Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum. It presents in primary, secondary, latent, and tertiary stages with varying signs and symptoms. It can infect multiple organ systems if left untreated, potentially causing serious complications. Diagnosis is usually made through blood tests detecting antibodies, though microscopy can also identify the bacteria. Syphilis remains a global health issue, with rates of infections increasing in recent decades.

1. MSK.
Syphilis.
Dr/ ABD ALLAH
NAZEER. MD.
Brain.
Spinal
Cord.
Eye.
Ear.
CVS. Lymph
nodes.
Kidney.
Joints.
Liver.
Skin@
mucous
membrane.

2. Syphilis is a sexually transmitted infection caused by the spirochete bacterium
Treponema pallidum subspecies pallidum. The primary route of transmission is
through sexual contact ; it may also be transmitted from mother to fetus during
pregnancy or at birth, resulting in congenital syphilis .
The signs and symptoms of syphilis vary depending in which of the four stages it
presents (primary, secondary, latent, and tertiary). The primary stage classically
presents with a single chancre (a firm, painless, non-itchy skin ulceration),
secondary syphilis with a diffuse rash which frequently involves the palms of the
hands and soles of the feet, latent syphilis with little to no symptoms, and tertiary
syphilis with gummas , neurological, or cardiac symptoms. It has, however, been
known as "the great imitator " due to its frequent atypical presentations.
Diagnosis is usually made by using blood tests ; however, the bacteria can also be
detected using dark field microscopy .
Syphilis is thought to have infected 12 million additional people worldwide in
1999, with greater than 90% of cases in the developing world . After decreasing
dramatically since the widespread availability of penicillin in the 1940s, rates of
infection have increased since the turn of the millennium in many countries, often
in combination with human immunodeficiency virus (HIV). This has been
attributed partly to unsafe sexual practices among men who have sex with men ,
increased promiscuity , prostitution , and decreasing use of condoms.

3. Signs and symptoms:
Primary syphilis is typically acquired by direct sexual contact with the infectious lesions
of another person. Approximately 3 to 90 days after the initial exposure (average 21
days) a skin lesion, called a chancre , appears at the point of contact. This is classically
(40% of the time) a single, firm, painless, non-itchy skin ulceration with a clean base
and sharp borders between 0.3 and 3.0 cm in size. The lesion, however, may take on
almost any form. In the classic form, it evolves from a macule to a papule and finally to
an erosion or ulcer . Occasionally, multiple lesions may be present (~40%), with
multiple lesions more common when coinfected with HIV. Lesions may be painful or
tender (30%), and they may occur outside of the genitals (2–7%). The most common
location in women is the cervix (44%), the penis in heterosexual men (99%), and anally
and rectally relatively commonly in men who have sex with men (34%). Lymph node
enlargement frequently (80%) occurs around the area of infection, occurring seven to
10 days after chancre formation. The lesion may persist for three to six weeks without
treatment.
Secondary syphilis occurs approximately four to ten weeks after the primary
infection.While secondary disease is known for the many different ways it can
manifest, symptoms most commonly involve the skin, mucous membranes , and
lymph nodes . There may be a symmetrical, reddish-pink, non-itchy rash on the
trunk and extremities, including the palms and soles. Rare manifestations include
hepatitis , kidney disease, arthritis.

4. Latent syphilis is defined as having serologic proof of infection without symptoms
of disease. It is further described as either early (less than 1 year after secondary
syphilis) or late (more than 1 year after secondary syphilis) in the United States.
The United Kingdom uses a cut-off of two years for early and late latent syphilis.
Early latent syphilis may have a relapse of symptoms. Late latent syphilis is
asymptomatic , and not as contagious as early latent syphilis.
Tertiary syphilis may occur approximately 3 to 15 years after the initial infection,
and may be divided into three different forms: gummatous syphilis (15%), late
neurosyphilis (6.5%), and cardiovascular syphilis (10%). People with tertiary
syphilis are not infectious. Gummatous syphilis or late benign syphilis usually
occurs 1 to 46 years after the initial infection, with an average of 15 years. This
stage is characterized by the formation of chronic gummas , which are soft,
tumor-like balls of inflammation which may vary considerably in size. They
typically affect the skin, bone, and liver, but can occur anywhere. Neurosyphilis
refers to an infection involving the central nervous system . It may occur early,
being either asymptomatic or in the form of syphilitic meningitis , or late as
meningovascular syphilis, general paresis , or tabes dorsalis , which is associated
with poor balance and lightning pains in the lower extremities. Late neurosyphilis
typically occurs 4 to 25 years after the initial infection. Meningovascular syphilis
typically presents with apathy and seizure , and general paresis with dementia
and tabes dorsalis.

