Malignant syphilis. Syphilis: signs, manifestations of all stages, diagnosis, how to treat. Types of skin manifestations and rashes of syphilis

Secondary period. This period begins from the moment the first generalized rash appears (on average 2.5 months after infection) and lasts in most cases for 2–4 years. The duration of the secondary period is individual and determined by the characteristics of the patient’s immune system. In the secondary period, the undulation of the course of syphilis is most pronounced, that is, the alternation of manifest and latent periods of the disease.

The intensity of humoral immunity at this time is also maximum, which causes the formation of immune complexes, the development of inflammation and the massive death of tissue treponemas. The death of some pathogens under the influence of antibodies is accompanied by a gradual cure of secondary syphilides within 1.5–2 months. The disease enters a latent stage, the duration of which may vary, but on average is 2.5–3 months.

The first relapse occurs approximately 6 months after infection. The immune system again responds to the next proliferation of pathogens by increasing the synthesis of antibodies, which leads to the cure of syphilides and the transition of the disease to a latent stage. The undulating course of syphilis is due to the peculiarities of the relationship between Treponema pallidum and the patient’s immune system.

Tertiary period. This period develops in patients who have not received any or insufficient treatment, usually 2–4 years after infection.

In the later stages of syphilis, cellular immune reactions begin to play a leading role in the pathogenesis of the disease. These processes occur without a sufficiently pronounced humoral background, since the intensity of the humoral response decreases as the number of treponemes in the body decreases.

Malignant course of syphilis. Malignant syphilis in each period has its own characteristics.

In the primary period, ulcerative chancre is observed, prone to necrosis (gangrenization) and peripheral growth (phagedenism), there is no reaction of the lymphatic system, the entire period can be shortened to 3-4 weeks.

In the secondary period, the rash tends to ulcerate, and papulopustular syphilides are observed. The general condition of the patients is disturbed, fever and symptoms of intoxication are expressed. Manifest lesions of the nervous system and internal organs are common. Sometimes there is a continuous recurrence, without latent periods.

Tertiary syphilides in malignant syphilis can appear early: a year after infection (galloping course of the disease). Serological reactions in patients with malignant syphilis are often negative, but can become positive after the start of treatment.

In the classic course of syphilis there are: three clinical periods: primary, secondary and tertiary, which successively replace each other. First clinical sign diseases - chancre, or primary sclerosis - appears after 3-4 weeks. after infection at the site through which treponemes entered the human body. Chancre is most often localized on the genitals, although other localizations are often noted, including oral and anal.

Incubation period

The time from the moment of infection until the appearance of Treponema pallidum of primary sclerosis at the site of introduction is called incubation period. It is sometimes shortened to 8-15 days or extended to 108-190 days. Its shortening is observed with a bipolar location of the chancre. The body is saturated with treponemes more quickly than the two foci, which accelerates the generalization of the infection and the development of immunological changes in the body. An extension of the incubation period occurs if the patient receives antibiotics for intercurrent diseases during the incubation period. The generally accepted duration is 3-4 weeks. Shortening the incubation period to 10-11 days and lengthening it to 60-92 days occurs in no more than 2% of patients. According to V. A. Rakhmanov (1967), the incubation period was less than 3 weeks in 14% of patients, in 86% it was more than 3 weeks, and in 15% it was 41-50 days. Therefore, in accordance with Instructions for the treatment and prevention of syphilis, approved by the Ministry of Health of the Republic of Belarus (1995), patients with acute gonorrhea with unidentified sources of infection, who have a permanent place of residence and work, are subject to a thorough clinical and serological examination and observation (after treatment of gonorrhea) for 6 months, and if it is impossible to establish for them long-term follow-up are subject to preventive antisyphilitic treatment in the amount of one course of treatment with penicillin in a hospital setting.

Primary syphilis

From the moment hard chancre appears, primary period of syphilis(Syphilis primaria, Syphilis I, Lues I), which continues until multiple syphilitic rashes appear on the skin and mucous membranes. This period lasts 6-8 weeks 5-8 days after the onset of chancre, regional lymph nodes begin to enlarge ( specific bubo, or regional scleradenitis), and after 3-4 weeks an increase in all lymph nodes is observed - specific polyadenitis. Recently, the absence of regional scleradenitis has been noted in 4.4-21% of patients. (Fournier did not find it in 0.06% of patients. Ricor wrote: “There is no chancre without a bubo.”) Third symptom primary syphilis - syphilitic lymphangitis(occurs less frequently, currently registered in 20% of men).

In the primary period of syphilis, especially towards its end (before the appearance of secondary fresh syphilis rashes), patients often experience malaise, insomnia, headaches, loss of appetite, increased irritability, bone pain (especially at night), sometimes an increase in temperature to 38-39 °C.

Primary period of syphilis divided by primary seronegative when standard seroreactions are still negative, and primary seropositive, when standard seroreactions become positive, which occurs approximately 3-4 weeks after the onset of primary syphiloma. It is believed that if even one of the reactions (for example, Wasserman, Kahn, Sachs-Vitebsky) is positive 3, 2 or even 1 time, then in this case the patient is diagnosed with primary seropositive syphilis.

Secondary syphilis

Secondary period of syphilis(Syphilis secundaria. Syphilis II, Lues II) occurs 6-8 weeks after the appearance of chancre, or 9-10 weeks after infection, and is characterized clinically mainly by lesions on the skin and mucous membranes in the form roseolous, papular, pustular rashes. In this case, internal organs (liver, kidneys), nervous and skeletal systems are affected. The rashes of the secondary period, having existed for several weeks, disappear spontaneously, leaving no scars, and a latent period of the disease begins. In the absence of treatment, after some time it is observed relapse of the disease(return) - rashes characteristic of the secondary period appear again on the skin and mucous membranes. This stage of syphilis is called secondary relapse(Syphilis II recidiva). After this, a latent period of the disease may begin again. With secondary recurrent syphilis, the rashes become smaller with each subsequent return of the disease, and the rashes themselves are more faded, large, monomorphic, asymmetrical and tend to be grouped (in the form of circles, arcs, ovals, garlands). The secondary period of syphilis lasts on average 3-4 years without treatment.

Tertiary syphilis

If the patient is not treated or is not treated sufficiently, then after 3-4 years (usually later) it may occur. tertiary period of syphilis(Syphilis tertiaria, Syphilis III, Lues III). In this case, the formation of tuberculate and nodular syphilides is characteristic. Morphological elements are formed on the skin, mucous membranes, subcutaneous fat, bones, internal organs and nervous system. When disintegrating, tubercles and gummas can cause destructive changes in the affected organs and tissues. The course of syphilis in this period is characterized undulation, when the phases of active manifestations are replaced by phases of hidden, or latent, manifestations of infection. Tertiary syphilis can last for many years. In the occurrence of tertiary syphilides, trauma (physical, psychological), chronic infection, intoxication (alcoholism), and severe somatic diseases (malaria, tuberculosis, etc.) play an important role.

Relapses of tertiary syphilis are rare and occur after a long latent period. It is believed that over the years the number of Treponema pallidum in organs and tissues gradually decreases. This explains the rarity of relapses and their limited nature, as well as the low infectiousness of patients with tertiary syphilis.

At the same time, experimental studies have established that Treponema pallidum, located in the tertiary elements, completely retains its pathogenicity. Seroreactions in 25-35% of patients are negative.

In some patients (untreated or insufficiently treated), the disease, bypassing the tertiary period or combined with it, leads to damage to internal organs, musculoskeletal system and to severe inflammatory and degenerative changes in the central nervous system (tabes dorsalis, progressive paralysis). They usually develop after a long latent period. Their pathogenesis has not yet been fully studied. Lesions of the nervous system are quite often combined with syphilitic lesions of internal organs (heart, aorta, liver). Much less frequently, progressive paralysis and tabes dorsalis are combined with tertiary syphilides of the skin and mucous membranes.

Atypical forms of syphilis

In addition to the described classical course of syphilis, it is much less common atypical manifestations.

Syphilis without chancre. The development of syphilitic infection without the formation of primary syphiloma occurs when Treponema pallidum penetrates the human body, bypassing the skin and mucous membranes. This can happen with deep cuts, injections, or when the pathogen is introduced directly into the bloodstream (transfusion syphilis). 2-2.5 months after infection, the disease manifests itself with symptoms of the secondary period. They are often preceded by prodromal phenomena (fever, headaches, pain in bones and joints). The further course of the disease is normal.

Malignant syphilis. The peculiarity of the development and course of syphilitic infection in this form is associated in most cases with weakening and exhaustion of the body, with a decrease in its reactivity. Clinically, malignant syphilis is distinguished by its severity and severity. Primary syphiloma in some patients has a tendency to grow peripherally. The primary period is often shortened. During the secondary period, against the background of general severe symptoms and high body temperature, pustular syphilides, mainly ecthyma and rupees, form on the skin. The precipitation of new elements occurs continuously, without latent intervals. In addition to the skin, the process may involve mucous membranes (deep ulcerations), bones, testicles (orchitis) and other organs and tissues. Internal organs and the nervous system are rarely affected, but the pathological process that develops in them is difficult. Changes in the lymph nodes are often absent, and standard seroreactions are negative. Outbreaks of the disease can drag on for many months.

Syphilis latent, unspecified. Syphilis is often diagnosed only on the basis of positive serological reactions in the absence of clinical manifestations and anamnestic data. The sexual partners (spouses) of such patients, despite constant and long-term sexual contacts, most often remain healthy and uninfected. This condition is called latent syphilis, unspecified.

In practice, there are cases when patients with syphilis first detected only in the tertiary period in the absence of indications of it in the past. There are observations when people with a “pure” venereological history, who, due to the nature of their work, undergo constant and long-term medical examinations with serological testing of blood for syphilis, are unexpectedly diagnosed with late forms of the disease during the next examination, including tabes dorsalis and vascular syphilis. Similar observations confirm possibility of an initially asymptomatic course of the disease.

According to M.V. Milich (1972, 1980), after the pathogen enters the body, a period of long asymptomatic syphilis may occur. In this case, after infection, the patient seems to bypass the early active forms of the disease. It is assumed that in these cases, treponemes that entered the body of a sexual partner from a patient with an active form of syphilis, due to some unfavorable conditions, are immediately transformed into L-forms, which determines the absence of a clinic and the negativity of serotests. Under favorable conditions, L-forms are reversed to their original state and cause the development of late forms of syphilis. Such patients are identified by chance during a serosurvey and are diagnosed as sick latent unspecified syphilis. 70-90% of them deny active syphilis in the past. In 71% of patients with late congenital syphilis, previous manifestations of early congenital syphilis were not identified, which indicates the possibility of a long asymptomatic course of infection with congenital syphilis.

M.V. Milich (1972) believes that it is possible three variants of the course of acquired syphilis:

1. usual stage course;
2. long-term asymptomatic;
3. cases of self-healing.

It is necessary to note the ability of Treponema pallidum transmitted during pregnancy from mother to fetus through the placenta.

===================================

Syphilis is caused by a bacterium called Treponema pallidum.

Infection most often occurs through sexual contact, somewhat less often - through blood transfusion or during gestation, when the bacterium falls from mother to child. Bacteria can enter the body through small cuts or abrasions on the skin or mucous membranes. Syphilis is contagious during its primary and secondary stages, and sometimes during the early latent period.

Syphilis is not spread by sharing toilets, bathtubs, clothing or utensils, through door handles and swimming pools.

How is syphilis transmitted?

The main method of transmission of syphilis is sexual. The disease is transmitted through unprotected sexual contact with a carrier of treponema.

The cause of infection can be not only vaginal, but also anal and oral-vaginal contact. The second route of transmission of syphilis - household - has become less common in the modern world.

In theory, you can become infected by sharing personal hygiene items, bedding, and outerwear with a sick person. However, such cases of infection are extremely rare, since the main causative agent of the disease is extremely unstable to environmental conditions.

Signs

1. In the place where the microorganism has penetrated the human body, primary syphiloma appears - the so-called chancre. It looks like a small (up to a centimeter in diameter) painless erosion of an oval or round shape with slightly raised edges.
   It can be found in men on the foreskin or in the area of ​​the head of the penis, in women on the labia majora and minora, in the cervix, as well as near the anus and on the mucous membrane of the rectum, less often on the abdomen, pubis and thighs. There are also non-genital localizations - on the fingers (usually among gynecologists and laboratory assistants), as well as on the lips, tongue, tonsils (a special form is chancre-amygdalitis).
2. A week after syphiloid, the next symptom of the disease appears - regional lymphadenitis. When chancre is localized in the genital area, under unchanged skin in the groin area, painless mobile formations appear, resembling a bean or a hazelnut in size, shape and consistency. These are enlarged lymph nodes. If primary syphiloma is located on the fingers, lymphadenitis will appear in the area of ​​the elbow, if the mucous membranes of the oral cavity are affected - submandibular and chin, less often - cervical and occipital. But if the chancre is located in the rectum or on the cervix, then lymphadenitis goes unnoticed - the lymph nodes located in the pelvic cavity enlarge.
3. The third symptom, typical of primary syphilis, is found more often in men: a painless cord appears on the back and at the root of the penis, sometimes with slight thickenings, painless to the touch. This is what syphilitic lymphadenitis looks like.

Sometimes the appearance of unusual erosion causes anxiety in the patient, he consults a doctor and receives appropriate treatment. Sometimes the primary element goes unnoticed (for example, when localized in the cervix).

But it is not so rare that a painless small ulcer does not become a reason to contact a doctor. They ignore it, and sometimes they smear it with brilliant green or potassium permanganate, and after a month they breathe a sigh of relief - the ulcer disappears.

This means that the stage of primary syphilis has passed and is being replaced by secondary syphilis.

If left untreated, tertiary syphilis develops in 30% of people with secondary syphilis. Tertiary syphilis kills one fourth of those infected. It is extremely important to recognize the signs of syphilis in women and men at least at this stage.

Signs of tertiary syphilis:

• In men, tertiary syphilis is diagnosed through the appearance of tubercles and gummas. The tubercles are quite small in size and quite a lot of them form on the body. Gummas are rare, quite large and located deep in the tissues. Inside these formations there is not such a large number of treponemes, so the risk of infecting another person is much lower than with secondary syphilis.
• In the tertiary form, the first signs of syphilis in women are tubercles and gummas as in men. Both tubercles and gummas eventually turn into ulcers, which will leave scars after healing. These scars have a detrimental effect on the condition of organs and tissues, severely deforming them. Gradually, organ functions are impaired, which can ultimately lead to death. If syphilis infection occurred from a partner through sexual contact, then the rash will primarily be in the genital area (on the vagina, etc.).
• In children, tertiary syphilis affects the skin, internal organs and nervous system with special tubercles - syphilides. Syphilides are formed due to the development of increased sensitivity of the child’s body to treponemes, which are contained in excess in the child’s body.

Tertiary syphilis can last for decades. The patient may suffer from the development of mental insanity, deafness, loss of vision, and paralysis of various internal organs. One of the most important signs of tertiary syphilis is significant changes in the patient’s psyche.

Women who have had syphilis are interested in the question of whether a healthy pregnancy is possible after this disease. However, doctors cannot give a definite answer, since everything will depend on the stage and timeliness of treatment of syphilis. Early detection of syphilis and rapid treatment guarantee the absence of complications in the future. A gynecologist will help determine the safe time to conceive.

