Tertiary syphilis is the late stage of a syphilis infection that damages the heart, brain, nerves, and other organs. It occurs 10 to 30 years after the initial infection if the disease is left untreated. Without treatment, about one-third of people with syphilis will develop this stage, which can be fatal. The good news is that tertiary syphilis is now rare in the United States because of widespread testing and effective antibiotic treatment for early-stage infections.
What Are the Stages of Syphilis Before Tertiary Syphilis?
Syphilis progresses through defined stages. Understanding these stages helps explain how tertiary syphilis develops. The first stage is primary syphilis. A painless sore called a chancre appears at the infection site, usually the genitals, rectum, or mouth. This sore lasts 3 to 6 weeks and heals on its own even without treatment.
The second stage is secondary syphilis. This stage starts weeks to months after the chancre heals. Symptoms include a rash on the palms and soles, fever, sore throat, fatigue, and swollen lymph nodes. These symptoms also go away without treatment. This is where many people mistakenly think they are cured. They are not. The infection remains in the body.
After secondary symptoms fade, the infection enters a latent stage. During early latency, which lasts less than a year, symptoms can return. During late latency, which lasts more than a year, there are no symptoms at all. The person is still infected. Tertiary syphilis develops from this late latent stage in about 15 to 30 percent of untreated cases. The CDC reports that this progression can take anywhere from 10 to 30 years.
What Are the Three Forms of Tertiary Syphilis?
Tertiary syphilis takes three distinct forms. Each affects different parts of the body and has different symptoms. Some people develop more than one form.
The first form is gummatous syphilis, also called late benign syphilis. Gummata are soft, tumor-like growths that form on the skin, bones, liver, and other organs. They are not cancerous. They are inflammatory lesions caused by the immune system reacting to the bacteria. These growths can destroy the tissue they form on. Gummatous syphilis is the least dangerous form because it responds well to treatment.
The second form is cardiovascular syphilis. This affects the heart and blood vessels. The bacteria damage the aorta, the large artery that carries blood from the heart. This damage can cause the aortic wall to weaken and bulge, a condition called aortic aneurysm. It can also damage the aortic valve, causing it to leak. According to the American Heart Association, cardiovascular syphilis was a leading cause of aortic aneurysms before antibiotics became widely available.
The third and most serious form is neurosyphilis. This affects the brain, spinal cord, and nerves. It can cause dementia, paralysis, loss of coordination, numbness, and vision problems. A specific type called general paresis causes progressive mental decline. Another type called tabes dorsalis damages the spinal cord and causes a staggering gait and loss of sensation in the legs. Neurosyphilis can occur at any stage of syphilis, but it is most common in tertiary disease.
What Are the Symptoms of Tertiary Syphilis?
Symptoms depend on which form of tertiary syphilis a person has. With gummatous syphilis, symptoms include soft, round swellings on the skin or inside the body. These gummata can break open and form ulcers. They can also destroy bone tissue, causing pain and deformity. Symptoms are usually mild and progress slowly.
Cardiovascular syphilis symptoms often do not appear until the damage is severe. Chest pain, shortness of breath, hoarseness, and a cough can occur. Some people feel a pulsating sensation in their chest from an aortic aneurysm. A ruptured aortic aneurysm is a medical emergency and is often fatal.
Neurosyphilis symptoms vary widely. They include headache, stiff neck, personality changes, memory loss, confusion, poor judgment, and depression. Physical symptoms include trouble walking, numbness in the feet and legs, vision loss, hearing loss, and loss of bladder control. A classic sign of tabes dorsalis is a sharp, stabbing pain in the legs that comes and goes. The CDC notes that neurosyphilis can mimic other neurological conditions like Alzheimer’s disease or multiple sclerosis, making diagnosis challenging.
How Is Tertiary Syphilis Diagnosed and Treated?
Diagnosis starts with a blood test. The most common screening tests are the rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) tests. If these are positive, a confirmatory test called the treponemal antibody test is done. For neurosyphilis, a lumbar puncture (spinal tap) is needed to test the cerebrospinal fluid.
Treatment for tertiary syphilis is penicillin G, given as an injection into the muscle. The standard treatment for early syphilis is a single shot. For tertiary syphilis, the CDC recommends three shots given at one-week intervals. For neurosyphilis, the treatment is intravenous penicillin G given every four hours for 10 to 14 days.