6. Congenital syphilis is that which is transmitted during pregnancy or during
birth. Two-thirds of syphilitic infants are born without symptoms. Common
symptoms that develop over the first couple years of life include:
hepatosplenomegaly (70%), rash (70%), fever (40%), neurosyphilis (20%), and
pneumonitis (20%). If untreated, late congenital syphilis may occur in 40%,
including: saddle nose deformation, Higoumenakis sign , saber shin , or
Clutton's joints among others.
Syphilis is transmitted primarily by sexual contact or during pregnancy from a
mother to her fetus ; the spirochaete is able to pass through intact mucous
membranes or compromised skin. It is thus transmissible by kissing near a
lesion, as well as oral, vaginal, and anal sex. Approximately 30 to 60% of
those exposed to primary or secondary syphilis will get the disease.
Diagnosis:
Syphilis is difficult to diagnose clinically early in its presentation. Confirmation
is either via blood tests or direct visual inspection using microscopy . Blood
tests are more commonly used, as they are easier to perform. Diagnostic tests
are, however, unable to distinguish between the stages of the disease.

10. Syphilitic Chancres
Genital (95%) and extragenital (5%).
Highly infectious.
Usually single.
Indurated.
Painless.
Edge regular.
Floor clean.
Heal in 3-6 weeks
Chancre of the genitalia, tongue, lip and hard palate.

12. Secondary Syphilis
Ddx“Great Imitator”
Pityriasis rosea
Drug eruptions (pruitic)
Lichen planus; Wickham’s striae, Koebner’s, pruitic
Psoriasis; no adenopathy
Sarcoidosis; need serology and silver staining of biopsy
Infectious mononucleosis, false pos RPR
Geographic tongue
Aphthous stomatitis
Distribution of skin lesions of secondary syphilis
• Macular lesions most often found in pink colored areas
• Papular lesions in light blue areas
• Pustular lesions in the purple areas

13. Aphthous stomatitis Bacterial-Syphilis

14. Condylomata lata:
Wart-like lesions in moist intertriginous areas.
Sessile
don’t bleed easily.
D.D.: Condyloma accuminata:
Pedunculated
Bleed easily.
All of these lesions teem with treponemes and are highly contagious
Naso-Labila fold.

15. CONGENITAL SYPHILIS.
Mucous patches and skin lesions in an infant Hutchinson's teeth

16. Hutchinson's teeth Moon's molar of congenital syphilis

17. Saddle nose
Perforation of the hard palate (resulting
from gummatous destruction)

18. TERTIARY SYPHILIS
Latent stage: After the rash clears, a person may have a period with no symptoms.
This is often called the "hidden stage." Even though symptoms go away, the
bacteria that cause syphilis are still in the body and begin to damage the internal
organs. This stage may be as short as 1 year or last from 5 to 20 years. Often, a
woman with latent-stage syphilis doesn't find out that she has the infection until
she gives birth to a child with syphilis.
Late (tertiary) stage: If syphilis is not found and treated in the early stages, it can
cause other serious health problems. These can include blindness, problems with
the nervous system and the heart, and mental disorders. It can also cause death.

19. Complications of tertiary (late) syphilis include:
Gummata, which are large sores inside the body or on the skin.
Cardiovascular syphilis, which affects the heart and blood vessels.
Neurosyphilis, which affects the nervous system.
Congenital syphilis refers to syphilis passed from the mother to the
baby during pregnancy or during labor and delivery. Congenital
syphilis can cause complications in newborns and children.
Palatal gumma.

