Potential Risks

Complications of late syphilis are usually irreversible. The most common form of disease is the gumma (late benign syphilis), a granulomatous inflammatory lesion with an area of central necrosis. Gummas range in size from microscopic to several centimeters in diameter. Virtually any organ of the body may develop gummas. The most commonly involved site is the skin; other sites include bone, mucous membranes, liver, upper respiratory tract, and stomach. Gummas may heal spontaneously with scarring but are often chronic and destructive.

Other common forms of late syphilis are cardiovascular syphilis and neurosyphilis. Cardiovascular complications cause the morbidity of deaths in untreated syphilis. The most common forms of cardiovascular syphilis are aortitis, aortic regurgitation, and aneurysms of the thoracic aorta. Neurosyphilis can be asymptomatic. In which case, the diagnosis is made by examining the cerebral spinal fluid which reacts positively to serologic tests for syphilis. Symptomatic neurosyphilis is characterized by cerebral infarct (meningovascular neurosyphilis), widespread loss of nerve cells (general paresis), or degeneration of the dorsal roots of the spinal cord (tabes dorsalis). Manifestations of neurosyphilis include personality changes, psychosis, strokes, ataxia, paresthesias, and blindness.

Neurosyphilis

Involvement of the central nervous system may be asymptomatic or symptomatic. Asymptomatic neurosyphilis is diagnosed upon the basis of cerebrospinal fluid abnormalities. These may include a positive Wasserman or VDRL test. Left untreated, the chances of symptomatic neurosyphilis developing increase over time.

Symptomatic syphilis may be manifested by personality changes, altered affect and judgment, diminished memory for recent events, and speech impairment. Physical assessment could reveal hyperactive reflexes, paresthesias, ataxia, alteration in temperature, pain, and position sense, as well as the Argyll Robertson pupil (reacts to accommodation but not light). Cognitive, motor, and sensory impairment are problems of patients with neurosyphilis.

Cardiovascular Syphilis

Involvement of the great vessels, particularly the aorta, is characteristic of cardiovascular syphilis. Signs of aortic regurgitation and cardiac insufficiency (fatigue, dyspnea) may develop; nursing intervention is appropriate to the disease’s manifestations. Intervention is symptomatic and may include neurological and cardiac work-ups by the physician. Medication is the intervention of choice to halt the syphilitic organism. In cardiovascular syphilis, endarteritis obstructs the arteries supplying blood to the larger vessels, producing necrosis and destruction of tissue, particularly in the aorta. The lesions of neurosyphilis result from obliteratives endarteritis of small arteries with subsequent death of nerve tissue.

Although permanent damage may be caused by gummas, cardiovascular syphilis, or neurosyphilis, antibiotic therapy may arrest the progression of the disease or result in the clinical improvement. The recommended treatment of late benign syphilis, cardiovascular syphilis, and asymptomatic or symptomatic neurosyphilis is 7.2 million units benzathine penicillin G given in doses of 2.4 million units by intramuscular injection at weekly intervals. An alternative treatment is APPG 9.0 million units total, given as 600,000 units by intramuscular injection daily for 15 days. Patients who are allergic to penicillin can be given 500 mg erythromycin or tetracycline four times a day by mouth for 30 days.

In the pregnant woman, spirochetes can cross the placenta, infecting the fetus. Untreated infection in the mother may result in abortion, stillbirth, prematurity, neonatal death, or congenital syphilis. Because penicillin crosses the placental barrier, treatment of the mother can cure the fetus. All female patients with venereal disease should be asked about pregnancy.