Tertiary syphilis

Alternative names
Late syphilis; Syphilis - tertiary

Tertiary syphilis is a late phase of the sexually transmitted disease syphilis, caused by the spirochete Treponema pallidum.

Causes, incidence, and risk factors

Tertiary syphilis can follow the initial infection, primary syphilis, by 3 to 15 years. Secondary syphilis is the stage that precedes tertiary syphilis if primary syphilis is not treated.

In tertiary syphilis, the spirochetes have continued to reproduce for years. Pockets of damage accumulate in various tissues such as the bones, skin, nervous tissue, heart, and arteries. These lesions are called gummas and are very destructive.

Lesions in the central nervous system produce neurological disease called neurosyphilis which can include tabes dorsalis, general paresis, and optic atrophy. Lesions of the heart, heart valves and aorta can lead to aneurysms, valvular heart disease, and aortitis.

Tertiary syphilis is less frequently seen today than in the past because of early detection and adequate treatment. The incidence of tertiary syphilis is approximately 5 per 100,000 individuals annually in the US.

Symptoms of tertiary syphilis depend on which organ systems have been affected. They vary widely and are difficult to diagnose. In individuals with tertiary syphilis the primary and secondary stages of syphilis usually have been long forgotten. Medical findings of aortic aneurysms and neurological problems require astute diagnostic ability to link them to syphilis. Some of the symptomatic problems are listed below.

  • Infiltrative tumors of skin, bones, or liver (gumma)  
  • Cardiovascular syphilis which affects the aorta and causes aneurysms or valve disease  
  • Central nervous system disorders (neurosyphilis)

Signs and tests

  • VDRL or RPR blood tests  
  • Confirmatory blood tests, such as FTA-ABS (fluorescent treponemal antibody test)  
  • Spinal fluid examination in neurosyphilis shows signs of meningitis.

The treatment of syphilis is determined by the length of time the person has been infected. Primary, secondary, and latent syphilis of less than 1 year duration is treated as follows:

  • Benzathine penicillin 2.4 million units injected into a muscle (IM) as a single dose.  
  • Doxycycline 100 mg by mouth twice per day for 2 weeks.  
  • Tetracycline 500 mg by mouth 4 times per day for 2 weeks.  
  • Erythromycin 500 mg by mouth 4 times per day for 2 weeks.  
  • Ceftriaxone 250 mg IM (intramuscular injection) daily for 10 days.

For treatment of syphilis of greater than 1 year duration :

  • Benzathine penicillin 2.4 million units IM weekly for 3 weeks.  
  • Doxycycline 100 mg by mouth twice per day for 30 days.  
  • Tetracycline 500 mg by mouth twice per day for 30 days.

For treatment of neurosyphilis:

  • Aqueous penicillin G 12 to 24 million units injected into a vein (IV) daily for 10 days followed by benzathine penicillin 2.4 million units once a week for 3 weeks.  
  • Procaine penicillin 2.4 million units IM daily given with oral probenecid 500 mg 4 times per day - both for 10 days.

To treat syphilis during pregnancy:

Penicillin is recommended as the only drug of choice. Tetracycline cannot be used because of toxicity to the fetus, and erythromycin may fail to prevent congenital syphilis in the fetus. Penicillin-allergic individuals should be desensitized and then treated with penicillin.

Several hours following treatment of early stages of syphilis, some individuals may undergo a febrile reaction called Jarisch-Herxheimer reaction. This is thought to be caused by the release into the circulation of material from dead or dying spirochetes. Symptoms of this reaction include:

  • Fever  
  • Chills  
  • Headache  
  • Nausea  
  • General feeling of being ill (malaise)  
  • Generalized joint aches (arthralgia)  
  • Generalized muscle aches (myalgia)

These symptoms usually disappear within 24 hours.

Follow-up blood tests must be done at 3, 6, 12, and 24 months to ensure that the infection has been eliminated.

Individuals with primary or secondary syphilis should abstain from sex until they have been treated. Syphilis is extremely contagious in the primary and secondary stages.

Expectations (prognosis)
Late syphilis may be permanently disabling and may lead to death.


  • Cardiovascularsyphilis  
  • Aneurysms  
  • Valvular heart disease  
  • Neurosyphilis       o tabes dorsalis       o general paresis       o optic nerve atrophy or optic neuritis

Calling your health care provider
Untreated syphilis can result in serious health problems. It is imperative that you inform your physician of the possibility of having had syphilis previously, even if it was many years ago.


People who have multiple or unknown sex partners or partners who are involved in any high-risk sexual practices are at risk for acquiring sexually transmitted diseases (STDs). Individuals who recognize that they are at risk have taken the first step toward prevention.

Total abstinence is the only way to completely avoid the possibility of infection with a sexually transmitted disease. Monogamous sex with a healthy partner is lower risk, and protected sex using condoms also dramatically reduces risk. Condoms act as a barrier to the transmission of infectious organisms (pathogens) and should be used in any and all situations that could be considered risky.

Syphilis is a reportable disease. The infection must be reported by health care professionals to public health authorities. Information acquired from reporting helps public health investigators identify, locate, and treat infected sexual contacts, which helps prevent continued spread of disease.

Johns Hopkins patient information

Last revised: December 5, 2012
by Potos A. Aagen, M.D.

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