20. THE SKELETAL MANIFESTATIONS OF CONGENITAL SYPHILIS.
Unfortunately, congenital syphilis is still a problem in some
countries. The disease is an intra-uterine infection which usually
manifests shortly after birth. Spirochetes cross the placental barrier
after the fourth month of pregnancy, though clinical symptoms may
not appear for several weeks after birth. Congenital syphilis is
divided into early (before 2 years of age) and late. The disease is
seldom seen in North America and in some hospitals routine
serological tests have been discontinued (Wilkinson and Heller 1971
; Rosenfeld, Weinert and Kahn 1983; Toohey 1985). In the United
Kingdom about 10 cases are seen each year (Ewing et al 1985).
Primary skeletal involvement is rare (Levin 1970; Toohey 1985). It is
a bilaterally symmetrical polyostotic condition which affects mainly
tubular bones, but any bone may be affected (McLean 1931).
Diagnosis may be difficult when the classical presentation of
bilaterally symmetrical osteoperiostitis is absent.

21. Radiograph of left upper limb with diffuse metaphysitis, osteitis and dactylitis.

22. Radiographs showing symmetrical erosions (Wimberger’s sign)
in the upper tibiae and focal changes in the distal femora.

23. Exuberant callus formation of distal femora.

24. Radiograph showing infraction of right distal femur and fracture of left upper tibia

25. Erosion of sigmoid notch of ulna.

26. Dactylitis of left foot showing complete healing at two-year
follow-up; the same changes were seen in the right foot

27. Radiograph showing epiphyseal displacement of right distal
femur with complete resolution at three-year follow-up.

28. Anterior-posterior projection of bilateral lower extremities — widespread osseous deformities
are shown involving the epiphyseal-metaphyseal junctions and long bone cortices

29. Lucent bands in proximal and distal extremity of
femur, tibia and fibula , humerus, radius and ulna.

30. Focal fragmentation and Destruction in distal femur.

31. Wimberger Sign: Metaphyseal destruction in the upper medial tibia,
usually sparing the most recently formed few millimeters of metaphysis

32. Bilateral callus after pathologic fracture in proximal femur.

33. Callus, periosteal reaction and
metaphyseal abnormalities Periosteal reaction .

34. Diffuse osteitis and metaphysitis in long bones.

35. Neurosyphilis.
I. Asymptomatic neurosyphilis: 15-40% of patients with syphilis will have some
CSF abnormalities
• Diagnosed by positive CSF VDRL; serum treponemal and non-treponemal tests
usually positive as well
• LP: 10-100 WBC (lymphocyte predominance), protein 50-100
• Rarely CSF VDRL will be negative with positive serum tests; in that case, if the
patient has a CSF consistent with syphilis, many people will treat for neurosyphilis
II. Acute syphilitic meningitis: 6% of syphilis patients
• Typically the earliest manifestation of neurosyphilis
• Often associated with cranial nerve palsies, fever, HA, meningismus, and may
have signs of cortical involvement
• CSF may be much like asymptomatic neurosyphilis or may demonstrate higher
cell counts/protein and lower glucose
• Serum and CSF VDRL almost always positive
III. Meningovascular syphilis: 10-12% of patients
• Syphilitic endarteritis causes infarction clinically similar to stroke, although may
have a prodrome
• CSF: lymphocytosis, elevated protein; CSF VDRL usually positive

36. IV. General paresis: Relatively rare; occurs 15-20 years after initial infection
• Syphilitic infection of the meninges and cortex causes personality changes, paranoia,
emotional liability, eventually progressing to memory loss and dementia
• CSF: elevated lymph's and/or protein; VDRL usually positive in pre-HIV era but current
data suggests sensitivity of 27-92%. Treponemal tests may be more sensitive but often are
not standardized for use on CSF. A PCR has been developed but data on utility not known.
V. Tabes dorsalis: Now rare; disease of posterior columns of spinal cord that occurs 18-25
years after infection. Often coexists with general paresis.
• Manifestations: abnormal gait, paresthesias, lightning pains of extremities, loss of
proprioception on exam, positive Romberg; Argyll-Robertson pupils may be seen with this
and/or general paresis • Abnormal CSF is less common in this setting, and CSF VDRL was
normal in up to 1/3 of cases in pre-HIV era
VI. Pearls about neurosyphilis:
• Any inflammatory disease of the eye can be mimicked by neurosyphilis
• The cranial nerves most commonly involved in neurosyphilis are VII and VIII
• Syphilitic otitis causes tinnitus and may be the only symptom at presentation
• In non-HIV+ patients, those with neurosyphilis should have a positive serum treponemal
test (MHATP/FTA)
• In non-HIV+ patients, a positive CSF VDRL always indicates neurosyphilis, whereas a
positive CSF PCR for syphilis simply indicates that CSF invasion has occurred
• HIV+ patients may have titers discordant from their true disease state and therefore
probably warrant more aggressive treatment; they may also progress more quickly
than pts in the pre-HIV era.