When syphilis is detected at the stage of tertiary development (the beginning of damage to internal organs), the doctor will insist on terminating the pregnancy in order to avoid serious consequences for the child. In this case, a favorable outcome is excluded.

After infection with syphilis, it may take some time before the first signs of the disease appear. As a rule, the incubation period lasts from 2 to 6 weeks, depending on the location of the entry gate of the infection, how many pathogens have entered the body, the state of the immune system, concomitant diseases and a host of other factors.

On average, the first signs of syphilis can be noticed after 3-4 weeks, but sometimes this period can last up to 6 months.
.

In the vast majority of cases, the onset of the disease is indicated by the appearance of primary syphilis - chancre. This is a small, painless ulcer of a round or oval shape, with a dense base.

It may be reddish or the color of raw meat, with a smooth bottom and slightly raised edges. The size varies from a few millimeters to 2-3 centimeters.

Most often its diameter is about a millimeter.
.

Syphilis is a sexually transmitted disease that occurs in a similar way in both sexes. The only differences are that primary syphilis is more often diagnosed in men, and the secondary and latent form is more often diagnosed in women.

In men

Before you begin treatment for syphilis, it is worth knowing how syphilis manifests itself. So the most important sign of syphilis in a patient manifests itself in the form of a hard, dense chancre and a significant increase in the size of the lymph nodes.

In men, syphilis most often affects the penis and scrotum - it is on the external genitalia that the disease primarily manifests itself in the form of negative symptoms. In women, the disease most often affects the labia minora, vagina and mucous membranes.

If sexual partners practice oral or anal sex, infection and subsequent damage to the circumference of the anus, oral cavity, mucous membrane of the throat and skin in the chest and neck area occurs.

The course of the disease is long-term, if it is not treated in a timely manner, it is characterized by a wave-like manifestation of negative symptoms, a change in both the active form of the pathology and the latent course.

Primary syphilis begins from the moment when primary syphiloma, chancre, appears at the site of introduction of pale spirochetes. A chancre is a single, round-shaped erosion or ulcer, which has clear, smooth edges and a shiny bluish-red bottom, painless and non-inflamed. The chancre does not increase in size, has scanty serous contents or is covered with a film or crust; a dense, painless infiltrate is felt at its base. Hard chancre does not respond to local antiseptic therapy.

The formation of a painless hard chancre on the labia in women or the glans penis in men is the first sign of syphilis. It has a dense base, smooth edges and a brown-red bottom.

During the incubation period, there are no clinical signs of the disease; the primary signs of syphilis are characterized by chancre, the secondary ones (lasting 3-5 years) are spots on the skin. The tertiary active stage of the disease is the most severe and, if not treated promptly, leads to death. The patient's bone tissue is destroyed, his nose collapses, and his limbs are deformed.

Primary signs

Almost all changes that occur in the body at the primary and secondary stages are reversible, even if they affect internal organs. But if treatment is delayed, the disease can progress to a late stage, at which all its manifestations become a serious problem and can lead to the death of the patient.

Reversible manifestations

These include symptoms of primary syphilis - chancre, as well as part of the secondary - spotty and nodular rashes, baldness, Venus necklace. All these manifestations - regardless of their location - normally disappear after treatment and most often leave no traces. We can even cure meningitis of early neurosyphilis.

Irreversible manifestations

These include purulent manifestations of secondary syphilis, as well as all the symptoms of tertiary syphilis. Purulent lesions vary in size and depth - from small pustules to large ulcers.

When the ulcers go away, they leave scars of the same size. Tubercles and gummas are more dangerous formations. When destroyed, they damage the surrounding tissue, disfigure the patient and can even make him disabled.

What else can or cannot syphilis do in the victim’s body? Let's try to “filter” myths from real facts.

Does syphilis affect hair?

Yes, it amazes, but not always. Hair suffers, as a rule, in the second year of the disease, when repeated rashes develop.

Hair damage manifests itself in several types of baldness. The most typical is “fine-focal” baldness - in the form of small areas (foci) of a round or irregular shape on the occipital or parietal-temporal region.

However, the hair in these areas does not completely fall out, and the overall picture resembles “moth-eaten fur.”
.

The second type of baldness due to syphilis is “diffuse” baldness, that is, uniform damage to the entire scalp. This symptom occurs not only with syphilis, but also with many other diseases (pyoderma of the scalp, systemic lupus erythematosus, seborrhea and others).

Also, there are combined variants of baldness, including diffuse and fine-focal types at the same time.

In addition, rashes on the scalp are often covered with a greasy crust and look very similar to seborrhea.

All hair changes caused by syphilis are temporary and quickly disappear after treatment.

Can eyebrows or eyelashes be affected by syphilis?

Yes they can. Eyebrows and eyelashes, as well as hair on the head, can fall out during the secondary period. Their growth is gradually restored, but it occurs unevenly. As a result, different lengths of hairs form a stepped line. This phenomenon in medicine is called the “Pincus symptom.”

Are teeth affected by syphilis?

- Dental damage is not typical for syphilis, but can occur if a person has had it since birth. The abnormal condition of the teeth in congenital syphilis is manifested by deformation of the front incisors: the chewing edges become thinner and form a semilunar notch. Such teeth are called Hutchinson teeth, and are usually combined with congenital blindness and deafness.

Can acne be a symptom of syphilis?

They can. One of the forms of rashes of the secondary period manifests itself in the form of pustules, which are very reminiscent of ordinary youthful acne. They are called acne pustular syphilides. Such “pimples” are usually located on the forehead, neck, back and shoulders.

They are quite difficult to distinguish from ordinary acne.

You should suspect syphilis if:

• the rashes do not correspond to the age of the owner - i.e. These are not youthful rashes;
• they periodically appear and disappear (relapses of secondary syphilis);
• the patient often exhibits other infectious diseases - pustular syphilides appear, as a rule, in persons with weakened immunity.

Is there discharge from the genital tract with syphilis?

The classic first manifestations of the disease are the appearance of chancre (primary syphiloma) and enlarged lymph nodes.

A chancre is an ulcer or lesion of round or oval shape with clear edges. It is usually red in color (the color of raw meat) and secretes a serous fluid, giving it a “varnished” appearance.

Discharge of chancre during syphilis contains many pathogens of syphilis, and they can be detected there even during a period when a blood test does not show the presence of the pathogen in the body. The base of primary syphiloma is hard, the edges are slightly raised (“saucer-shaped”).

Chancroid usually does not cause pain or any other bothersome symptoms.

Incubation period

Before selecting the correct treatment for syphilis, it is worth knowing at what stage of the disease the disease develops. The disease itself has 4 stages – let’s look at them in more detail. Treatment of the disease is quite possible at each of its stages, with the exception of the last, when all organs and systems are affected and cannot be restored - the only difference is the duration and intensity of the course.

Symptoms of syphilis during its incubation, latent period do not manifest themselves as such - in this case, the disease is diagnosed not by its external manifestations, but based on the results of tests carried out using the PCR technique. The duration of the incubation period is 2-4 weeks, after which the disease passes to the stage of primary syphilis.

Primary stage of syphilis and its symptoms

Every person should know how the disease manifests itself - the sooner it is diagnosed, the sooner treatment for syphilis is started, the better the chances of a successful recovery.

How does syphilis manifest in men? Before describing the signs of the disease, it is worth talking about the incubation period. It lasts about three weeks. But there are also cases when this period increases from approximately a couple of months to three. It may also appear after eight days without showing any special symptoms indicating the severity of the disease.

How long does it take for syphilis to appear in men? When considering the issue, it should be noted that when during the incubation period a person used antibiotics of any kind, the manifestation of symptoms may drag on for a longer period. This also happens when a man has a venereal ulcer.

The incubation period is no less dangerous for others and sexual partners than a pronounced disease.

The course of syphilis is long-term, wave-like, with alternating periods of active and latent manifestations of the disease. In the development of syphilis, periods are distinguished that differ in the set of syphilides - various forms of skin rashes and erosions that appear in response to the introduction of pale spirochetes into the body.

It begins from the moment of infection and lasts on average 3-4 weeks. Pale spirochetes spread through the lymphatic and circulatory tract throughout the body, multiply, but clinical symptoms do not appear.

A person with syphilis is unaware of his illness, although he is already contagious. The incubation period can be shortened (up to several days) and extended (up to several months).

Extension occurs when taking medications that somewhat inactivate the causative agents of syphilis.

On average, it is 4-5 weeks, in some cases the incubation period of syphilis is shorter, sometimes longer (up to 3-4 months). It is usually asymptomatic.

The incubation period may increase if the patient has taken any antibiotics due to other infectious diseases. During the incubation period, test results will show a negative result.

The time between infection and the appearance of the first signs of syphilis depends on the person's immunity and on the method by which the bacteria were transmitted. As a rule, this occurs after a month, but manifestations may appear earlier or later, or be absent altogether.

The very first visible symptom of syphilis is an ulcer, which appears in the place where the syphilitic bacteria have invaded. At the same time, the lymph node located nearby becomes inflamed, and behind it - the lymphatic vessel. For doctors, this stage is distinguished in the primary period.

After 6-7 weeks, the ulcer goes away, but the inflammation spreads to all lymph nodes, and a rash appears. This is how the secondary period begins. It lasts from 2 to 4 years.

Hard chancre on the genitals

During this time, periods with active manifestations of syphilis alternate with a latent course without symptoms. Rashes of various types and forms appear and disappear several times on the patient’s face and body, all lymph nodes become inflamed, and some internal organs are affected. If these manifestations are still ignored and the person does not receive treatment, then syphilis progresses to the final stage - tertiary.

Syphilis can be described as a systemic disease that affects the entire body. Its external manifestations are often similar to those of other diseases, therefore, for an accurate diagnosis, in addition to studying the clinical picture, it is necessary to carry out laboratory tests of the skin to identify the presence of the causative agent of syphilis, and take a blood sample for the Wasserman reaction.

Exactly what signs of syphilis will appear in a particular patient depend on many factors. The state of the immune system, age, lifestyle and other individual characteristics matter.

Syphilis occurs in three clinical periods:

• primary period
• secondary
• and tertiary, which are preceded by a practically asymptomatic period lasting about 3 weeks.

Third stage

Nowadays, every person infected with Treponema pallidum can quickly and efficiently receive adequate and effective treatment. Only a few go through all stages of syphilis. Without treatment, a person lives in terrible agony for 10 or even 20 years, after which he dies. Below is a brief description of the stages of syphilis. Stage of incubation period

Stage name	Temporal boundaries	Description of symptoms
Incubation period	From the moment of infection to 189 days.	During this period, there are objectively no manifestations in the patient’s body. If the infection gets into several places in the body at once, this shortens the incubation period to 1-2 weeks. If an infected person takes antibiotics, for example, for the flu or for a sore throat, then the incubation period can last even six months. The end of this period occurs with the appearance of the first symptom - chancre and inflammation of the lymph nodes. If the pathogen enters directly into the blood, then the stage of primary syphilis does not appear and the disease passes directly to the secondary stage.

Stage of primary syphilis

Congenital syphilis

If infection occurs during fetal development from an infected mother, then they speak of congenital syphilis. This is one of the most dangerous and severe forms, because most cases end in the death of the child before birth or immediately after it. But in some cases, he survives and is born already infected with syphilis.

Symptoms may appear immediately after birth or in infancy (early syphilis) or years later, at the age of 10-15 years. But more often than not, children are born with signs of infection. It is difficult to predict in advance which systems will be affected.

Characteristic signs are low birth weight, sunken bridge of the nose, large head, loose and pale skin, thin limbs, dystrophy, pathologies of the vascular system, as well as a number of characteristic changes in the liver, kidneys, lungs and endocrine glands.

The symptoms of this disease are extremely varied and can affect almost all organ systems.

Neonatal syphilis in pregnancy results in fetal death in 40% of infected pregnant women (stillbirth or death soon after birth), so all pregnant women should be tested for syphilis at their first prenatal visit.

Diagnosis is usually repeated in the third trimester of pregnancy. If infected children are born and survive, they are at risk of serious problems, including developmental delays.

Fortunately, syphilis during pregnancy is treatable.

Syphilis can be transmitted during pregnancy, from an infected mother to her child at 10-16 weeks. Frequent complications are spontaneous abortions and fetal death before birth. Based on time criteria and symptoms, congenital syphilis is divided into early and late.

Early congenital syphilis

Children with obvious underweight, with wrinkled and sagging skin, resemble little old people. Deformation of the skull and its facial part (“Olympic forehead”) is often combined with dropsy of the brain and meningitis.

Keratitis is present - inflammation of the cornea of ​​the eyes, loss of eyelashes and eyebrows is visible. In children aged 1-2 years, a syphilitic rash develops, localized around the genitals, anus, on the face and mucous membranes of the throat, mouth, and nose.

The healing rash forms scars: scars that look like white rays around the mouth are a sign of congenital lues.

Syphilitic pemphigus is a rash of vesicles observed in a newborn several hours or days after birth. It is localized on the palms, skin of the feet, on the folds of the forearms - from the hands to the elbows, on the torso.

Secondary syphilis

This stage develops 2.5-3 months from the moment of infection and lasts from two to four years. It is characterized by wave-like rashes that go away on their own after a month or two, leaving no marks on the skin. The patient is not bothered by itching or fever. Most often, the rash occurs

• roseola - in the form of rounded pink spots;
• papular - pink and then bluish-red nodules, resembling lentils or peas in shape and size;
• pustular - pustules located on a dense base, which can ulcerate and become covered with a dense crust, and when healing often leaves a scar.
  Different elements of the rash, such as papules and pustules, may appear at the same time, but any type of rash contains a large number of spirochetes and is very contagious. The first wave of rashes (secondary fresh syphilis) is usually the brightest, most abundant, accompanied by generalized lymphadenitis. Later rashes (secondary recurrent syphilis) are paler, often asymmetrical, located in the form of arcs, garlands in places exposed to irritation (inguinal folds, mucous membranes of the mouth and genitals).

In addition, with secondary syphilis there may be:

• Hair loss (alopecia). It can be focal - when bald spots the size of a penny coin appear in the temples and back of the head, less often eyelashes and eyebrows, a beard are affected, or it can be diffuse, when hair loss occurs evenly throughout the head.
• Syphilitic leucoderma. Whitish spots up to a centimeter in size, better visible in side lighting, appear most often in the neck area, less often on the back, lower back, stomach and limbs.

Unlike rashes, these manifestations of secondary syphilis do not disappear spontaneously.

Alas, if the striking manifestations of secondary fresh syphilis did not force the patient to seek help (and our people are often ready to treat such “allergies” on their own), then less pronounced relapses go unnoticed even more so. And then, 3-5 years from the moment of infection, the tertiary period of syphilis begins - but this is a topic for another article.

Thus, the pale spirochete does not cause its owner any particular trouble in the form of pain, itching or intoxication, and the rashes, especially those that tend to go away on their own, unfortunately, do not become a reason for everyone to seek medical help.

Meanwhile, such patients are contagious, and the infection can be transmitted not through sexual contact. Shared dishes, bed linen, a towel - and now the primary element is looking at the new infected with bewilderment.

Syphilis today is an extremely important problem for medicine, since this disease has an impact on the social sphere and can lead to the inability to have children, disability, mental disorders and death of patients.

For some time after scarring of the primary chancre, there are no clinical manifestations. After 2-3 months, secondary syphilides appear, this time throughout the body. They are quite abundant, varied in shape and can be located on any part of the body, including the palms and feet.

