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Figure 25.13 Appearance of the Mucous Patches of Secondary Syphilis These lesions are swarming with Treponema pallidum and are highly infectious.

Figure 25.14 A Gumma of Tertiary Syphilis Gummas consist of an inflammatory mass which can perforate, as in this example in the roof of the mouth. Gummas can occur anywhere in the body.

Many of the manifestations of secondary syphilis are due to the reaction of circulating T. pallidum with specific antibodies to form immune complexes. By this time, the spirochetes have spread throughout the body, and infectious lesions occur on the skin and mucous membranes in various locations, especially in the mouth (figure 25.13). Syphilis can be transmitted by kissing during this stage. The secondary stage lasts for weeks to months, sometimes as long as 1 year, and then gradually subsides. About 50% of untreated cases never progress past the secondary stage; however, after a latent period of from 5 to 20 years or even longer, some people with the disease develop tertiary syphilis. ■ immune complexes, p. 448

Tertiary syphilis, or the third stage of syphilis, represents a hypersensitivity reaction to small numbers of T. pallidum that grow and persist in the tissues. In this stage, the patient is no longer infectious. The remaining T. pallidum organisms may be present in almost any part of the body, and the symptoms of tertiary syphilis depend on where the hypersensitivity reactions occur. If they occur in the skin, bones, or other areas not vital to existence, the disease is not life threatening. If, however, they occur within the walls of a major blood vessel such as the aorta, the vessel may become weakened and even rupture, resulting in death. Hypersensitivity reactions to T. pallidum in the eyes cause blindness; central nervous system involvement most commonly manifests itself as a stroke. A granulomatous necrotizing mass called a gumma (figure 25.14), analogous to the tubercle of tuberculosis, can involve any part of the body. A characteristic pattern of symptoms and signs called general paresis develops an average of 20 years after infection. Typical findings include personality change, emotional instability, delusions, hallucinations, memory loss, impaired judgment, abnormalities of the pupils of the eye, and speech defects. ■ tubercle, p. 583

The main characteristics of the three stages of syphilis are summarized in table 25.10.

Congenital Syphilis During pregnancy, T. pallidum readily crosses the placenta and infects the fetus. This can occur at any stage of pregnancy, but damage to the fetus does not generally develop until the fourth month. Therefore, if the mother's syphilis is diagnosed and treated before the fourth month of pregnancy, the fetus will be treated too and will not develop the disease. Without treatment, the risk to the fetus depends partly on the stage of the mother's infection. Three-fourths or more of the fetuses become infected if the mother has primary or early secondary syphilis; risk decreases with the duration of the mother's infection but is still significant into the latent period. Fetal infections can occur in the absence of any symptoms of syphilis in the mother. About two out of every five infected fetuses are lost through miscarriage or stillbirth. The remainder are born with congenital syphilis. Although these infants frequently appear normal at the time of birth, some of them develop secondary syphilis, which is often fatal, within a few weeks. Others develop characteristic deformities of their face, teeth (figure 25.15), and other body parts later in childhood.

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