37. CT images of the vertex calvaria. A, Axial CT image (2.5-mm section thickness)
demonstrates irregular bone destruction involving the calvaria. The outer cortex is
predominantly involved. Irregular channel-like areas of bone destruction are best
demonstrated in the vertex lesion (arrow). B, 3D volume-rendered image (using
2.5-mm reconstructed images) demonstrates the irregular worm-eaten nature of
the destructive lesions, characteristic of syphilitic osteomyelitis.(arrows).

38. A, Axial fast spin-echo (FSE) T2-weighted image with fat saturation (TR, 3300 ms; TE,86.4 ms; echo-train,
12). B, Coronal spin-echo T1-weighted image (TR, 400 ms; TE, 8.0 ms) after gadolinium
administration (20 mL). Axial FSE T2-weighted image (A) demonstrates abnormal marrow edema in
the frontal bone (arrow). There is subgaleal/periosteal inflammatory tissue adjacent to the right
frontal destructive lesion, which exhibits increased signal intensity on T2-weighted image (A, white
arrowhead). The bone destruction is irregular and predominantly involves the outer cortex (A, black
arrowhead). The vertex lesion enhances intensely, involving nearly the entire thickness of the calvaria
(B, black arrowhead). Mild dural enhancement is noted along the right convexity (B, arrow), consistent
with inflammatory involvement. The adjacent subgaleal/periosteal inflammatory process enhances
intensely (white arrowheads). No parenchymal signal-intensity abnormalities are identified.

39. Neurosyphilis , axial T2-weighted MR images (A, B) demonstrate well-defined areas of abnormal high signal in the basal ganglia
bilaterally and in a wedge-shaped distribution in the right parietal lobe (arrows). Axial T1-weighted images post-gadiolinium. Coronal
T1-weighted images post-gadolinium demonstrate irregular ring enhancement of the lesions (arrows). (Syphilitic gumma)

40. Neurosyphilis, axial T2-weighted MRI (A) demonstrates a dural-based, peripherally
hyperintense and centrally hypointense lesion located lateral to the left frontal lobe
(arrows). Axial (B) and coronal (C) T1-weighted MR images post-gadolinium
demonstrate peripheral enhancement of the lesion (arrows). (Syphilitic gumma).

41. Syphilitic Gummas mimicking neoplasm.

42. Cerebral syphilitic gumma simulating neoplasm.

43. Syphilitic Gummas showed a round mass-like lesion at the left frontal region.

44. Cerebral syphilitic gumma in HIV infection.

45. Intracranial Syphilitic
Gumma Mimicking a
Brain Stem Glioma

46. Images of a 50-year-old man with a 3-month history of progressive dementia, who
presented with seizures. Serologic evidence of active neurosyphilis was present, and there
was no evidence of herpes virus infection. A, Axial FLAIR image obtained at midbrain level.
B, Axial FLAIR image obtained at the level of the pons. Asymmetrical bilateral signal
hyperintensity in the mesial temporal lobes can be seen and is greater on the right side than
on the left. C, Axial T1-weighted image obtained at the level of the low midbrain. This image
shows mild left temporal lobe atrophy, evidenced by dilation of the temporal horn (Arrow ).

47. Axial FLAIR image of the same patient, obtained 10 days after treatment with
penicillin. There are essentially no imaging differences as compared with the
pretreatment images. F IG 3. Axial FLAIR image of the same patient, obtained 4
months after treatment with penicillin. There is significant interval improvement
in the previously noted mesial temporal signal abnormalities. There is also slight
right temporal atrophy, with compensatory dilation of the temporal horn.