It is difficult to say exactly what kind of rashes will appear. These can be simply reddish or pink spots (roseola), papules (nodules) or pustules (bubbles with liquid), or pustules.

Rare but characteristic symptoms of secondary syphilis are the necklace and diadem of Venus - a chain of syphilis on the neck or along the scalp.

Sometimes areas of alopecia – hair loss – appear. Most often the scalp is affected, less often - eyelashes, eyebrows, armpits and groin areas.

Clinical manifestations of secondary syphilis are not constant. A few weeks after its appearance, it becomes pale until it disappears completely. This is often perceived as the disappearance of the disease, but this is only temporary relief. How long it will last depends on many factors.

Syphilis typically has a relapsing course. Asymptomatic periods are replaced by obvious manifestations of the disease. The rash appears and disappears. Relapses are characterized by more faded rashes located in areas that are subject to mechanical irritation.

Other clinical signs may also appear - headaches, weakness, slight fever, joint and muscle pain.

It is difficult to say how long the secondary stage of the disease will last. Without treatment, it can last from 2-3 to decades.

At this stage, the patient is most contagious. The discharge from rashes, especially weeping ones, contains a large number of pathogens. It is in this case that there is a possibility of domestic infection of people living in the same house.

Photos of such manifestations of the disease will not evoke positive emotions in anyone. The secondary stage occurs approximately in the eighth week after the first chancre appears and disappears. If nothing is done now, the secondary period can last about five years.

- elevated temperature;

- headache;

- decreased appetite;

- dizziness;

- increased fatigue and malaise;

- presence of a runny nose and cough, which is similar to a cold;

Secondary syphilis begins 2-4 months after infection and can last from 2 to 5 years. Characterized by generalization of infection.

At this stage, all systems and organs of the patient are affected: joints, bones, nervous system, hematopoietic organs, digestion, vision, hearing. The clinical symptom of secondary syphilis is rashes on the skin and mucous membranes, which are widespread (secondary syphilides).

The rash may be accompanied by body aches, headache, fever and may feel like a cold.

The rash appears in paroxysms: after lasting 1.5 - 2 months, it disappears without treatment (secondary latent syphilis), then appears again. The first rash is characterized by abundance and brightness of color (secondary fresh syphilis), subsequent repeated rashes are paler in color, less abundant, but larger in size and prone to merging (secondary recurrent syphilis).

The frequency of relapses and the duration of latent periods of secondary syphilis vary and depend on the body’s immunological reactions in response to the proliferation of pale spirochetes.

Syphilides of the secondary period disappear without scars and have a variety of forms - roseola, papules, pustules.

Syphilitic roseolas are small round spots of pink (pale pink) color that do not rise above the surface of the skin and epithelium of the mucous membranes, which do not peel and do not cause itching; when pressed on, they turn pale and disappear for a short time. Roseola rash with secondary syphilis is observed in 75-80% of patients. The formation of roseola is caused by disturbances in the blood vessels; they are located throughout the body, mainly on the torso and limbs, in the face - most often on the forehead.

The secondary period begins approximately 5-9 weeks after the formation of chancre, and lasts 3-5 years. The main symptoms of syphilis at this stage are skin manifestations (rash), which appears with syphilitic bacteremia; condylomas lata, leukoderma and baldness, nail damage, syphilitic tonsillitis.

Generalized lymphadenitis is present: the nodes are dense, painless, the skin over them is at normal temperature (“cold” syphilitic lymphadenitis). Most patients do not note any special deviations in their health, but a rise in temperature to 37-37.50, a runny nose and a sore throat are possible.

Because of these manifestations, the onset of secondary syphilis can be confused with a common cold, but at this time the syphilis affects all systems of the body.

The main signs of the rash (secondary fresh syphilis):

• The formations are dense, the edges are clear;
• The shape is regular, round;
• Not prone to fusion;
• Does not peel off in the center;
• Located on visible mucous membranes and throughout the entire surface of the body, even on the palms and soles;
• No itching or pain;
• They disappear without treatment and do not leave scars on the skin or mucous membranes.

In dermatology, special names have been adopted for the morphological elements of the rash that can remain unchanged or transform in a certain order. The first on the list is a spot (macula), which can go into the stage of a tubercle (papula), a vesicle (vesicula), which opens with the formation of erosion or turns into an abscess (pustula), and when the process spreads deeper, into an ulcer.

All of the above elements disappear without a trace, unlike erosions (after healing, a spot first forms) and ulcers (the outcome is scarring). Thus, it is possible to find out from trace marks on the skin what the primary morphological element was, or to predict the development and outcome of existing skin manifestations.

For secondary fresh syphilis, the first signs are numerous pinpoint hemorrhages in the skin and mucous membranes; abundant rashes in the form of rounded pink spots (roseolae), symmetrical and bright, randomly located - roseola rash. After 8-10 weeks, the spots turn pale and disappear without treatment, and fresh syphilis turns into secondary latent syphilis, which occurs with exacerbations and remissions.

The acute stage (recurrent syphilis) is characterized by preferential localization of the rash elements on the skin of the extensor surfaces of the arms and legs, in the folds (groin areas, under the mammary glands, between the buttocks) and on the mucous membranes.

There are significantly fewer spots, their color is more faded. The spots are combined with a papular and pustular rash, which is more often observed in weakened patients.

During remission, all skin manifestations disappear. During the relapse period, patients are especially infectious, even through household contacts.

The rash in secondary acute syphilis is polymorphic: it consists of spots, papules and pustules at the same time. The elements are grouped and merged, forming rings, garlands and semi-arcs, which are called lenticular syphilides.

After they disappear, pigmentation remains. At this stage, diagnosing syphilis based on external symptoms is difficult for a layperson, since secondary recurrent syphilides can be similar to almost any skin disease.

Lenticular rash with secondary recurrent syphilis

Pustular (pustular) rash with secondary syphilis

You can find out what syphilis looks like only after the incubation period has passed. The disease has four stages in total, each of which has its own symptoms.

The long incubation period lasts 2-6 weeks, but sometimes the disease may not develop for years, especially if the patient took antibiotics or was treated for infectious colds. At this time, laboratory tests will not give a reliable result.

There are not so many features that depend on a person’s gender. Sex differences may be due to:

• over time of detection;
• with a risk of infection;
• characteristics of the disease itself;
• with complications;
• as well as with different social significance of the disease in each gender.

How long it takes for syphilis to appear depends not on gender, but on the characteristics of a particular person’s body. But the disease is often diagnosed in women later - already in the secondary period, about 3 months or more after infection. This is due to the fact that the appearance of chancre in the vagina or cervix usually goes unnoticed.

It is also believed that women have a higher risk of becoming infected. If there are microdamages on the skin and mucous membranes, then the likelihood of disease transmission increases several times. The most traumatic of all types of sexual contact is anal. Women in anal contacts more often act in a passive role. But it should be taken into account that homosexual men are also at risk. Read more about the routes of transmission and the risks of infection in the special material.

We will consider the features of the course, complications and social significance for each gender separately.

How is syphilis diagnosed?

In the process of diagnosing such a serious disease, you should not diagnose yourself, even if its characteristic symptoms and signs are clearly expressed. The thing is that rash, thickening and enlargement of lymph nodes can also manifest themselves in other diseases as a characteristic sign.

It is for this reason that doctors diagnose the disease itself by visually examining the patient, identifying characteristic symptoms on the body, and by conducting laboratory tests.

In the process of a comprehensive diagnosis of the disease, the patient undergoes:

1. Examination by a dermatologist and venereologist. It is these specialists who examine the patient, his genitals and lymph nodes, skin, collect anamnesis and refer him for laboratory tests.
2. Detection of treponema in internal contents, gum fluid and chancre using PCR, direct reaction to immunofluorescence and dark-field microscopy.

In addition, doctors conduct various tests:

• non-treponemal - in this case, the presence of antibodies against the virus, as well as tissue phospholipids that are destroyed by it, are detected in the blood in the laboratory. This Wasserman reaction, VDRL and others.

• treponemal, when the presence or absence of antibodies to such a pathogen as treponema pallidum is diagnosed in the blood. These are RIF, RPGA, ELISA, immunoblotting level research.

In addition, doctors also prescribe instrumental examination methods to search for gummas - this is research using ultrasound, MRI, CT and x-rays.

Possible consequences

Pathology in both sexes and all ages is associated with serious consequences:

• failure or deformation of internal organs;
• internal hemorrhages;
• irreversible changes in appearance;
• death.

In some cases, syphilis may appear after treatment: due to re-infection or unscrupulous therapy.

The most common consequences of an advanced form of syphilis are:

1. The brain is affected, and this contributes to the progression of paralysis of both the upper and lower extremities. Mental disorders can also be observed. Sometimes dementia progresses and cannot be treated.
2. When the spinal cord is damaged, walking is impaired and orientation in space is lost. The most severe case is when the patient cannot move at all.
3. The circulatory system is affected, primarily large vessels.

The consequences of treated syphilis usually include decreased immunity, problems with the endocrine system, and chromosomal lesions of varying severity. In addition, after treatment of treponema pallidum, a trace reaction remains in the blood, which may not disappear until the end of life.

If syphilis is not detected and treated, it can progress to the tertiary (late) stage, which is the most destructive.

Late stage complications include:

1. Gummas, large ulcers inside the body or on the skin. Some of these gummas “resolve” without leaving traces; in place of the rest, syphilis ulcers are formed, leading to softening and destruction of tissue, including the bones of the skull. It turns out that the person is simply rotting alive.
2. Lesions of the nervous system (latent, acute generalized, subacute (basal) meningitis, syphilitic hydrocephalus, early meningovascular syphilis, meningomyelitis, neuritis, tabes spinal cord, paralysis, etc.);
3. Neurosyphilis, which affects the brain or the membrane covering the brain.

If Treponema infection occurs during pregnancy, the consequences of the infection may appear in a child who receives Treponema pallidum through the mother’s placenta.

Syphilis occurs under the guise of many other diseases - and this is another danger of this infection. At each stage - even late - an insidious venereal disease can pretend to be something else.

Here is a list of diseases most similar to syphilis. But note: it is not complete at all. Differential diagnosis of syphilis (that is, ways to distinguish it from other diseases) is a difficult task. For this purpose, the patient is interviewed in detail, a thorough examination is carried out, and most importantly, laboratory tests are prescribed.

It is impossible to independently make a diagnosis from photographs or descriptions of manifestations. If you have any suspicion, you should contact a venereologist - in our time this can be done anonymously.

	Characteristics of the disease
Chancroid	outwardly similar to its solid “brother”, but is caused by another sexually transmitted pathogen. Quite a rare disease.
Genital herpes	similar to small multiple chancre. But at the same time, itching is almost always observed, which does not occur with syphilitic ulcers.
Lymphogranuloma venereum	similar manifestations to chancroid, but much less common than syphilis
Furuncle	when a secondary infection occurs, the chancre suppurates and may resemble an ordinary boil in appearance
Genital trauma	externally looks like an ulcer and resembles a syphilitic ulcer if located in skin folds	Bartholinitis in women	manifests itself in the form of swelling and redness of the labia. Unlike primary syphilis - painful	Balanoposthitis or phimosis in men	manifestations are similar to ulcers and rashes that appear on the foreskin. This case differs from primary syphilis in its painless course.	Common panaritium	Unlike most manifestations of primary syphilis, chancre-felon is painful and very difficult to distinguish from ordinary felon	Angina	characterized by a unilateral painless course

	Characteristics of the disease
Widespread rash over the entire body	allergic and infectious processes (infectious mononucleosis, measles, rubella, scarlet fever and others)
Psoriasis	widespread scaly plaques throughout the body, an autoimmune hereditary (non-contagious) disease
Lichen planus	very similar to psoriasis, also a non-contagious disease
Condylomas lata	resemble genital warts (viral disease) and hemorrhoids
Pustular syphilitic lesions	resemble common acne or pyoderma	Alopecia or baldness	multifactorial disease, often hereditary (in the latter case, it develops with age, gradually and does not recover on its own)	Angina	manifestation of syphilis with damage to the tonsils (bilateral damage)	Aphthous stomatitis	damage to the oral mucosa with the development of small ulcers may be a manifestation of secondary syphilis	Jams in the corners	have a bacterial, viral or fungal cause of appearance, and are also an element of secondary syphilis	Hoarseness of voice	a classic manifestation of laryngitis, may appear with secondary syphilis when the vocal cords are affected

Treatment of syphilis

Due to damage to the immune system, the disease can damage a woman’s health. Therefore, diagnosis and treatment must be immediate. Depending on the stage of the disease, a treatment regimen is determined.

Stage of syphilis	Treatment regimen
Primary	The patient is prescribed injections of a drug of the penicillin group. Additional means of combating the pathogen are antihistamines. The duration of therapy is determined by the doctor (on average 16 days)
Secondary	The duration of injections increases. In the absence of positive results after Penicillin, Ceftriaxone, Doxycycline are recommended
Tertiary	Tertiary syphilis involves the use of the penicillin group of drugs, in addition to Biyoquinol

Attention! Self-medication for suspected syphilis is strictly prohibited. Taking self-prescribed antibiotics will only muffle the symptoms, but will not have a detrimental effect on the pathogen.

Video - Consequences, complications and prevention of syphilis

Modern treatment with effective drugs allows us to talk about timely cure of the patient, but only if the disease has not progressed to the last stage of its course, when many organs, bones and joints are destroyed and damaged, which cannot be restored.

Treatment of pathology should be carried out exclusively by a qualified venereologist in a medical hospital, based on the results of an examination, a survey of the patient and the results of laboratory and instrumental studies.

So treating syphilis at home, using your own and folk methods and recipes, is unacceptable. It is worth remembering that this disease is not just an acute respiratory viral infection, which can be cured with hot tea with raspberries - it is a very serious infectious period that destroys the body from the inside.

At the first suspicion or symptoms of the disease, immediately consult a doctor, undergo an examination and a prescribed course of treatment.

Treatment for syphilis begins after a reliable diagnosis is made, which is confirmed by laboratory tests. Treatment of syphilis is selected individually, carried out comprehensively, recovery must be determined in a laboratory.

Modern methods of treating syphilis, which venereology has today, allow us to speak of a favorable prognosis for treatment, subject to correct and timely therapy that corresponds to the stage and clinical manifestations of the disease.

But only a venereologist can choose a therapy that is rational and sufficient in terms of volume and time. Self-medication of syphilis is unacceptable.

Untreated syphilis becomes a latent, chronic form, and the patient remains epidemiologically dangerous.

The treatment of syphilis is based on the use of penicillin antibiotics, to which the pale spirochete is highly sensitive. If the patient has allergic reactions to penicillin derivatives, erythromycin, tetracyclines, and cephalosporins are recommended as an alternative.

In cases of late syphilis, iodine and bismuth preparations, immunotherapy, biogenic stimulants, and physiotherapy are additionally prescribed.

It is important to establish sexual contacts of a patient with syphilis, and be sure to carry out preventive treatment of possibly infected sexual partners. At the end of treatment, all previously patients with syphilis remain under dispensary observation with a doctor until the result of a complex of serological reactions is completely negative.

The main method of treating syphilis is antibacterial therapy. At the moment, as before, penicillin antibiotics are used (short and long-acting penicillins or durable penicillin medications).

In the event that this type of treatment is ineffective, or the patient has an individual intolerance to this group of drugs, he is prescribed drugs from the reserve group (macrolides, fluoroquinolones, azithromycins, tetracyclines, streptomycins, etc.).

