The spirochete Treponema pallidum causes syphilis. Transmission occurs primarily through sexual contact during the primary, secondary, and early latent stages of infection.

Aortic insufficiency or aneurysm, meningitis, and widespread central nervous system damage can result from advanced syphilis.

The typical patient history will point to unprotected sexual contact with an infected person or with multiple or anonymous sexual partners.

In a patient with primary syphilis, you may observe one or more chancres (small, fluid-filled lesions) on the genitalia and others on the anus, fingers, lips, tongue,
nipples, tonsils, or eyelids. In female patients, chancres may develop on the cervix or the vaginal wall. These usually painless lesions start as papules and then erode. They have indurated, raised edges and clear bases and typically heal after 3 to 6 weeks, even when untreated. In the primary stage, palpation may reveal enlarged unilateral or bilateral regional lymph nodes (adenopathy).

In secondary syphilis (beginning within a few days or up to 8 weeks after the initial chancres appear), the patient may complain of headache, nausea, vomiting, malaise, anorexia, weight loss, sore throat, and a slight fever.

On inspection, you may see symmetrical mucocutaneous lesions. The rash of secondary syphilis may appear macular, papular, pustular, or nodular. Lesions are uniform, well defined, and generalized. Macules typically erupt between rolls of fat on the trunk and, proximally, on the arms, palms, soles, face, and scalp. In warm, moist body areas (the perineum, scrotum, or vulva, for example), the lesions enlarge and erode, producing highly contagious, pink or grayish white lesions (condylomata lata).

Alopecia, which usually is temporary, may occur with or without treatment. The patient may also complain of brittle, pitted nails.

Palpation may disclose generalized lymphadenopathy.

In latent syphilis, physical signs and symptoms are absent except for possible recurrence of mucocutaneous lesions that resemble those of secondary syphilis.

In late syphilis, the patient’s complaints will vary with the involved organ. Late syphilis has three subtypes: neurosyphilis, late benign syphilis, and cardiovascular syphilis.

If neurosyphilis affects meningovascular tissues, the patient may report headache, vertigo, insomnia, hemiplegia, seizures, and psychological difficulties. If neurosyphilis affects parenchymal tissue, he may report paresis, alteration in intellect, paranoia, illusions, and hallucinations. Inspection may reveal Argyll Robertson pupil (a small, irregular pupil that is nonreactive to light but accommodates for vision), ataxia, slurred speech, trophic joint changes, positive Romberg’s sign, and a facial tremor.

If the patient has late benign syphilis, he may complain of gummas—lesions that develop between 1 and 10 years after infection. A single gumma may be a chronic, superficial nodule or a deep, granulomatous lesion that’s solitary, asymmetrical, painless, indurated, and large or small. Visible on the skin and mucocutaneous tissues, gummas commonly affect bones and can develop in any organ. If they involve the nasal septum or palate, they may cause perforation and disfigurement.

In cardiovascular syphilis, decreased cardiac output may cause decreased urine output and decreased sensorium related to hypoxia. Auscultation may reveal pulmonary congestion.