For people allergic to penicillin, there are alternatives. Doxycycline and tetracycline are oral antibiotics that can be used, but they are less effective for late-stage disease. Desensitization to penicillin is often recommended so the patient can receive the best treatment. The key point is that treatment stops the infection from progressing. It cannot reverse damage that has already occurred to the heart, brain, or other organs.
What Does Research on Tertiary Syphilis Show?
Research published in Clinical Infectious Diseases has shown that the rate of tertiary syphilis has dropped dramatically since the 1940s. Before penicillin, it was a common cause of dementia and aortic aneurysm. Today, it accounts for less than 2 percent of syphilis cases in the United States. However, the overall rate of syphilis has been rising since 2000, particularly among men who have sex with men. This means more people are at risk of progressing to tertiary stage if their early infections go undetected.
Studies have also clarified how the bacteria cause damage. Treponema pallidum, the bacterium that causes syphilis, triggers a chronic inflammatory response. The immune system attacks the bacteria, but the inflammation also damages the body’s own tissues. This explains why gummatous lesions are full of immune cells and why cardiovascular syphilis involves scarring of the aorta. The damage is not from the bacteria directly but from the body’s prolonged immune reaction.
Research from the World Health Organization indicates that neurosyphilis is more common in people with HIV. HIV weakens the immune system, making it harder to control the syphilis infection. Coinfection with HIV also increases the risk of treatment failure. For this reason, the CDC recommends that everyone diagnosed with syphilis be tested for HIV and vice versa.
| Form of Tertiary Syphilis | Affected Body Parts | Typical Symptoms | Response to Treatment |
|---|---|---|---|
| Gummatous | Skin, bones, liver | Soft growths, ulcers, bone pain | Good, lesions heal |
| Cardiovascular | Aorta, heart valves | Chest pain, shortness of breath, hoarseness | Prevents progression, does not reverse damage |
| Neurosyphilis | Brain, spinal cord, nerves | Dementia, paralysis, numbness, vision loss | Stops infection, neurological damage may be permanent |
What Are Common Misconceptions About Tertiary Syphilis?
A common myth is that tertiary syphilis always causes visible skin sores. In reality, many people have no skin symptoms at all. Cardiovascular syphilis and neurosyphilis can develop silently for years. Another misconception is that a negative blood test in the latent stage means the infection is gone. The blood test can become negative in late latency even though the bacteria are still present. This is called seroreversion and it can delay diagnosis.
Some people believe that tertiary syphilis is always fatal. This is not entirely accurate. Gummatous syphilis rarely causes death. Cardiovascular syphilis can be fatal if an aneurysm ruptures, but it is treatable if caught early. Neurosyphilis can cause severe disability but is not always fatal with proper treatment. The key is that the damage is cumulative and often irreversible.
There is also a belief that syphilis is a disease of the past. This is false. The CDC reported over 200,000 cases of syphilis in the United States in 2022, the highest number since 1950. The rise is driven by a combination of factors including decreased condom use, increased substance use, and gaps in public health funding. Tertiary syphilis may be rare now, but it will not stay rare if early infections continue to rise.
What to Avoid If You Have Syphilis
If you have been diagnosed with syphilis at any stage, there are things you should not do. Do not assume you are cured because symptoms went away. The symptoms of primary and secondary syphilis disappear on their own. The infection does not. You need antibiotic treatment to actually clear the bacteria from your body.
Do not rely on herbal remedies or alternative treatments. There is no clinical evidence that any supplement, diet, or herbal preparation can cure syphilis. The only proven treatment is antibiotics. The World Health Organization states clearly that untreated syphilis can cause severe, permanent damage. Do not delay treatment.
Do not have sex until your doctor confirms the infection is gone. Syphilis is highly contagious during the primary and secondary stages. It can also be transmitted during early latency. After treatment, you need to wait for follow-up blood tests to confirm the infection is cleared. The CDC recommends repeat testing at 6 and 12 months after treatment for late-stage disease.
Frequently Asked Questions
Can tertiary syphilis be cured?
Yes, the infection can be cured with penicillin, but damage to organs cannot be reversed. Treatment stops the infection from getting worse.
How long does it take for tertiary syphilis to develop?
It typically takes 10 to 30 years after the initial infection. Some people never develop it, but about one-third of untreated cases do.
Is tertiary syphilis contagious?
No, tertiary syphilis is not contagious to sexual partners. The bacteria are no longer active in the skin or mucous membranes at this stage.
What is the death rate for tertiary syphilis?
Before antibiotics, about 10 percent of people with tertiary syphilis died from cardiovascular complications. With treatment, death is much less common but still possible.