48. Brain imaging studies. (a) Pre-treatment brain magnetic resonance imaging scan showing
bilateral mesial temporal high T2 signal intensity (arrows). (b) Pre-treatment brain
positron emission tomography/computed tomography brain scan revealing a focus of
intensely increased 18F-fluorodeoxyglucose uptake limited to the head of the right
hippocampus (arrow) on a background of globally decreased 18F-fluorodeoxyglucose
uptake. (c) Post-treatment brain magnetic resonance imaging scan showing marked
improvement in the previously identified bilateral hyperintensities, which were replaced by
atrophy (arrows). (d) Post-treatment positron emission tomography brain scan showing
normal 18F-fluorodeoxyglucose uptake in the right hippocampus..

49. Magnetic Resonance Imaging (MRI) of the brain. A/ Axial fluid attenuated
inversion recovery (FLAIR). B/ Sagittal fluid attenuated inversion recovery (FLAIR).
C/ Coronal 3D -T1-TFE. D/Coronal T2WI – TSE. All images are showing marked
diffuse loss of brain parenchyma including mesiotemporal atrophy. Note that
there are no areas of increased signal intensity in the FLAIR and T2W images.

50. Axial fluid-attenuated inversion recovery images (A–C) show hyperintensity of bilateral
mesial temporal structures, insula, pulvinar of the thalami, and right temporo-occipital
cortex. Isotropic trace diffusion-weighted imaging (D) and apparent diffusion coefficient
(E) maps show restricted diffusion in the right temporo-occipital cortex and right insula.

51. syphilitic aseptic meningitis.

52. Neurosyphilis in HIV-Positive and HIV-Negative Patients:
Syphilis is caused by the spirochete Treponema pallidum and remains an important
and frequently encountered sexually transmitted disease. During the era of acquired
immunodeficiency syndrome (AIDS), there has been a dramatic rise in the number of
cases of syphilis and a corresponding increase in the incidence of neurosyphilis.
Invasion of the central nervous system by the organism can occur at any stage of
syphilitic infection, and occurs in about 5% to 10% of untreated patients. However,
neurosyphilis has been reported to develop in one third of patients who progress to
late stages of the disease. Syphilis is clearly recognized as one of the infectious
complications of infection with the human immunodeficiency virus (HIV). Evidence of
an increased occurrence of syphilis with HIV infection has been previously reported.
The association is not unexpected because AIDS and neurosyphilis are both sexually
transmitted diseases. Early diagnosis is critical in the management of the disease in
that it is easily treatable with appropriate antibiotics, but establishing the diagnosis is
often difficult because most patients are asymptomatic or present with nonspecific
symptoms. Some classic forms of the disease (general paresis of the insane and tabes
dorsalis) are seen rarely in the era of antibiotics, and it appears that the expected
progression of disease is altered by HIV infection. Identification of the more common
radiologic appearances of neurosyphilis are important in order that appropriate
clinical testing and treatment can be initiated. The neuroimaging findings of patients
with neurosyphilis in a group of patients with and without HIV infection.

53. 33-year-old HIV-positive woman with seizures and left hemiparesis. A,
Noncontrast brain CT image reveals a region of low attenuation in the distribution
of the right middle cerebral artery that involves cortex and adjacent white matter,
consistent with infarction (arrows). B, On the contrast-enhanced image there is
striking parenchymal enhancement indicating a subacute stage of the infarction.

54. A 43-year-old HIV-positive man
with left hemiparesis and seizures
who had a brain stem infarction
with basilar arteritis. A, T2-
weighted (2550/80/1) axial MR
image shows a large area of
increased signal in the pons. No
normal flow void is present in the
basilar artery. The area of low
intensity anterior to the pons
(arrow) represents pulsatile
cerebrospinal fluid flow in the
basilar cisterns in this patient with
meningovascular syphilis.
The contrast enhanced T1-weighted
images (not shown) revealed mild
pontine enhancement. B, Sagittal
projection image from 3-D time-of-flight
MR angiography shows high-grade
narrowing of the basilar
artery (arrows).