) It should be noted that at the early stage of syphilis, antibacterial treatment is most effective and leads to complete cure.
.

During the course of treatment, the attending physician can adjust the treatment regimen and, if necessary, prescribe a second course of antibiotic therapy.

An important criterion for a patient’s cure is the performance of control serological tests.

In parallel with antibacterial therapy, the patient is prescribed immunostimulating therapy. Nonspecific treatment is also mandatory (vitamin therapy, injections of biogenic stimulants, pyrotherapy and ultraviolet irradiation).

During treatment, any sexual contact is prohibited, as this can lead to infection of the sexual partner or re-infection of the patient.

Note: if unplanned sexual intercourse occurs without the use of personal protective equipment (or with the integrity of the condom being damaged during sexual intercourse), experts recommend taking a preventive injection, which almost 100% prevents the development of syphilis.

Antibiotics are the mainstay of treatment for syphilis. Treponema pallidum is extremely sensitive to penicillin.

One therapeutic course (2-2.5 months) at the initial stage of the disease is quite enough to completely get rid of the infection. If the patient is intolerant to penicillin, erythromycin, tetracycline, etc. are prescribed. As an additional therapy for syphilis, taking vitamins and immunomodulatory drugs is indicated.

With an advanced form of the disease, the treatment period can last a year or more. After the expected recovery, the patient must undergo a re-examination of the body and undergo some tests to judge the success of the therapy.

It should be recalled that the human body is not capable of developing immunity to syphilis, as, say, to chickenpox, therefore, even after complete recovery, re-infection with this infection is possible.

Treatment of syphilis is carried out taking into account the clinical stages of the disease and the patient's susceptibility to drugs. Seronegative early syphilis is easier to treat; in late versions of the disease, even the most modern therapy is not able to eliminate the consequences of syphilis - scars, organ dysfunction, bone deformities and nervous system disorders.

There are two main methods of treating syphilis: continuous (permanent) and intermittent (course). During the process, control tests of urine and blood are required; the well-being of patients and the functioning of organ systems are monitored. Preference is given to complex therapy, which includes:

• Antibiotics (specific treatment for syphilis);
• General strengthening (immunomodulators, proteolytic enzymes, vitamin-mineral complexes);
• Symptomatic drugs (painkillers, anti-inflammatory, hepatoprotectors).

Prescribe a diet with an increased proportion of complete proteins and a limited amount of fat, and reduce physical activity. Sexual contact, smoking and alcohol are prohibited.

Psychological trauma, stress and insomnia negatively affect the treatment of syphilis.

In women and men, treatment of syphilis should be comprehensive and individual. This is one of the most dangerous sexually transmitted diseases, leading to serious consequences if not treated correctly, so under no circumstances should you self-medicate at home.

The basis of treatment for syphilis is antibiotics, thanks to which the effectiveness of treatment is close to 100%. The patient can be treated on an outpatient basis, under the supervision of a doctor who prescribes comprehensive and individual treatment.

Today, penicillin derivatives in sufficient doses (benzylpenicillin) are used for antisyphilitic therapy. Premature cessation of treatment is unacceptable; it is necessary to complete the full course of treatment.

At the discretion of the attending physician, treatment complementary to antibiotics may be prescribed - immunomodulators, probiotics, vitamins, physiotherapy, etc. During treatment, any sexual intercourse and alcohol are strictly contraindicated for a man or woman.

After completion of treatment, it is necessary to undergo control tests. These may be quantitative non-treponemal blood tests (for example, RW with cardiolipin antigen).

Follow-up

After you are treated for syphilis, your doctor will ask you to:

• periodically take blood tests to ensure that the body responds positively to the usual dosage of penicillin;
• avoid sexual contact until treatment is completed and blood tests show that the infection has been completely cured;
• inform your partners about the disease so that they also undergo diagnosis and, if necessary, treatment;
• be tested for HIV infection.

Diagnostics

When infected with syphilis, the causes always fade into the background. The main thing in such a situation is to correctly diagnose the stage, type and form of the disease.

For the most accurate diagnosis of syphilis, as a rule, an infected person is asked to undergo a series of treponemal or serological tests, on the basis of which the doctor receives a complete picture of the disease and develops an optimal treatment regimen.

How to test for syphilis? When a patient comes in with a suspected infection, the doctor will adhere to a specific plan of action. Initially, the doctor will perform a visual examination of the patient to analyze the external clinical manifestations of syphilis in the body.

To do this, the lymph nodes are palpated, the oral cavity, mucous membranes of the genital organs, hair and nasopharynx are examined. If no symptoms are detected, as syphilis manifests itself on the skin and mucous membranes, the examination is completed and the patient is sent to the laboratory for testing.

Tests are of the treponemal and non-treponemal type, depending on the stage of the disease and how long it takes for syphilis to appear after infection. Treponemal tests are less effective at the secondary and tertiary stages of the disease, since they are based primarily on the detection of spirochete bacteria in the blood.

Non-treponemal tests reveal the presence in the body of an infected person of antibodies that react to the spirochete that spreads the infection and are released in pathologically large quantities.

Treponema pallidum bacteria can also be identified and detected by microbiological testing based on a smear from the chancre of an infected person. As a rule, ulcerative lesions on the skin contain a large number of harmful microorganisms, which are easy to see with a certain method of staining and examination on a darkened glass.

Note that analyzes of the primary manifestations of syphilis are carried out on the basis of smears taken directly from the surface of the ulcers. It is the ulcers that contain a large number of dangerous bacteria, which are then easily identified under a microscope.

Diagnostic measures for syphilis include a thorough examination of the patient, taking an anamnesis and conducting clinical studies:

1. Detection and identification of the causative agent of syphilis by microscopy of serous discharge from skin rashes. But in the absence of signs on the skin and mucous membranes and in the presence of a “dry” rash, the use of this method is impossible.
2. Serological tests (nonspecific, specific) are performed with serum, blood plasma and cerebrospinal fluid - the most reliable method for diagnosing syphilis.

The diagnosis of syphilis will directly depend on the stage at which it is. It will be based on the patient’s symptoms and the tests obtained.

In the case of the primary stage, hard chancre and lymph nodes are subject to examination. At the next stage, the affected areas of the skin and papules of the mucous membranes are examined.

In general, bacteriological, immunological, serological and other research methods are used to diagnose infection. It should be taken into account that at certain stages of the disease, test results for syphilis may be negative in the presence of the disease, which makes it difficult to diagnose the infection.

To confirm the diagnosis, a specific Wasserman reaction is performed, but it often gives false test results. Therefore, to diagnose syphilis, it is necessary to simultaneously use several types of tests - RIF, ELISA, RIBT, RPGA, microscopy method, PCR analysis.

The doctor knows how to recognize syphilis at different active and chronic stages. If you suspect a disease, you should contact a dermatovenerologist.

During the first examination, chancre and lymph nodes are examined; during the second examination, affected areas of the skin and papules of the mucous membranes are examined. To diagnose syphilis, bacteriological, immunological, positive serological and other tests are used.

To confirm, a specific Wasserman reaction is carried out, revealing a 100% result of infection. False-positive reactions to syphilides cannot be ruled out.

Possible complications

The course of syphilis is characterized by a destructive nature, since it affects many internal organs and systems. In addition, in the absence of timely treatment, syphilis can lead to the most dangerous complications - death. If a woman becomes infected with treponema pallidum, but refuses treatment or the incubation period is prolonged for one reason or another, then the following complications are highly likely:

• the development of neurosyphilis (brain damage) leads to destruction of the nervous system and complete (sometimes partial) loss of vision;
• the advanced stage of the disease leads to damage to joints and bones;
• with neurosyphilis, the development of meningitis;
• paralysis;
• infection of the fetus during pregnancy.

Carefully! If Treponema pallidum is not blocked in a timely manner, then tertiary syphilis can lead to irreversible processes (ulcerative formations on internal organs) and, ultimately, death.

Pregnant mothers and newborns

Mothers infected with syphilis are at risk of miscarriage and premature birth. There is also a risk that a mother with syphilis will pass the disease to her fetus. This type of disease is known as congenital syphilis (discussed above).

If a child has congenital syphilis and it is not detected, the child may develop late stage syphilis. This can lead to problems with:

• skeleton;
• teeth;
• eyes;
• ears;
• brain.

Neurological problems

Syphilis can cause a number of problems with your nervous system, including:

• stroke ;
• meningitis;
• hearing loss;
• loss of pain and temperature sensations;
• sexual dysfunction in men (impotence);
• urinary incontinence in women and in men;
• sudden, lightning pain.

Cardiovascular problems

These may include an aneurysm and inflammation of the aorta - your body's main artery - and other blood vessels. Syphilis can also damage the heart valves.

HIV infection

Prevention of syphilis

To date, doctors and scientists have not yet invented special vaccines that are effective in preventing syphilis. If the patient has previously had this sexually transmitted infection, he can become infected and get it again. As a result, only preventive measures will help avoid infection and thereby prevent damage to the internal organs and systems of the body.

First of all, it is worth excluding promiscuous sexual relations with an untested partner, especially without a condom. If you have had such sex, immediately treat your genitals with an antiseptic and visit a doctor for a preventive examination and examination.

Having syphilis once does not mean that a person is protected from it. Once it is cured, you can change it again.

It is enough to understand that not every person knows that he is currently a carrier of the infection and, if the patient has a regular sex life, doctors recommend regular examinations by highly specialized doctors, tests for STDs, thereby identifying the disease in its early stages currents.

After treatment, patients are required to undergo clinical observation (for each form of syphilis there is a corresponding period determined by the instructions). Such methods provide clear control over the successful implementation of antisyphilitic therapy.

Without fail, all sexual and household contacts of the patient must be identified, examined and sanitized in order to prevent the possibility of the spread of infection among the population.
.

During the entire period of clinical observation, patients who have had syphilis are required to abstain from sexual intercourse, and they are also prohibited from being blood donors.

Public prevention measures are considered to be:

• Annual medical examination of the population (over 14 years of age) including blood donation for breast cancer.
• Regular screening for syphilis of persons at risk (drug addicts, homosexuals and prostitutes).
• Examination of pregnant women to prevent congenital syphilis.

Pregnant women who have previously had syphilis and have already been removed from the register are prescribed additional preventive treatment.

Post Views: 1,143

Definition. Syphilis (Syphilis, Lues)- a general infectious disease caused by Treponema pallidum and affecting all human organs and tissues, among which the most common are the skin and mucous membranes.

29.1. HISTORY OF STUDYING SYPHILIS

The word "syphilis" first appeared in the poem of the outstanding Italian scientist, doctor, philosopher and poet from Verona, Girolamo Fracastoro (Girolamo Fracastoro)"Syphilis, or the French disease" (Syphilis sive morbo Gillico), published in Venice in 1530. After the hero of the poem, the shepherd Syphilus, punished by the gods with a disease of the genital organs for his friendship with a pig (Sys- pig, Philos- loving), the disease was given the name “syphilis”. According to another version, it comes from the name of Niobe’s son Syphilus, mentioned by Ovid.

The first official mention of syphilis is considered to be the work of the Spanish doctor and poet Gisper. The causes of the syphilis epidemic that swept through the late 15th century. and the beginning of the 16th century. many European countries are not well understood. Some authors (the so-called Americanists) believe that syphilis appeared in Europe only after the discovery of America, while others (Europeanists) believe that this disease has existed in Europe since ancient times.

According to adherents of the version of the “American” origin of syphilis, at the time of the syphilis epidemic in Europe, doctors did not know this disease. They consider one of the main pieces of evidence to be the description by the Spanish physician Dias de Isla (1537) of an epidemic of a “new disease” in Barcelona; he indicated that he treated people from the crew of Christopher Columbus. The infection of the sailors allegedly occurred from local residents of the island of Haiti, and the latter became infected from llamas while engaging in bestiality (spirochetosis in llamas has been known and proven for a long time). In the port cities of Spain, after the return of Columbus's expedition, cases of syphilis began to be recorded for the first time. The infection then spread throughout Europe, facilitated by the mercenary troops (landsknechts) of the French king Charles VIII, who, after his troops entered Rome, besieged Naples. According to contemporaries, in Rome, where there were up to 14,000 Spanish prostitutes, the Landsknechts indulged in “unlimited debauchery.” Because of the "terrible

disease" that struck the army, the king was forced to lift the siege of Naples and release the soldiers; with the latter, the infection spread throughout many European countries, which caused an epidemic, and according to some sources, a pandemic of syphilis. Thus, according to this theory, the birthplace of syphilis is America (the island Haiti).

According to defenders of the version of the existence of syphilis among the peoples of Europe since ancient times, abscesses and ulcers in the mouth and larynx, alopecia, inflammation of the eyes, condylomas in the genital area, described by Hippocrates, can be recognized as a manifestation of syphilis. The causal connection between lesions of the nose and diseases of the genital organs is mentioned in the treatises of Dioscarides, Galen, Paul of Aegina, Celsus and others. Plutarch and Archigenes observed bone lesions reminiscent of those in syphilis. Aretaeus and Avicenna provide descriptions of ulcers of the soft palate and tongue, some lesions similar to primary syphiloma, condylomas lata and pustular syphilides.

By the beginning of the 16th century. syphilis became known throughout almost the entire European continent. Its spread was facilitated by the social changes of the era of nascent capitalism: the growth of cities, the development of trade relations, long wars, and mass movements of the population. Syphilis quickly spread along sea trade routes and beyond Europe. During this period the disease was particularly severe. Fracastoro pointed out destructive changes in the skin, mucous membranes, bones, pronounced in patients, exhaustion, phagedenic multiple and deep long-term non-healing ulcers, tumors of the face and extremities, and a depressed state. “This serious disease affects and destroys meat, breaks and rots bones, tears and destroys nerves” (Díaz Isla).

Syphilis spread throughout Europe, as mentioned above, along with wars, accompanying armies like a terrible shadow. Therefore, in the name of this disease, the people invested their negative attitude towards the peoples of the neighboring country, where, as it was believed, this disease came from. Thus, syphilis was called a disease of Spanish and French, Italian and Portuguese, German and Turkish, Polish, even a disease from China, a disease from the Liu Kiu Islands, as well as the disease of St. Job, St. Maine, Moebius, etc. Only the name “syphilis” “did not affect national pride and saints and remained in practice to this day.

The most modern point of view on the origin of syphilis is represented by the so-called “Africanists”. According to their theory, the causative agents of tropical treponematoses and the causative agent of venereal syphilis are variants of the same treponema. Initially, treponematosis arose as yaws (tropical syphilis) among primitive people living in Central Africa. The further evolution of treponematoses is closely related to the evolution of human society. When the first human settlements emerged in areas with a dry and cooler climate, treponematosis occurred in the form of bejel, and with the advent of cities, when the possibility of direct transmission of the pathogen through household means was limited, treponematosis was transformed into venereal syphilis.

Thus, at present there is no single point of view on the origin of syphilis. In this regard, the opinion of M.V. Milich is interesting, who believes that syphilis appeared on Earth almost simultaneously with humans, and various theories of its origin only force one to pay attention to the historical information available on this issue.

