotic tissue in ulcers. Skin lesions are usually asymptomatic. When the tongue is involved with an early glossitis, there may be discomfort eating hot or acidic foods. Bone lesions are painful. Symptoms of neurosyphilis may include headache, body aches, fatigue, weight loss, dizziness, paresis, behavior change, dementia, ataxia, blindness, deafness, incontinence, and impotence.

Systemic signs of tertiary disease include a heart murmur, aortitis, cranial nerve palsies, pupillary abnormalities (Argyll Robertson pupil), signs of tabes dorsalis, foot ulcers, and iritis.

Tertiary, or late syphilis, occurs after a latent period of 2-20 years after infection. Damage to the skin, bones, and the central nervous (CNS) and cardiovascular systems is due to host delayed-type hypersensitivity reactions to a small number of organisms. An accelerated course and neurologic disease are observed more often in HIV infection, when disease progresses to the tertiary phase in months rather than years. Skin lesions endure for months to years untreated. If present, neurosyphilis or cardiovascular syphilis may result in death. Prognosis depends upon the duration and extent of disease.

Related topics: ocular syphilis, early congenital syphilis, late congenital syphilis


A52.9 – Late syphilis, unspecified

72083004 – Late syphilis

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Differential Diagnosis & Pitfalls

Differential of mucocutaneous findings:
  • Granuloma annulare
  • Sarcoidosis
  • Cutaneous tuberculosis
  • Cutaneous T-cell lymphoma
  • Halogenoderma (Bromoderma, Iododerma)
  • Psoriasis
  • Discoid lupus erythematosus
  • Nodular basal cell carcinoma
  • Squamous cell carcinoma in situ (Bowen disease)
  • Rosacea
  • Stasis ulcer
  • Leukoplakia
  • Lyme disease
  • Cogan syndrome

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Last Reviewed:09/02/2020
Last Updated:06/09/2022
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Tertiary syphilis
A medical illustration showing key findings of Tertiary syphilis (Systemic Symptoms) : Cranial nerve palsy, Heart murmur
Clinical image of Tertiary syphilis - imageId=860159. Click to open in gallery.  caption: 'A close-up of a round ulcerated plaque.'
A close-up of a round ulcerated plaque.
Copyright © 2024 VisualDx®. All rights reserved.