55. A 48-year-old HIV-negative man with fever, elevated
serum white blood cell count, and left hemiparesis,
who had multiple manifestations of neurosyphilis. A,
Axial T2-weighted (2650/80/1) image reveals poorly
defined regions of increased signal in the pons
(straight arrows) corresponding to areas of brain
stem infarction. A flow void in the basilar artery is
present, unlike in Figure 2, but it is small (curved
arrow). B, Axial enhanced T1-weighted (600/30/1)
image demonstrates a linear band of enhancement
within the area of pontine infarction (arrow). C,
Coronal enhanced T1-weighted (600/30/1) image
reveals extraaxial enhancement around the
supraclinoid segment of the right internal carotid
artery (arrows) corresponding to localized meningitis.
There is also a large enhancing infarction in the right
gangliocapsular structures producing mass effect on
the ventricular system. D, Coronal 3-D time-of-flight
MR angiography projection image shows severe
stenosis of the right supraclinoid internal carotid
artery (short, thick arrow), with decreased caliber of
the ipsilateral proximal middle cerebral artery (long,
thin arrows). E, The sites of arteritis identified in D
are confirmed on conventional angiography of the
right internal carotid artery (arrows). F,
Vertebrobasilar angiogram also demonstrates
vasculitis involving the distal basilar artery, with
marked irregularity (arrows).

56. Cerebral gumma discovered in a 22-year-old HIV-positive man with headache and
ataxia (courtesy of H. Waskin, MD). A, Coronal T1-weighted (750/25/2) image
after contrast administration reveals an ill-defined enhancing mass in the right
parietal cortex with surrounding edema (arrows). Slightly more posteriorly, there
was a faint tag of meningeal enhancement (not shown). B, Axial enhanced T1-
weighted (500/20/1) image at the level of the lesion after approximately 3
months of high-dose penicillin therapy shows resolution of the mass and edema.

57. Syphilitic Gummas in a Patient with Human Immunodeficiency Virus Infection.

58. Syphilitic myelitis with diffuse spinal cord abnormality on MR imaging:
Syphilitic myelitis is a very rare manifestation of neurosyphilis.
The MRI appearance of syphilitic myelitis is not well
documented and only a few cases have been reported.
Magnetic resonance imaging of the spine showed diffuse high
signal intensity in the whole spinal cord on T2-weighted
images. Focal enhancement was observed in the dorsal aspect
of the thoracic cord on T1-weighted gadolinium-enhanced
images. To our knowledge, diffuse spinal cord abnormality in
syphilitic myelitis has not been reported in the international
literature. Disappearance of the diffuse high-signal lesions
with residual focal enhancement was noted after antibiotic
therapy. The patient suffered significant neurological deficit
despite improvement in the MR images.

59. Tabes dorsalis, also known as syphilitic myelopathy, is a slow
degeneration (specifically, demyelination) of the nerves primarily in the
dorsal columns (posterior columns) of the spinal cord (the portion
closest to the back of the body). They help maintain a person's sense of
position proprioception), vibration, and discriminative touch.
Sagittal (A) and axial (B) section of T2WI on MRI showing intramedullary hyperintensity
and cord atrophy in dorsal spinal cord in man with tabes dorsalis of syphilis.

60. Syphilitic myelitis:
Magnetic resonance
imaging features.

61. Syphilitic myelitis: Magnetic resonance imaging features
(a) Sagittal T2-weighted image of the thoracic spinal cord shows long-segment diffuse
high signal intensity from T6 to T11 with cord swelling. (b) Coronal T1-weighted image
with contrast shows focal enhancement at T8/T9 level. (c) Sagittal T1-weighted image
with contrast. (d) Axial T1-weighted image with contrast at T8/T9 level

62. Follow-up magnetic resonance imaging performed 1 month after onset of
treatment. (a) Sagittal and (b) axial gadolinium-enhanced T1-weighted images
show residual focal enhancement in the thoracic cord at T8/T9 level.

63. Follow-up magnetic resonance imaging performed 3 months
after onset of treatment. (a) Sagittal T2-weighted image and (b)
sagittal gadolinium-enhanced T1-weighted image show normal
spinal cord and the abnormal signals have disappeared.