29.2. ETIOLOGY

The causative agent of syphilis is Treponema pallidum (Treponema pallidum belongs to the order Spirochaetales)- a weakly staining spiral-shaped microorganism with 8-14 regular curls, identical in shape and size, which are preserved during any movements of Treponema pallidum and even when it gets between any dense particles (erythrocytes, dust particles, etc.). There are four types of movement of Treponema pallidum:

1) translational (forward and backward);

2) rotational;

3) flexion, including rocking, pendulum-shaped and whip-shaped (under the influence of the first injections of penicillin);

4) contractile (wavy, convulsive). Occasionally corkscrew-shaped (helix-shaped)

the movement is caused by a combination of the first three.

Treponema pallidum reproduces by transverse division into two or more parts. Under unfavorable conditions (exposure to antibodies, antibiotics, etc.), L-forms and cysts are formed, and the latter can again form spiral forms under appropriate conditions.

Treponema pallidum is not very resistant to various external influences. The optimal temperature for them is 37 °C. At 40-42 °C they die within 3-6 hours, and at 55 °C - in 15 minutes. Outside the human body, in biological substrates, treponemes remain viable for a short time (until they dry out). Antiseptic agents quickly cause its death.

29.3. CONDITIONS AND ROUTES OF INFECTION

Infection with syphilis occurs through contact - often direct, less often indirect. Direct contact is usually manifested by sexual intercourse, sometimes by kissing. Doctors should remember the possibility of occupational infection through direct contact with a patient during his examination and treatment procedures.

Indirect contact occurs through various objects contaminated with infectious material (spoons, mugs, cigarette butts, medical instruments used mainly in gynecological and dental practice).

All manifestations of syphilis on the skin and mucous membranes are called syphilides. Syphilides that are completely or partially devoid of epithelium are contagious to a healthy person. In these cases, treponema pallidum appears on the surface of the skin or mucous membrane. Under certain conditions, milk from a nursing mother, semen, discharge from the cervical canal of the uterus, and blood, including menstrual blood, can be infectious. Sometimes treponema pallidum is found in patients with syphilis in the elements of the skin rash of certain dermatoses, for example, in the contents of herpes blisters and dermatitis blisters.

The stratum corneum is impermeable to treponema pallidum, therefore infection with syphilis through the skin occurs only when its integrity is violated, which may be invisible to the eye, microscopic.

29.4. GENERAL PATHOLOGY

Treponema pallidum, penetrating the skin or mucous membrane, spreads quite quickly beyond the site of inoculation. In the experiment, they are found in lymph nodes, blood, brain tissue after a few hours and even

minutes after infection. In humans, personal prophylaxis carried out with local treponemocidal agents is justified only within 2-6 hours. The spread of pale treponema in the body occurs through the lymphatic and blood vessels, however, being facultative anaerobes, they reproduce only in the lymph, which contains 200 times less oxygen than arterial blood, and 100 times less than venous blood.

The course of syphilis is long. It distinguishes several periods: incubation, primary, secondary and tertiary.

Incubation period - this is the period from the moment of infection until the appearance of the first symptoms of the disease. Its duration for syphilis is approximately a month. In old age and in weakened patients it lasts longer, when a large number of Treponema pallidums are introduced into several “gates of infection” it is shorter. A significant extension of the incubation period (up to 6 months) occurs as a result of the use of antibiotics acting on Treponema pallidum for any concomitant diseases in doses insufficient to eliminate them. A similar prolongation of incubation is observed in the case of antibiotic intake by the source of infection. In rare cases, the incubation period is shortened to 10 days.

During the incubation period, Treponema pallidum, multiplying in the lymphatic tissue, penetrates the blood, so direct transfusion of such blood can cause the development of syphilis in the recipient. In citrated blood, Treponema pallidums die within five days of preservation.

It should be noted that already in the first days after infection, treponema pallidum can be found in the perineural lymphatic spaces, which is why they are likely to move along the nerve fibers with subsequent early penetration into the central nervous system.

Thus, by the end of the incubation period the infection is generally widespread.

Primary period Syphilis begins with the appearance of a kind of erosion or ulcer at the site of inoculation of pale treponema, which is called primary syphiloma, or chancre. The second symptom characteristic of the primary period is regional lymphadenitis (accompanying bubo), which forms within 5-7 (up to 10) days after formation.

calling chancre. The duration of the primary period is approximately 7 weeks. Its first half is characterized by negative results of the Wasserman reaction and is called primary seronegative syphilis. After 3-4 weeks, the reaction becomes positive, and syphilis becomes seropositive. At the same time, polyadenitis develops - an increase in all peripheral lymph nodes. The most common lesions are the posterior cervical and cubital ganglia; Damage to the peripapillary nodes is almost pathognomonic, but it is rare.

1-2 weeks before the end of the primary period, the number of pale treponema multiplying in the lymph reaches a maximum, and they penetrate in masses through the thoracic lymphatic duct into the subclavian vein, causing septicemia. In some patients, septicemia is accompanied by fever, headache, aching bones and joints. These phenomena are regarded as prodromal, i.e., preceding the full clinical picture of the disease. The syphilitic prodrome is characterized by a discrepancy between the temperature and the general condition of the patients: at high temperatures they feel quite satisfactory. Dissemination of Treponema pallidum in large quantities throughout the body leads to the appearance of widespread rashes on the skin and mucous membranes, as well as damage to internal organs (liver, kidneys), nervous system, bones and joints. These symptoms mark the beginning of the secondary period of syphilis.

It should be emphasized that the primary period ends not with the resolution of chancre, but when secondary syphilides arise. Therefore, in some patients, the healing of hard chancre, in particular ulcerative chancre, is completed already in the secondary period, while in others, erosive chancre manages to resolve even in the middle of the primary period: 3-4 weeks after its appearance.

In some cases, manifestations of primary syphilis may be absent, and 10-11 weeks after infection, secondary syphilis immediately develops. This is due to the entry of pale treponema directly into the blood, bypassing the skin or mucous membrane - during blood transfusion, as a result of a cut or injection. This type of syphilis is called decapitated syphilis.

Secondary period Syphilis manifests itself as macular, papular and pustular syphilides. Its duration is currently 3-5 years. Secondary period

There is an alternation of active clinical manifestations (fresh and recurrent syphilis) with periods of latent (latent) syphilis. Initial rashes associated with generalized dissemination of Treponema pallidum are widespread and correspond to secondary fresh syphilis. Its duration is 4-6 weeks. Subsequent outbreaks of the disease, developing at an unspecified time and accompanied by limited skin lesions, characterize secondary recurrent syphilis. Secondary latent syphilis is detected only with the help of specific serological reactions.

The reason for the development of relapses is the dissemination of Treponema pallidum from the lymph nodes, in which they persist and multiply during the latent period of syphilis. The appearance of syphilides in certain areas of the integumentary epithelium is facilitated by various exogenous factors that injure the skin (sunburn, tattoo, cupping) or mucous membranes (caries teeth, smoking). Most often, the skin of the genitals and anal area that is exposed to friction suffers.

Often, the differential diagnosis of fresh and recurrent syphilis is very difficult. This is due to two circumstances. In cases where a patient with fresh secondary syphilis has a widespread rash, consisting, for example, of roseolas on the trunk and papules in the anal area, the former will resolve earlier than the latter, and at the time of examination the skin lesions may be limited (in the anus), i.e., characteristic of recurrent syphilis. The second circumstance is that fresh syphilis now sometimes manifests itself very sparingly and thereby simulates relapse.

In the secondary period, there are also lesions of internal organs, mainly the liver, kidneys, musculoskeletal system (periostitis, arthritis) and the nervous system (meningitis).

Tertiary period develops in approximately 50% of patients with syphilis and is characterized by the formation of gummas and tubercles. Typically, tertiary syphilis was observed on average 15 years after infection. However, according to modern data, most often it develops in the 3-5th year of illness. Sometimes it can appear during the first year after several relapses of the secondary period, following each other ("galloping syphilis"). The infectiousness of tertiary syphilides is low.

The tertiary period is characterized by more severe damage to internal organs (cardiovascular system, liver, etc.), nervous system, bones and joints. Various injuries play a provoking role in the development of bone gummas and arthropathy. Tertiary syphilis is characterized, as is secondary, by alternating clinical relapses (active tertiary syphilis) with remissions (latent tertiary syphilis). The cause of the development of tertiary syphilides is, apparently, not the hematogenous dissemination of Treponema pallidum, but their local activation. This position is supported, firstly, by the fact that blood in the tertiary period is contagious in extremely rare cases, and, secondly, by the tendency of tubercular syphilide to grow along the periphery.

Hidden syphilis. Often, the diagnosis of syphilis is first established only by accidentally detected positive serological reactions. If it is not possible to find out the nature of the previous clinical picture, then resolving the question of which period this latent syphilis belongs to faces great difficulties. This may be the primary period (the chancre and accompanying bubo have already resolved, but secondary syphilides have not yet appeared), the latent period that replaced secondary fresh or recurrent syphilis, the latent period of tertiary syphilis.

Since the periodization of latent syphilis is not always possible, it is divided into early, late and undifferentiated (unspecified). Early latent syphilis refers to the primary period and the beginning of the secondary (with a duration of infection of up to 2 years), late - to the end of the secondary period and tertiary.

The diagnosis of early latent syphilis is established according to the following criteria: the presence of active manifestations of syphilis in the partner, a high titer of reagins in the Wassermann reaction, anamnestic data on self-medication or treatment of gonorrhea, relatively rapid negativity of serological reactions after treatment for syphilis.

Features of the course of syphilis. The first feature is the natural alternation of active and latent manifestations of syphilis, the second is the change in its clinical picture with changing periods. These features are due to the development in the body of a patient with syphilis of specific immune reactions - immunity and allergies. Alternation of active and latent periods of syphilis, characterizing the first

The peculiarity of its course is determined by the state of immunity. Immunity for syphilis is infectious, non-sterile in nature: it exists only in the presence of infection in the body, its intensity depends on the number of pale treponemas, and after their elimination, immunity disappears. The development of infectious immunity in syphilis begins on the 8-14th day after the formation of chancre. With the proliferation of Treponema pallidum, which leads to the appearance of secondary syphilides, the tension of the immune system increases and eventually reaches its maximum, ensuring their death. Syphilides resolve and a latent period begins. At the same time, the tension of the immune system decreases, as a result of which treponema pallidum, remaining in a latent period at the site of former syphilides and in the lymph nodes, becomes active, multiplies and causes the development of relapse. The tension of the immune system increases again, and the entire cycle of syphilis is repeated. Over time, the number of pale treponemes in the body decreases, so the waves of immunity increase gradually become smaller, i.e., the intensity of the humoral response decreases.

Thus, the leading role in the pathogenesis of syphilis as it develops is played by cellular immune reactions.

Along with the described staged course of syphilis, a long asymptomatic course is sometimes observed, ending after many years with the development of syphilis of the internal organs or nervous system. In some cases, such syphilis is diagnosed accidentally in the late latent period (“unknown syphilis”). The possibility of a long asymptomatic course of this disease is apparently due to the treponemostatic (suppressing the vital activity of treponemes) properties of normal immobilisins contained in the blood serum of a number of healthy people. It should be borne in mind that the immobilisins in the serum of patients with syphilis differ from normal immobilisins. The first are specific immune antibodies, the second are normal serum globulin proteins.

The reason for the transformation of the clinical picture of syphilis when changing its periods (the second feature of the course of syphilis) was previously considered to be changes in the biological properties of pale treponemas. However, it was subsequently proven that inoculation of pale treponema, taken from chancre, into the skin of a patient with secondary syphilis causes the development of papules, and the inoculum

tion into the skin of a patient with tertiary syphilis - the development of a tubercle. On the other hand, the result of infection of a healthy person from a patient with secondary or tertiary syphilis is the formation of hard chancre. Thus, the nature of the clinical picture of syphilis in a given period depends not on the properties of Treponema pallidum, but on the reactivity of the patient’s body. Its specific manifestation is an allergic reaction (delayed hypersensitivity), which gradually but steadily intensifies.

Initially, the body reacts to the introduction of pale treponemes by forming a perivascular infiltrate, consisting mainly of lymphocytes and plasma cells. As the allergy increases, the cellular reaction to Treponema pallidum changes and, as a result, the clinical picture of syphilis changes.

Secondary syphilides are characterized by an infiltrate consisting of lymphocytes, plasma cells and histiocytes. In the tertiary period, when sensitization to Treponema pallidum reaches its greatest severity, a typical infectious granuloma develops (necrosis in the center of the infiltrate consisting of lymphocytes, plasma, epithelioid and giant cells), the clinical manifestations of which are tubercle and gumma.

In cases where immune reactions are suppressed (in people severely weakened by hunger, exhausted by chronic diseases), so-called malignant syphilis can develop. It is characterized by destructive ulcerative-cortical syphilides (rupees, ecthyma); repeated rashes of papulopus-tulous, ulcerative-cortical and other secondary syphilides over many months without latent intervals (hence one of the synonyms of malignant syphilis - galloping syphilis); prolonged fever, weight loss (pernicious syphilis). There may be a shortening of the primary period, absence or weak reaction of the lymph nodes.

Reinfection and superinfection in syphilis. Reinfection and superinfection mean re-infection. The difference between them is that reinfection develops as a result of re-infection of a previously ill person with syphilis, and superinfection develops as a result of re-infection of a patient with syphilis. Reinfection is possible due to the disappearance of immunity after syphilis is cured.

Superinfection develops extremely rarely, since it is prevented by the infectious immunity of the patient. It is possible only in the incubation period and in the first two weeks of the primary period, when the tension of immunity is still insignificant; in the tertiary period and with late congenital syphilis, since there are so few foci of infection that they are not able to maintain immunity, and, finally, when immunity is disrupted as a result of insufficient treatment, which leads to suppression of the antigenic properties of Treponema pallidum, as well as as a result of poor nutrition, alcoholism and other debilitating chronic diseases.

Reinfection and superinfection must be differentiated from relapse of syphilis. Evidence of re-infection is, firstly, the identification of a new source of infection and, secondly, the classical course of a new generation of syphilis, starting with the formation after an appropriate incubation period of a hard chancre (in a different place, unlike the first one) and regional lymphadenitis, and in case of reinfection - and positivity of previously negative serological reactions with an increase in reagin titer. To prove reinfection, additional data is also required indicating that the first diagnosis of syphilis was reliable, the patient received full treatment, and serological reactions in the blood and cerebrospinal fluid were completely negative.

In some cases, reinfection can be established based on a smaller number of criteria, not only in the primary, but also in the secondary, including latent, period, but this should be approached very carefully.

29.5. CLASSIFICATION OF SYPHILIS

There are congenital syphilis, early syphilis, late syphilis, as well as other and unspecified forms.

Since this classification is intended mainly for processing and analyzing statistical indicators, let us consider the clinical picture of syphilis according to traditional ideas about its course.

29.6. CLINICAL PICTURE OF THE PRIMARY PERIOD OF SYPHILIS

Chancroid is characterized by: painlessness, a smooth, even bottom of the ulcer the color of raw meat or spoiled lard, the absence of inflammatory phenomena, the presence of a compaction at the base in the form of a plate or a nodule of cartilaginous density. Hard chancre usually has a diameter of 10-20 mm, but there are so-called dwarf chancres - 2-5 mm and giant chancre - 40-50 mm (see color incl., Fig. 37). Giant chancres are usually localized on the pubis, abdomen, scrotum, inner thighs, and chin. Some features of chancres are noted depending on the location: on the frenulum of the penis they take on an elongated shape and bleed easily during erection; on the sides of the frenulum they are poorly visible and have practically no compaction; The chancre of the urethral opening is always hard and bleeds easily; When the chancre is localized in the urethra, mild pain is noted, especially upon palpation. In women, the chancres in the area of ​​the opening of the urethra are always dense, while in the chancres of the vulvo-vaginal fold the compaction is not pronounced (see color incl., Fig. 38).

