Porth's Essentials of Pathophysiology, 4e

1060

Genitourinary and Reproductive Function

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FIGURE 41-9. Syphilitic chancre of the penis shaft. (From the Centers for Disease Control and Prevention Public Health Image Library. No. 6758. Courtesy of Gavin Hart, N. J. Fiumara.)

sensory loss (i.e., tabes dorsalis). Cardiovascular manifes- tations usually result from scarring of the medial layer of the thoracic aorta with aneurysm formation. These aneu- rysms produce enlargement of the aortic valve ring with aortic valve insufficiency. Diagnosis andTreatment The diagnosis of syphilis can be made rapidly by dark- field microscopic examination of the exudate from skin lesions. However, the test is reliable only when a speci- men with actively motile T. pallidum is examined imme- diately by a trained microscopist. Treponema pallidum does not survive transport to a laboratory and it cannot be cultured. It does, however, evoke a humoral immune response and production of antibodies that provide the basis for serologic tests. Although PCR tests have been developed for syphilis, serology tests remain the mainstay for diagnosis. Two general types of serology tests are available: nonspe- cific (nontreponemal) tests and the specific treponemal tests. 4 The nontreponemal tests measure immunoglobin (Ig) G and IgM antibodies developed against molecules released from damaged cells during the early stages of the infection and present on the cell surface of trepone- mas. These antibodies are detected by tests such as the FIGURE 41-10. A maculopapular rash is present on the palm due to secondary syphilis. Note that some of the rash is sparsely distributed to areas of the forearm as well. (From the Centers for Disease Control and Prevention Public Health Image Library. No. 3478. Courtesy of Susan Lindsley.)

contagious at this stage, but because the symptoms are mild, it frequently goes unnoticed. The chancre usually heals within 3 to 12 weeks, with or without treatment. The timing of the second stage of syphilis varies even more than that of the first, lasting from 1 week to 6 months. The symptoms of a rash (especially on the palms [Fig. 41-10] and soles), fever, sore throat, stomati- tis, nausea, loss of appetite, and inflamed eyes may come and go for a year but usually last for 3 to 6 months. Secondary manifestations may include alopecia and gen- ital lesions called condylomata lata . These elevated 2- to 3-cm red-brown lesions, which contain many spirocetes and are highly infectious, may ulcerate and produce a foul discharge. After the second stage, syphilis frequently enters a latent phase that may last the lifetime of the person or progress to tertiary syphilis at some point. Persons can be infective during the first 1 to 2 years of latency. Tertiary syphilis is a delayed response to the untreated disease. Approximately one third of people with untreated syphilis develop syphilis after a latent period of 5 years or more. 9 When syphilis does progress to the symptomatic tertiary stage, it commonly develops into one of three forms: localized destructive lesions called gummas , cen- tral nervous system lesions, or cardiovascular manifesta- tions. The syphilitic gumma is a peculiar, rubbery, necrotic lesion that is caused by noninflammatory tissue necrosis. Gummas can occur singly or multiply and vary in size from microscopic lesions to large, tumorous masses. They most commonly are found in the liver, testes, and bone. Central nervous system lesions can produce dementia, blindness, or injury to the spinal cord, with ataxia and