70. OTOSYPHILIS.
OTOLOGIC SIGNS AND SYMPTOMS
Otosyphilis can closely resemble Meniere's disease, perilymph
fistula, sudden hearing loss, autoimmune inner ear disease, and
bilateral vestibular loss. Because the inner ear communicates
with spinal fluid via the cochlear aqueduct, otosyphilis is a
variety of neurosyphilis and neurological symptoms are also
possible.
Early neurosyphilis mainly presents as meningitis with or without
cranial nerve involvement and meningovascular disease or
stroke. Hearing symptoms of early neurosyphilis might be a
sudden hearing loss.
Late neurosyphilis may affect the brain (general paresis), or
spinal cord (tabes dorsalis). In the ear, late neurosyphilis may
present as hearing loss, fluctuating hearing, or vestibular
imbalance/weakness (vertigo).

71. Enhanced MRI shows enhancement within
the cisternal segment of the
vestibulochoclear nerve complex on the
right (curved open arrow), within both
internal auditory canals, within the left
cochlea (curved solid arrow), and within
the tympanic portion of the right facial
nerve (small arrow). The enhancement
within the internal auditory canals
involves both the nerves within the CSF
and the meninges lining the canal.
Enhancement is also seen within the
middle turn of the right cochlea. fig 2.
Axial T1-weighted MR image (450/15/4),
obtained after the administration of
contrast medium from a position that is
slightly superior to that of figure 1, shows
enhancement of the labyrinthine and
geniculate portions of the right facial
nerve (large arrow) and enhancement of
the meninges lining both internal auditory
canals (small arrows). Enhancement of the
intracanalicular segments of the seventh
and eighth cranial nerve complex is
appreciated bilaterally.

72. Otosyphilis with Bilateral Sudden Hearing.

73. Syphilis of the heart and aorta.
Syphilis is a disease caused by infection with the microorganism
Treponema pallidum, is widespread in its early stages, affecting the
entire body. During this initial phase there may be transient
inflammation of the heart muscle, but usually with little or no
impairment of the circulation. In the late stages of the disease, there
may be syphilitic involvement of the heart, confined almost purely to
the aorta and aortic valve. A particularly severe form of aortic
insufficiency may develop, with subsequent dilation and
enlargement of the heart and, eventually, heart failure. The disease
process often involves the base of the aorta and the blood flow
through the openings into the coronary vessels from the aorta,
causing impairment of the coronary circulation, with resultant
angina pectoris and, on rare occasions, myocardial infarction, the
death of portions of heart muscle.

74. Thoracic aortic
aneurysm,
syphilis aortitis.

75. Syphilitic aortitis is a finding seen in tertiary syphilis.

76. Chronic syphilitic aortic aneurysm
complicated with chronic aortic dissection.

77. Syphilitic Aortitis.

78. Giant syphilitic aortic aneurysm.

79. Syphilitic aortitis with ascending aorta aneurysm.

80. Contrast-enhanced CT scan of the abdomen (A) and pelvis (B) shows irregular wall thickening
in the neck of the gallbladder (arrow in A), with multiple, enlarged inguinal lymph nodes
(arrows in B) showing relatively preserved fatty hila. CT scan of the chest (C) shows multiple,
well-defined, small, subcentimetre nodules (arrows), in both lower lobes in pulmonary syphilis

81. SYPHILITIC PAROTITIS :
large, hard mass in the
right parotid gland with
diameter of more than 5
cm, a smaller similar
lesion in the left parotid
gland and
lymphadenopathy of
the right axilla.

83. Primary syphilis with left cervical and supraclavicular
nodes and MR hyperintense nodes on STIR sequence.

84. An axial MRI scan after administration of contrast material shows an
enlarged lymph node with high signal intensity. (B) The enhanced
mass had invaded both pharyngeal recesses in syphilitic patient.

85. SYPHILITIC ARTHRITIS.
The joints may be involved at most stages of congenital and acquired
syphilis. It is a protean
condition, and may appear in many transitional forms between the
various clinical types.
In congenital syphilis, arthritis occurs in two forms, and a third form is
common to both the
congenital and the acquired disease. In infants the typical form is Parrot's
syphilitic osteochondritis, whilst in older children "Clutton's joints" are the
Common manifestation (Clutton, 1886). Certain other forms are analogous
to the signs of tertiary syphilis seen in adult cases of acquired syphilis.
D'Arcy Power (1908) classified congenital syphilitic arthritis as follows:
(i) Suppurative arthritis;
(i) Hydrarthrosis;
(iii) Symmetrical serous synovitis; Clutton's joints;
(iv) Gummatous synovitis;
(v) Chondro-arthritis; ulcerating or von Gie joints.