In rare cases, chancre-amygdalitis occurs, characterized by thickening and enlargement of the palatine tonsil without the formation of erosion or ulcers and accompanied by pain and difficulty swallowing. Chancres of the gums, hard and soft palate, and pharynx are extremely rare. Of the extragenital chancres, chancres of the hands deserve attention; they are observed more often in men, mainly on the right hand. A chancre-felon is isolated (see color incl., Fig. 39), the finger appears bluish-red, swollen, club-shaped, swollen, patients experience sharp, “shooting” pains, on the dorsal surface of the phalanx there is an ulcer with a bottom covered necrotic-purulent discharge. Chancres around the anus look like cracks. Chancres of the rectum are manifested by pain in the rectum shortly before defecation and some time after it, as well as the glassy nature of the stool.

Special varieties of chancre also include:

1) “burn” (combustiform), which is an erosion prone to pronounced peripheral growth with

weak compaction at the base; as erosion grows, its boundaries lose their correct outlines, the bottom becomes red and granular;

2) Vollmann's balanitis - a rare type of primary syphiloma, characterized by many small, partially merging, sharply demarcated erosions without noticeable compaction at the base of the glans penis or on the outer labia;

3) herpetiform chancre, reminiscent of genital herpes.

Regional scleradenitis, as Ricor puts it, “is a faithful companion of chancre, accompanies it invariably and follows it like a shadow.” Scleradenitis develops on the 5-7th day after the appearance of chancroid and is characterized by the absence of pain and inflammation, woody density. Usually a group of lymph nodes enlarges at once, but one of them stands out as larger.

Hard chancroid of the genital organs is accompanied by inguinal lymphadenitis (at present, inguinal lymphadenitis does not occur in all patients), however, when the chancre is localized on the cervix (as well as in the rectum), the pelvic lymph nodes react, therefore the accompanying bubo cannot be determined in these cases by conventional research methods succeeds.

Complicated hard chancre is sometimes observed (in patients suffering from alcoholism, tuberculosis, malaria, hypovitaminosis C and other diseases that weaken the body). Due to the addition of streptococcal, staphylococcal, diphtheroid or other infections, hyperemia and swelling of the skin surrounding the chancre develop, the discharge becomes purulent, and pain appears. On the genitals of men, this manifests itself in the form of balanitis and balanoposthitis (inflammation of the glans and foreskin of the penis). In case of swelling of the foreskin, phimosis may develop (see color incl., Fig. 40), and the head of the penis cannot be exposed. With swelling of the foreskin located behind the exposed head, paraphimosis sometimes occurs (see color incl., Fig. 41). Its outcome may be gangrene of the head. The most severe complication, which develops mainly when a fusospirile infection is associated, is gangrenization of chancre, manifested by the formation of a dirty gray or black scab on its surface and is usually accompanied by fever, chills, headache, general

weakness (gangrenous chancroid). When the scab is rejected, a large ulcer forms. In some cases, there is a long-term progressive course of the gangrenous process with its spread beyond the chancre (phagedenic chancroid).

With complicated chancre, regional lymph nodes become painful, and the skin over them can become inflammatory.

At the end of the primary period, polyadenitis develops.

Differential diagnosis hard chancre is carried out with the following diseases: balanitis and balanoposthitis, genital herpes, scabies ecthyma, chancriform pyoderma, gonococcal and trichomonas ulcers, soft chancroid, tuberculous ulcer, diphtheria ulcer, acute vulvar ulcer, fixed toxicoderma, lymphogranuloma venereum, squamous cell skin cancer. Differential diagnosis is based on the characteristics of the clinical picture, medical history, detection of Treponema pallidum and the results of serological reactions.

29.7. CLINICAL PICTURE OF SECONDARY

SYPHILIS PERIOD

Clinical manifestations of the secondary period of syphilis are characterized mainly by damage to the skin and visible mucous membranes and, to a lesser extent, changes in internal organs, the musculoskeletal system and the nervous system. Manifestations of secondary syphilis on the skin include macular, papular and pustular syphilides, as well as syphilitic alopecia and pigmentary syphilide. All secondary syphilides share the following general symptoms.

1. Unique color. Only at the very beginning do they have a bright pink color. Subsequently, their color acquires a stagnant or brownish tint and becomes faded (“boring,” in the figurative expression of French syphilidologists).

2. Focus. Elements of syphilitic rashes usually do not merge with each other, but remain separated from each other.

3. Polymorphism. There is often a simultaneous eruption of various secondary syphilides, for example macular and papular or papular and pustular (true polymorphism), or there is a variegation of the rash due to elements

being at different stages of development (evolutionary or false polymorphism).

4. Benign course. As a rule, secondary syphilides, excluding rare cases of malignant syphilis, resolve without leaving scars or any other permanent traces; their rash is not accompanied by disturbances in the general condition and subjective disorders, in particular itching, a common symptom of various skin diseases.

5. Absence of acute inflammatory phenomena.

6. Rapid disappearance of most syphilides under the influence of specific therapy.

7. Extremely high infectivity of erosive and ulcerated secondary syphilides.

The first rash of the secondary period (secondary fresh syphilis) is characterized by an abundance of rash, symmetry, and small size of the elements. With secondary recurrent syphilis, the rashes are often limited to individual areas of the skin, tend to group, form arcs, rings, garlands, the number of elements decreases with each subsequent relapse.

Spotted syphilide (syphilitic roseola, see color incl., Fig. 42) is a hyperemic spot, the color of which ranges from barely noticeable pink (peach color) to rich red, morbilliform, but most often it is pale pink, “faded.” Due to evolutionary polymorphism, roseola may have a different pink hue in the same patient. When pressure is applied, roseola completely disappears, but when the pressure stops, it appears again. Diascopy of roseola, which has existed for about 1.5 weeks, reveals a brownish color caused by the breakdown of red blood cells and the formation of hemosiderin. The outlines of roseola are round or oval, indistinct, as if finely torn. The spots are located isolated from each other, focally, and are not prone to merging and peeling. Roseola does not differ from the surrounding skin in either relief or consistency; there is no peeling even during resolution (which distinguishes it from the inflammatory elements of most other dermatoses). The size of roseola ranges from 2 to 10-15 mm. Roseola becomes more pronounced when the human body is cooled with air, as well as at the beginning of treatment of the patient with penicillin (in this case, roseola may appear in places where they were not present before the injection) and when the patient is given 3-5 ml of a 1% solution.

thief of nicotinic acid ("ignition" reaction). Recurrent roseola appears from 4-6 months from the moment of infection to 1-3 years. On the genitals it is rarely observed and is hardly noticeable. Differential diagnosis of roseola syphilide is carried out with the following dermatoses: macular toxicoderma, pityriasis rosea, “marbled” skin, pityriasis versicolor, spots from squash bites, rubella, measles.

Papular syphilide presented by papules of dense consistency, located separately, sometimes grouped or ring-shaped. Their color ranges from soft pink to brownish-red (copper) and bluish-red. Papules are not accompanied by any subjective sensations, but pressing on them with a button probe or a match causes acute pain (Jadassohn's symptom). During the period of resolution of the papules, short-term peeling is observed, after which a horny corolla (Bietta's collar) surrounding them remains. Papular syphilides last 1-2 months, gradually resolve, leaving behind brownish pigmentation.

Depending on the size of the papules, lenticular, miliary and nummular syphilides are distinguished.

1. Lenticular (lenticular) papular syphilide (Syphilis papulosa lenticularis)- the most common type of papular syphilide, which occurs both in the secondary fresh and in the secondary recurrent period of syphilis. A lenticular papule is a round-shaped nodule with a truncated apex (“plateau”), with a diameter of 0.3 to 0.5 cm, red in color. The surface of the papule is smooth, shiny at first, then covered with thin transparent scales, characteristic peeling of the “Biette collar” type, with the scales framing the papule along its circumference like a delicate fringe. With secondary fresh syphilis, a large number of papules occur on any part of the body, often on the forehead (corona veneris). On the face, in the presence of seborrhea, they are covered with oily scales (papulae seborrhoicae). With secondary recurrent syphilis, papules are grouped and form fancy garlands, arcs, rings (syphilis papulosa gyrata, syphilis papulosa orbicularis).

Differential diagnosis of lenticular syphilide is carried out with the following dermatoses: guttate parapsoriasis, lichen planus, vulgar psoriasis, papulo-necrotic tuberculosis of the skin.

2. Miliary papular syphilide (Syphilis papulosa milliaris seu lichen syphiliticum) characterized by papules 1-2 mm in diameter, located at the mouth of the pilosebaceous follicles. The nodules have a round or cone-shaped shape, a dense consistency, and are covered with scales or horny spines. The color of the papules is pale pink, they stand out faintly against the background of healthy skin. The rashes are localized on the trunk and limbs (extensor surfaces). Often, after resolution, a scar remains, especially in people with reduced body resistance. Some patients are bothered by itching; Elements resolve very slowly, even under the influence of treatment. Miliary syphilide is considered a rare manifestation of secondary syphilis.

Differential diagnosis must be carried out with lichen scrofuls and trichophytids.

3. Monetoid (nummular) papular syphilide (Syphilis papulosa nummularis, discoides) appears as somewhat flattened hemispherical dermal papules 2-2.5 cm in size. The color of the papules is brownish or bluish-red, rounded in outline. Coin-shaped papules usually appear in small numbers in patients with secondary recurrent syphilis, often grouped with other secondary syphilides (most often with lenticular, less often with roseolous and pustular syphilides). When coin-shaped papules dissolve, pronounced pigmentation remains. There are cases when there are many small papules around one coin-shaped papule, which resembles an exploding shell - blasting syphilide, corymbiform syphilide (syphilis papulosa co-rimbiphormis). Even less common is the so-called cockade syphilide. (syphilis papulosa en cocarde), in which a large coin-shaped papule is located in the center of the ring-shaped papule or is surrounded by a rim of infiltrate from fused small papular elements. In this case, a small strip of normal skin remains between the central papule and the rim of the infiltrate, resulting in a morphological element that resembles a cockade.

Papules, located in the folds between the buttocks, labia, between the penis and the scrotum, are subject to the irritating effects of sweat and friction, due to which they grow along the periphery, and the stratum corneum covering them is macerated and rejected (erosive, weeping papules). Subsequently, vegetative tissues develop from the bottom of the erosive papules.

tions (vegetative papules) and, in the end, they merge with each other, forming a continuous plaque, the surface of which resembles cauliflower - condylomas lata (see color incl., Fig. 43).

Palmar and plantar syphilides, which have become more common in the last decade, have a unique clinical picture. In these cases, the papules are only visible through the skin in the form of red-brown, and after resolution - yellowish, clearly defined spots, surrounded by a Biette's collar. Sometimes horny papules are observed on the palms and soles, which are very reminiscent of calluses, sharply demarcated from healthy skin.

Pustular syphilides represent a rare manifestation of secondary syphilis. According to various authors, the frequency of pustular syphilides ranges from 2 to 10% and they occur in weakened patients. The following clinical manifestations of pustular syphilides are distinguished: acne (acne syphilitica), impetiginous (impetigo syphilitica), smallpox (varicella syphilitica, see color on, fig. 44), syphilitic ecthyma (ecthyma syphiliticum, see color on, fig. 45), syphilitic rupee (rupia syphilitica).

In differential diagnosis with dermatoses, with which pustular syphilides are similar, an important criterion is the presence of a clearly demarcated ridge of copper-red infiltrate along the periphery of the pustular elements.

Syphilitic alopecia (see color incl., Fig. 46) can be small-focal and diffuse (the latter is currently more common), manifests itself at 3-5 months of the disease. Small focal alopecia develops as a result of direct damage to the hair follicle by Treponema pallidum, diffuse alopecia - as a result of intoxication.

The skin with small focal alopecia is not inflamed and does not peel off, the follicular apparatus is preserved. Mostly on the temples and back of the head, many bald spots with an average size of 1.5 cm are found, which do not increase in size and do not merge. The hair in the affected areas resembles moth-eaten fur.

With diffuse alopecia, uniform hair thinning is noted.

Differential diagnosis of syphilitic alopecia must be carried out with alopecia of various origins, as well as with fungal infections of the scalp.

Pigmentary syphilide (syphilitic leukoderma,

see color on, fig. 47) develops 3-6 months after infection, less often in the second half of the disease and, as a rule, is localized on the back and side surfaces of the neck. First, hyperpigmentation of the skin appears, then light spots appear against its background. They are round, approximately the same size, do not peel, do not cause any subjective sensations, do not grow along the periphery and do not merge with each other. Sometimes the spots are so close to each other that they create a mesh, lacy pattern.

Syphilitic leukoderma is more often observed in women, often combined with alopecia, but unlike it, it lasts for many months and is difficult to treat. Leukoderma is considered a manifestation of syphilis associated with damage to the nervous system and caused by trophic disorders in the form of impaired pigment formation (hyper- and hypopigmentation). It should also be emphasized that in the presence of leukoderma, patients, as a rule, also experience pathological changes in the cerebrospinal fluid.

Differential diagnosis should be carried out with secondary leukoderma that occurs after sun exposure in patients with pityriasis versicolor.

Secondary syphilides of the mucous membranes. The development of secondary syphilides of the oral mucosa is facilitated by the abuse of spicy food, strong drinks, smoking, as well as abundant microflora.

Roseola syphilide, as a rule, is not diagnosed, since it is almost impossible to see pale roseola against the background of the bright pink color of the mucous membranes. However, spotted syphilide can manifest itself in the form of syphilitic tonsillitis, which is characterized by purplish-cyanotic erythema with a sharp border ending not far from the free edge of the soft palate, and very slight pain that does not correspond to objective data.

Syphilitic papules on the mucous membranes gradually become moistened, so their surface macerates, swells and acquires an opal color, and subsequently erodes. An erosive (wetting) papule consists of three zones: in the center - erosion, around it - an opal ring, and along the periphery - congestive-hyperemic.

Prolonged irritation of papules with saliva and food can cause them to grow peripherally and merge with each other into plaques.

Erosive papules should be differentiated from aphthae, the initial element of which is a small vesicle that quickly opens to form a sharply painful ulcer surrounded by a narrow rim of bright hyperemia. There is no infiltration at its base. The bottom is covered with diphtheritic plaque.

An extremely rare occurrence, pustular syphilide of the mucous membranes manifests itself in the form of a painful, doughy swelling of a bright red color, disintegrating to form an ulcer.

Syphilitic lesions of internal organs in

in the secondary period can be observed in any internal organ, but the most common are syphilitic hepatitis, gastritis, nephrosonephritis and myocarditis. In most cases, visceropathies are not clinically expressed; in addition, they do not have pathognomonic signs, which often leads to diagnostic errors.

Syphilitic lesions of bones and joints in the secondary period they are usually limited to pain. Characterized by night pain in the bones, most often in the long tubular bones of the lower extremities, as well as arthralgia in the knee, shoulder and other joints. Less common are periostitis, os-theoperiostitis and hydrarthrosis.