86. Fig. la.-Case 1. Subchondral erosions of left lateral femoral Fig. lb.-Case 1. Appearances in
left knee joint have reverted to condyle and head of left fibula. Bands of bismuth deposition
are normal after 6 months. Bismuth bands now broader. seen in the metaphyseal areas.

87. Erosion at loser end or right radius in relation to inferior radio-ulnar joint.

88. Generalized increase in skeletal density due to
Adult type of widespread bismuth deposition.

89. Lateral views of both knee joints showing bilateral irregularity of articular
surfaces with a small loose body in the right anterior joint compartment.

90. Liver involvement in syphilis.
Congenital syphilis is increasingly being diagnosed in developed countries
after many years of decline. The liver is characteristically involved.
However, fulminant hepatic failure and subsequent liver calcifications are
both rare in patients with congenital syphilis. The infant reported here
had both of these rare manifestations of this disease.
Secondary syphilis is characterized by anicteric cholestasis, an
inflammatory syndrome, and periportal infiltrate inconstantly associated
with centrilobular necrosis, granulomatous reaction and presence of
treponemas in the lesions. Due to the increasing frequency of sexually
transmitted diseases, this diagnosis could become more frequent.
Tertiary syphilis, especially in cases involving visceral gummatous
disease, can be confused with cancer of the solid organs. The tertiary
hepatic syphilis that manifested with intrahepatic masses in a patient
who had an underlying primary peritoneal serous carcinoma (PPSC).

91. Tertiary syphilis mimicking hepatic metastases.

92. Magnetic resonance of abdomen showing two lesions within the
right lobe of the liver along the peripheral surface (black arrows).

93. Gummatous hepatic syphilis simulating malignancy.

94. CT-scan demonstrates liver healing one year after successful treatment.

95. Disappearance of lives IPT after antibiotic therapy.

96. Syphilitic hepar lobatum CT shows a liver with lobulated contours, capsular
retractions and wedge-shaped hypodense areas in arterial (A) and portal (B)
phases. Left portal vein thrombosis (B) was associated to left lobe atrophy.

97. MRI shows that the lesions
remained hypovascular in
arterial (A) and portal
phases (B) and presented
contrast enhancement only
in the delayed phase (C).

98. HEPAR LOBATUM of tertiary syphilis at Museum of pathology.

99. Syphilis and kidney disease:
Syphilis can affect the kidney and usually causes a glomerular
lesion with variable amounts of proteinuria. Recognizing the
association of syphilis and proteinuria is important since
antibiotic therapy generally results in complete recovery of
the associated nephropathy. Kidney involvement due to
syphilis has been reported during secondary, latent and
tertiary syphilis. Patients may present with sub-nephrotic
albuminuria (most common presentation), membranous
glomerulonephritis (MGN), mesangial proliferative
glomerulonephritis (MPGN), rapidly progressive crescentic
glomerulonephritis or minimal change disease. MGN from
syphilis results from antitreponemal antibody
(Immunoglobulin G) deposition in the subepithelial layer of
the glomerular basement membrane.

100. Syphilitic patient with acute glomerulonephritis.

101. Syphilitic patient with acute glomerulonephritis.

102. Cutaneous manifestation of syphilis.
It should be noted that syphilis dermatological manifestations are very clear, but the
systemic involvement is still not so well established. It is possible that the association
with other organs in earlier stages, besides skin, is more frequent than one can
imagine. Specialized services have observed cutaneous stages overlay even in HIV-seronegative
patients, apart from early onset of systemic symptoms in this same
group. Syphilis classification in stages in only didactic, and as it is an infection,
Erythematous-violaceous papules scattered over the centrofacial region and forehead.

103. Lesions’ reduction after 7 days of the first dose of benzathine penicillin 2.400.000.

105. Thank You.