Syphilitic lesions of the nervous system in early forms of syphilis they manifest themselves mainly in the form of hidden, asymmetric meningitis, vascular lesions (early meningovascular neurosyphilis) and autonomic dysfunction.

29.8. CLINICAL PICTURE OF THE TERTIARY PERIOD OF SYPHILIS

Tertiary syphilides of the skin. The morphological substrate of tertiary syphilides is a product of specific inflammation - infectious granuloma. Their clinical manifestations in the skin - gummous and tubercular syphilide - differ from each other in the depth of development of the inflammatory process: gummas are formed in the subcutaneous tissue, and tubercles are formed in the skin itself. Their infectiousness is insignificant.

Gumma (see color incl., Fig. 48) is a dense consistency knot the size of a walnut, towering

above the level of the skin, painless when palpated, not fused with surrounding tissues. The skin over it is initially unchanged, then becomes bluish-red. The subsequent development of gumma can occur in different ways.

Most often, the gummous node softens in the center and opens with the release of several drops of glue-like exudate. The resulting defect quickly increases in size and turns into a typical gummous ulcer. It is painless, sharply delimited from the surrounding normal skin by a ridge of dense, undisintegrated gummous infiltrate, its edges are steep, the bottom is covered with necrotic masses. A gummous ulcer lasts for months, and with secondary infection and irritation in undernourished patients, even years. After the gummous ulcer heals, a very characteristic scar remains. In the center, at the site of the former defect, it is dense and rough; along the periphery, at the site of resolved infiltration - tender, atrophic. Often the peripheral part is pulled together by the central part, and the scar takes on a star-shaped appearance.

In other cases, the gummous node resolves without ulceration, and a scar forms in depth. At the same time, the skin only slightly sinks. The third possible outcome of the development of a gummous node is its replacement with fibrous tissue, impregnation with calcium salts and encapsulation. The knot acquires an almost woody density, becomes smooth, spherical, decreases in size and exists in this form for an indefinitely long time.

Gummas are usually single. Most often they develop on the front surface of the lower leg. Gummous ulcers sometimes merge with each other.

Tuberous syphilide characterized by a rash in limited areas of the skin of grouped dense, bluish-red, painless bumps ranging in size from small to large peas, lying at different depths of the dermis and not merging with each other. The outcome of the development of tubercles can be twofold: they either dissolve, leaving behind cicatricial atrophy, or become ulcerated. The ulcers are painless, sharply delimited from the surrounding healthy skin by a dense ridge of undissolved infiltrate, their edges are steep, the bottom is necrotic. Subsequently, they may become crusty. Healing of ulcers ends with scarring. There are four types of tubercular syphilide: grouped, serpiginous, diffuse and dwarf.

For grouped tubercular syphilide characterized by an isolated arrangement of tubercles and the formation, in connection with this, of focal round scars, each of which is surrounded by a pigment border.

Serpiginous tubercular syphilide It is characterized by uneven peripheral growth of the lesion due to the eruption of new tubercles. Since they also appear between the old tubercles, their partial fusion occurs, due to which, after the lesion has healed, a scar is formed, penetrated by strips of normal skin (mosaic scar). In the case of ulceration of the tubercles, three zones can be identified in the focus of serpiginous syphilide. The central zone is a mosaic scar, followed by an ulcerative zone, and along the periphery there is a zone of fresh tubercles. The focus of serpiginous tubercular syphilis has large scalloped outlines.

Diffuse tubercular syphilide (tubercular syphilide with a platform) is rare. It is formed as a result of the close adhesion of the tubercles to each other and has the appearance of a continuous plaque. After healing, a mosaic scar remains.

For dwarf tubercular syphilide characterized by a rash of grouped, small, size from a millet grain to a pinhead of tubercles, differing from the elements of miliary papular syphilide only by the scars.

Tertiary syphilides of the mucous membranes. On the mucous membranes (palate, nose, pharynx, tongue), tertiary syphilis manifests itself either in the form of individual gummous nodes or in the form of diffuse gummous infiltration. The process usually begins in the underlying bones and cartilage, much less often in the mucous membrane itself.

Gummas localized on the mucous membranes are characterized by the same features as skin gummas. Their disintegration often leads to perforation of the palate or nasal septum. Perforations are painless.

Perforation of the hard palate, which is observed only in syphilis, leads to disruption of phonation (the voice becomes nasal) and the act of swallowing - food enters the nasal cavity through the perforation. In the case of ulceration of diffuse gummous infiltration of the hard palate, several perforations are formed. Thanks to this, a “lattice scar” remains after healing.

Diffuse gummous infiltration of the soft palate causes impaired phonation and difficulty swallowing, with scarring

fusion of the soft palate with the posterior wall of the pharynx may occur, which leads to a narrowing of the pharynx.

The nasal septum is perforated at the border of the bone and cartilaginous parts (tuberculous lupus destroys only cartilaginous tissue). Significant destruction of the nasal septum, especially its destruction together with the vomer, causes the saddle of the nose.

Damage to the tongue in tertiary syphilis manifests itself as nodular glossitis(gumma of the tongue) or interstitial sclerosing glossitis(diffuse gummous infiltration). In the latter case, the tongue first increases in volume, and then, as a result of scarring, accompanied by atrophy of muscle fibers, it decreases in size and hardens, which leads to a limitation of its mobility and, therefore, difficulty in eating and speaking.

Tertiary syphilis of bones and joints. Bone damage in tertiary syphilis manifests itself in the form of osteoperiostitis or osteomyelitis. Radiography plays a leading role in their diagnosis. Most often the tibia is affected, less often - the bones of the forearm, collarbone, and skull.

Osteoperiostitis can be limited and diffuse. Limited osteoperiostitis is a gumma, which in its development either ossifies or disintegrates and turns into a typical gummous ulcer. Diffuse osteo-periostitis is a consequence of diffuse gummous infiltration; it ends with ossification with the formation of diffuse callus.

With osteomyelitis, the gumma either ossifies or a sequester forms in it. On the radiograph around the sequestrum, a zone of osteosclerosis is clearly visible, i.e., a zone of undisintegrated gummous infiltrate. Sometimes sequestration leads to the development of a gummous ulcer.

Damage to the joints in the tertiary period of syphilis in some cases is caused by diffuse gummous infiltration of the synovial membrane and joint capsule (hydrarthrosis), in others this is accompanied by the development of gummas in the epiphysis of the bone (osteoarthritis). The most commonly affected joints are the knee, elbow, or wrist joints. The inflammatory process is accompanied by effusion into the joint cavity, which leads to an increase in its volume. The clinical picture of hydrarthrosis is limited to this, however, with osteoarthritis, as a result of the destruction of bones and cartilage, joint deformation also develops. Distinguish

The essential features of both hydrarthrosis and osteoarthritis in tertiary syphilis are the almost complete absence of pain and preservation of the motor function of the joint.

Lesions of internal organs in the tertiary period of syphilis are characterized by the development of gumma or gummous infiltration, degenerative processes and metabolic disorders.

The most common lesions are the cardiovascular system in the form of syphilitic mesaortitis, the liver in the form of focal or miliary gummous hepatitis, the kidneys in the form of amyloid nephrosis, nephrosclerosis and gummous processes. Lesions of the lungs, stomach and intestines are expressed in the formation of individual gummas or diffuse gummatous infiltration.

Diagnosis of syphilitic lesions of internal organs is carried out on the basis of other manifestations of syphilis and serological reactions, X-ray data, often after a trial treatment.

Syphilis of the nervous system. The most common clinical forms of late neurosyphilis are progressive paralysis, tabes dorsalis, and cerebral gummas.

29.9. CLINICAL PICTURE OF CONGENITAL SYPHILIS

Congenital syphilis develops as a result of infection of the fetus from a sick mother. The possibility of intrauterine infection appears after the formation of the placenta and, consequently, the placental blood circulation, i.e., by the end of the third or beginning of the fourth month of pregnancy. The pathogenesis of congenital syphilis depends largely on the immune response of the fetus and, to a lesser extent, on the cytodestructive effect of Treponema pallidum.

The pregnancy of women with syphilis ends in different ways: abortion (medical), death of newborns (on average about 25%), premature birth, the birth of a child with active manifestations of syphilis and the birth of a patient with latent syphilis (on average 12%) and, finally, the birth of a healthy child (in 10-15% of cases). This or that pregnancy outcome is determined by the degree of activity of the syphilitic infection. The greatest likelihood of fetal infection exists in women who become infected with syphilis during pregnancy or a year before its onset.

According to ICD-10, early congenital syphilis is distinguished, which manifests itself before the age of two years, and late, which manifests itself two or more years after the birth of the child. Early and late congenital syphilis can be symptomatic and hidden, which is understood as the absence of clinical manifestations with positive serological reactions and negative results of cerebrospinal fluid examination.

According to the domestic classification, there are: fetal syphilis; early congenital syphilis, which includes syphilis of infants; and syphilis of early childhood, late congenital syphilis, latent congenital syphilis.

Fetal syphilis ends with his death on the 6-7th lunar month of pregnancy (not earlier than the 5th). The dead fetus is born only on the 3-4th day, and therefore it is macerated in the amniotic fluid.

Congenital syphilis in infancy (up to one year) isolated due to the characteristics of the clinical picture. Children born with active manifestations of syphilis are not viable and quickly die. Clinical manifestations of syphilis on the skin that develop after birth in the first months of a child’s life are classified as secondary syphilides (they are not always found). However, in addition to the typical secondary syphilides characteristic of acquired syphilis, pathognomonic symptoms are observed with syphilis in infants. Papular syphilide may manifest as diffuse papular infiltration of the skin and mucous membranes. The skin of the palms, soles, and buttocks thickens, becomes dark red, tense, and shiny; When the infiltrate resolves, large-plate peeling occurs. A similar process develops around the mouth and chin. As a result of active movements of the mouth (screaming, sucking), deep cracks are formed, diverging radially from the mouth opening. Once they heal, linear scars remain for life (Robinson-Fournier scars). Diffuse papular infiltration of the nasal mucosa is accompanied by a runny nose (specific rhinitis) with the formation of purulent-bloody crusts, which significantly complicate nasal breathing. In some cases, destruction of the nasal septum and deformation of the nose (saddle nose) occur. Sometimes diffuse papular infiltration develops in the laryngeal mucosa, which causes hoarseness, aphonia, and even laryngeal stenosis.

Pathognomonic symptoms of syphilis in infancy also include syphilitic pemphigus. It is characterized by the formation of blisters the size of a pea to a cherry, filled with serous or serous-purulent exudate, sometimes mixed with blood, and surrounded by a narrow brownish-red rim. The bubbles hardly grow along the periphery and do not merge with each other. First of all (and necessarily!) they appear on the palms and soles. Treponema pallidums are found in their contents. Simultaneously with the eruption of blisters, damage to the internal organs develops, which is accompanied by the general serious condition of the sick child. Syphilitic pemphigus must be differentiated from staphylococcal pemphigus (pemphigus of newborns), in which the palms and soles remain unaffected, the blisters have a pronounced tendency to grow peripherally and merge, and the general condition is disturbed only after the appearance of the rash.

Pathognomonic manifestations of congenital syphilis in infancy include osteochondritis, developing in the metaphysis at the border with the cartilage of long tubular bones, most often of the upper extremities. As a result of the breakdown of the specific infiltrate, the epiphysis can separate from the diaphysis. The excruciating pain that arises does not allow the child to make even the slightest movements of the affected limb, which may suggest paralysis and therefore justifies the name of this process - “Parrot pseudoparalysis”.

There are also various lesions of the central nervous system, as well as the organ of vision, the most specific for the latter is chorioretinitis.

Congenital syphilis of early childhood (from 1 to 2 years) in its main clinical signs it does not differ from secondary recurrent syphilis.

Currently, not all children have typical signs of early congenital syphilis on their skin, and predominantly lesions of the nervous system, bones, visual organs and internal organs are detected.

Late congenital syphilis (after 2 years). It is characterized by symptoms of tertiary syphilis and, in addition, special changes in a number of organs and tissues. Some changes are pathognomonic for congenital syphilis and are its unconditional or reliable signs, others can be observed not only with congenital syphilis and therefore serve only as probable signs of it. In addition, there are dis-

trophies resulting from specific damage to the endocrine glands.

Among the unconditional signs, Hutchinson's triad is distinguished:

1) Getginson's teeth: upper middle incisors, differing in size, smaller than normal, shaped like a barrel or a screwdriver, tapering towards the cutting edge, semilunar notch on the cutting edge;

2) parenchymal keratitis, manifested by lacrimation, photophobia, blepharospasm, clouding of the cornea, which leads to decreased or loss of vision;

3) labyrinthine deafness, caused by inflammation and hemorrhages in the labyrinth area in combination with dystrophic changes in the auditory nerve.

Possible signs include the following:

1) saber shins as a consequence of forward arching of the tibia (the diagnosis should be confirmed by radiography);

2) radiant Robinson-Fournier scars around the oral opening;

3) buttock-shaped skull, developing as a result of os-theoperiostitis of the frontal and parietal bones and limited hydrocephalus;

4) syphilitic chorioretinitis;

5) tooth deformations(purse-shaped and barrel-shaped teeth);

6) syphilitic gonitis;

7) damage to the nervous system.

Dystrophies include thickening of the sternal end of the clavicle (Ausitidian symptom), absence of the xiphoid process, high (lancet, gothic) palate, shortening of the little fingers, etc.

Along with the symptoms described above, late congenital syphilis is characterized by damage to visceral organs, especially the liver and spleen, cardiovascular, nervous and endocrine systems.

Diagnostics Congenital syphilis is carried out on the basis of the clinical picture, data from serological reactions and examination of cerebrospinal fluid, and the mother’s medical history.

29.10. LABORATORY DIAGNOSIS OF SYPHILIS

Laboratory diagnosis of syphilis includes identifying Treponema pallidum and conducting serological tests.

The best way to detect Treponema pallidum is the dark-field microscope method, which allows

It makes it possible to observe the treponema in a living state with all the features of its structure and movement.

Material for research is collected mainly from the surface of chancre and erosive papules. They must first be cleaned using saline lotions to remove various types of contaminants and previously used external medications. Before collection, the surface of the chancre (or other syphilide) is dried with gauze, then the infiltrate is grabbed with two fingers of the left hand (in a rubber glove) and slightly squeezed from the sides, and the erosion is carefully stroked with a loop or a cotton-gauze swab until tissue fluid appears (no blood). ). A drop of the resulting liquid is transferred with a loop onto a thin glass slide, previously degreased with a mixture of alcohol and ether, mixed with the same amount of physiological solution and covered with a thin cover glass. The prepared preparation with live treponemes is microscoped in a dark field of view. To obtain it, it is necessary to replace the condenser in the microscope with a special, so-called paraboloid condenser, and apply a drop of cedar oil or distilled water to its upper lens (under the slide). In the absence of a paraboloid condenser, you can use a regular condenser if you attach a circle of thick black paper to the upper surface of its lower lens so that there is a gap of 2-3 mm along the edge of the lens. To prevent the circle from moving, when cutting it out, you should leave four protrusions that would rest against the metal frame of the lens.

Particular difficulties arise when differentiating pathogenic treponema and saprophytic treponemes, which have their own distinctive features:

T. refringens, found in material from the genitourinary tract, it is much thicker, its curls are coarse, wide, uneven, the ends are pointed, the glow is brighter, with a slightly golden tint. Movements are rare, erratic;

T. microdentium, detected by microscopy of smears from the oral cavity, shorter and thicker than Treponema pallidum, fewer curls (4-7), they are somewhat pointed, angular, looks brighter, flexion movements are rare.

It must be remembered that when microscopying tissue fluid mixed with blood, the interpretation of the analysis can be complicated by fibrin threads, which have an uneven thickness.

well, significant length and large curls. Such formations move passively, depending on the fluid flow. We must also not forget about treponemas, which are found in tropical diseases (G. carateum, T. pertenue).

To study fixed (dry) smears, it is necessary to use Romanovsky-Giemsa staining. In this case, all spirochetes turn purple and only T. palli-dum takes on a pink color.

Serological diagnosis of syphilis

Serodiagnosis is used for the following purposes: confirmation of the clinical diagnosis of syphilis, diagnosis of latent syphilis, monitoring the effectiveness of treatment, determining the cure of patients with syphilis.

Both cellular (macrophages, T-lymphocytes) and humoral mechanisms (synthesis of specific Igs) take part in the body’s immune response. The appearance of anti-syphilitic antibodies occurs in accordance with the general patterns of the immune response: first IgM is produced, as the disease progresses, the synthesis of IgG begins to predominate; IgA is produced in relatively small quantities. The issue of the synthesis of IgE and IgD has not been sufficiently studied at present. Specific IgM appears 2-4 weeks after infection and disappears in untreated patients after about 6 months; in the treatment of early syphilis - after 1-2 months, late - after 3-6 months. IgG usually appears at 4 weeks after infection and usually reaches higher titre levels than IgM. Antibodies of this class can persist for a long time even after the patient has been clinically cured.

The antigenic structure of Treponema pallidum includes lipoprotein antigens (antibodies to them are formed in the body at the end of the incubation period) and antigens of a polysaccharide nature. A large number of substances of a lipid nature appear in the patient’s body as a result of the destruction of tissue cells, mainly lipids of mitochondrial membranes. Apparently, they have the same structure as the lipid antigens of Treponema pallidum and have the properties of autoantigens. Antibodies to them appear in the patient’s body approximately 2-3 weeks after the formation of chancre.

In Russia, laboratory diagnosis of syphilis is carried out in accordance with the order of the Ministry of Health of the Russian Federation? 87 of March 26, 2001 “On improving the serological diagnosis of syphilis.” The order approved the Methodological Instructions “Performing screening and diagnostic tests for syphilis.”

Modern serodiagnosis of syphilis is based on a combination of nontreponemal and treponemal tests.

Non-treponemal tests detect early antibodies to lipoid antigens, such as cardiolipin, cholesterol, lecithin. Non-treponemal tests are used for primary screening, and in a quantitative version with titer determination to monitor the effectiveness of treatment based on the dynamics of decrease in antibody titer in serum. To make a diagnosis of syphilis, a positive result in a non-treponemal test must be confirmed in a treponemal test.

Non-treponemal tests include the microprecipitation reaction (RMR) with cardiolipin antigen, which is carried out with plasma or inactivated blood serum, or its analogue RPR/RPR (rapid plasma reaction) in qualitative and quantitative versions.

Treponemal tests detect specific antibodies to species-specific antigens Treponema pallidum. These include the immunofluorescence reaction (RIF), the immobilization reaction of Treponema pallidum (PIT), the passive hemagglutination reaction (RPHA), and enzyme-linked immunosorbent assay (ELISA). They are used to confirm the diagnosis of syphilis. ELISA, RPGA and RIF are more sensitive than RIT; at the same time, ELISA, RPGA, RIF after suffering and cured syphilis remain positive for many years, sometimes for life. Due to the fact that ELISA and RPGA are more highly sensitive, specific and reproducible methods, they can be used as screening and confirmatory tests.

1. Immunofluorescence reaction (RIF).

The principle of the reaction is that the test serum is treated with an antigen, which is a pale treponema strain of Nichols, obtained from rabbit orchitis, dried on a glass slide and fixed with acetone. After washing, the drug is treated with luminescent serum against human immunoglobulins. Fluorescent complex (anti-human immunoglobulin + fluorescein isothiocyanate) binds to human

immunoglobulin on the surface of Treponema pallidum and can be identified by fluorescence microscopy. For the serodiagnosis of syphilis, several modifications of the RIF are used:

A) immunofluorescence reaction with absorption (RIF-abs.). Group antibodies are removed from the test serum using cultural treponemes destroyed by ultrasound, which dramatically increases the specificity of the reaction. Since the test serum is diluted only 1:5, the modification remains highly sensitive. RIF-abs. becomes positive at the beginning of the 3rd week after infection (before the appearance of chancre or simultaneously with it) and is a method for early serodiagnosis of syphilis. Often the serum remains positive several years after full treatment of early syphilis, and in patients with late syphilis - for decades.

Indications for performing RIF-abs.:

Elimination of false-positive results of treponemal tests;

Examination of persons with clinical manifestations characteristic of syphilis, but with negative results of non-treponemal tests;

b) IgM-RIF-abs reaction. It was mentioned above that in patients with early syphilis, IgM appears in the first weeks of the disease, which during this period are carriers of the specific properties of the serum. At later stages of the disease, IgG begins to predominate. The same class of immunoglobulins is also responsible for false-positive results, since group antibodies are the result of long-term immunization with saprophytic treponemes (oral cavity, genital organs, etc.). The separate study of Ig classes is of particular interest in the serodiagnosis of congenital syphilis, in which anti-treponemal antibodies synthesized in the child’s body are represented almost exclusively by IgM, and IgG mainly of maternal origin. IgM-RIF-abs reaction. is based on the use in the second phase of an anti-IgM conjugate instead of anti-human fluorescent globulin containing a mixture of immunoglobulins.

Indications for this reaction are:

Diagnosis of congenital syphilis (the reaction allows you to exclude IgG of maternal origin, which passes through the placenta and can cause false positives)

resident result RIF-abs. if the child does not have active syphilis); assessment of the results of treatment of early syphilis: with full treatment IgM-RIF-abs. negatived; V) reaction 19SIgM-RIF-abs. This modification of RIF is based on the preliminary separation of larger 19SIgM molecules from smaller 7SIgG molecules of the serum under study. This separation can be done using gel filtration. Research in the RIF-abs reaction. serum containing only the 19SIgM fraction eliminates possible sources of error. However, the reaction technique (especially fractionation of the test serum) is complex and time-consuming, which seriously limits the possibility of its practical use.

2. Immobilization reaction of Treponema pallidum (RIBT,

RIT).

The principle of the reaction is that when the patient’s serum is mixed with a suspension of live pathogenic Treponema pallidum in the presence of complement, the motility of Treponema pallidum is lost. Immobilisin antibodies detected in this reaction are classified as late antibodies and reach their maximum level by the 10th month of the disease. Therefore, the reaction is unsuitable for early diagnosis. However, with secondary syphilis the reaction is positive in 95% of cases. For tertiary syphilis, RIT gives positive results in 95 to 100% of cases. With syphilis of internal organs, central nervous system, congenital syphilis, the percentage of positive RIT results approaches 100. Negative RIT as a result of full treatment does not always occur; the reaction may remain positive for many years. Indications for reactions are the same as for RIF-abs. Of all the trep tests, RIT is the most complex and time-consuming.

3. Enzyme-linked immunosorbent assay (ELISA).

The principle of the method is that Treponema pallidum antigens are loaded onto the surface of a solid-phase carrier (wells of polystyrene or acrylic panels). Then the test serum is added to such wells. If there are antibodies against Treponema pallidum in the serum, an antigen + + antibody complex is formed, bound to the surface of the carrier. At the next stage, anti-species (against human immunoglobulins) serum labeled with an enzyme (peroxidase or alkaline phosphatase) is poured into the wells. Labeled antibodies (conjugate)

interact with the antigen + antibody complex, forming a new complex. To detect it, a solution of substrate and indicator (tetramethylbenzidine) is poured into the wells. Under the action of the enzyme, the substrate changes color, which indicates a positive result of the reaction. In terms of sensitivity and specificity, the method is close to RIF-abs. Indications for ELISA are the same as for RIF-abs. The response can be automated.

4. Passive hemagglutination reaction (RPHA).

The principle of the reaction is that formalinized red blood cells are used as an antigen, on which treponema pallidum antigens are absorbed. When such an antigen is added to the patient's serum, red blood cells stick together - hemagglutination. The specificity and sensitivity of the reaction is higher compared to other methods for detecting antibodies to Treponema pallidum, provided the quality of the antigen is high. The reaction becomes positive in the 3rd week after infection and remains so many years after recovery. A micromethod for this reaction has been developed, as well as an automated microhemagglutination reaction.

For various types of examination for syphilis, the following serological diagnostic methods are recommended:

1) examination of donors (ELISA or RPGA is mandatory in combination with MRP, RPR);

2) initial examination for suspected syphilis (RMP or RPR in qualitative and quantitative versions, in case of a positive result, confirmation by any treponemal test);

3) monitoring the effectiveness of treatment (non-treponemal tests in a quantitative setting).

29.11. BASIC PRINCIPLES OF TREATING PATIENTS WITH SYPHILIS

Specific treatment for a patient with syphilis is prescribed only after confirmation of the clinical diagnosis by laboratory methods. The diagnosis is established on the basis of appropriate clinical manifestations, detection of the pathogen and the results of a serological examination of the patient. Antisyphilitic drugs without confirmation of the presence of a syphilitic infection are prescribed for preventive treatment, prophylactic treatment, as well as for trial treatment.

Preventive treatment is carried out to prevent syphilis for persons who have had sexual and close household contact with patients with the early stages of syphilis.

Preventive treatment is carried out according to indications for pregnant women who are sick or have had syphilis, as well as children born to such women.

Trial treatment can be prescribed if specific lesions of the internal organs, nervous system, sensory organs, or musculoskeletal system are suspected in cases where the diagnosis cannot be confirmed by convincing laboratory data, and the clinical picture does not exclude the presence of a syphilitic infection.

For patients with gonorrhea with unknown sources of infection, serological testing for syphilis is recommended.

Cerebrospinal fluid examination is carried out for diagnostic purposes in patients with clinical symptoms of damage to the nervous system; it is also advisable for latent, late forms of the disease and for secondary syphilis with manifestations in the form of alopecia and leukoderma. Liquorological examination is also recommended for children born to mothers who have not received treatment for syphilis.

A consultation with a neurologist is carried out if there are relevant patient complaints and neurological symptoms are identified (paresthesia, numbness of the limbs, weakness in the legs, back pain, headaches, dizziness, diplopia, progressive decrease in vision and hearing, facial asymmetry

and etc.).

When treating a patient with syphilis and carrying out preventive treatment in the case of anamnestic indications of penicillin intolerance, an alternative (backup) treatment method should be selected for the patient.

In case of a shock allergic reaction to penicillin, it is necessary to have an anti-shock first aid kit in the treatment room.

Various penicillin preparations are used as the main treatment for syphilis.

In outpatient settings, foreign durable drugs of penicillin are used - extensillin and retarpen, as well as their domestic analogue - bicillin-1. These are one-component drugs representing the dibenzylethylenediamine salt of penicillin. Their single administration in a dose of 2.4 million units ensures the preservation of treponemal-

cidal concentration of penicillin for 2-3 weeks; injections of extensillin and retarpen are carried out once a week, bicillin-1 - once every 5 days. Bicillin-3 and bicillin-5 can also be used in outpatient treatment. Three-component domestic bicillin-3 consists of dibenzylethylenediamine, novocaine and sodium salts of penicillin in a ratio of 1:1:1. Injections of this drug in a dose of 1.8 million units are given 2 times a week. Two-component bicillin-5 consists of dibenzylethylenediamine and novocaine salts of penicillin in a ratio of 4: 1. Injections of this drug in a dose of 1,500,000 units are made once every 4 days.

Medium duration drugs - domestic novocaine salt of penicillin and foreign procaine-penicillin - after their administration in a dose of 0.6-1.2 million units ensure that penicillin remains in the body for 12-24 hours. These drugs are used intramuscularly 1-2 times a day. Durant and medium-duration drugs are administered intramuscularly, into the upper outer quadrant of the buttock, in two stages.

In hospital settings, the sodium salt of penicillin is used, which provides a high initial concentration of the antibiotic in the body, but is eliminated quite quickly. The optimal solution in terms of ease of use and high efficiency is the administration of penicillin sodium salt at a dose of 1 million units 4 times a day.

The calculation of penicillin preparations for the treatment of children is carried out in accordance with the child’s body weight: at the age of up to 6 months, the sodium salt of penicillin is used at the rate of 100 thousand units/kg, after 6 months - 50 thousand units/kg. A daily dose of novocaine salt (procaine penicillin) and a single dose of durant drugs are used at the rate of 50 thousand units/kg body weight.

In the Russian Federation, treatment and prevention of syphilis is carried out strictly according to the instructions approved by the Ministry of Health of the Russian Federation. Is the Order currently in effect in the country? 328 of July 25, 2003, Ministry of Health of the Russian Federation “On approval of the protocol for the management of patients with syphilis” and methodological recommendations? 98/273, approved by the Ministry of Health in December 1998, in which the proposed methods of treatment and prevention of syphilis are based on new principles and approaches:

1) priority of outpatient treatment methods;

2) reduction of treatment time;

3) exclusion from the mandatory set of methods of nonspecific and immunotherapy;

4) a differentiated approach to the prescription of various penicillin preparations (durant, medium-durant and soluble) depending on the stage of the disease;

5) differentiated administration of various penicillin preparations to pregnant women in the first and second half of pregnancy in order to create optimal opportunities for sanitation of the fetus;

6) in the treatment of neurosyphilis, priority is given to methods that facilitate the penetration of the antibiotic through the blood-brain barrier;

7) reducing the time of clinical and serological control.

The indication for the use of various methods of treating syphilis with benzylpenicillin and other groups of antibiotics is the establishment of a diagnosis of syphilis at any time. Benzylpenicillin drugs are the main ones in the treatment of all forms of syphilis.

A contraindication to the use of penicillin drugs for the treatment of syphilis may be their individual intolerance.

If there are contraindications to the use of penicillin drugs, alternative drugs specified in the relevant section of the guidelines are prescribed and desensitizing therapy is carried out.

Clinical and serological control after completion of treatment

Adults and children who received preventive treatment after sexual or close household contact with patients with early stages of syphilis are subject to a single clinical and serological examination 3 months after treatment.

Patients with primary seronegative syphilis are under control for 3 months.

Patients with early forms of syphilis who had positive results of non-treponemal tests before treatment are subject to clinical and serological control until they are completely negative and then for another 6 months, during which it is necessary to conduct two examinations. The duration of clinical and serological monitoring should be individualized depending on the results of treatment.

For patients with late forms of syphilis, whose non-treponemal tests often remain positive after treatment,

valid, a three-year period of clinical and serological control is provided. The decision to deregister or extend control is made individually. During follow-up, non-treponemal tests are carried out once every 6 months during the second and third years. Treponemal seroreactions (RIF, ELISA, RPGA, RIT) are examined once a year.

Patients with neurosyphilis, regardless of stage, should be monitored for three years. The results of treatment are monitored using serological tests of blood serum at the time specified above, as well as mandatory liquorological examination over time.

Persons with early forms of syphilis who demonstrate sero-resistance are under clinical and serological control for three years. Children born to mothers with syphilis, but who did not themselves have congenital syphilis, are subject to clinical and serological control for 1 year, regardless of whether they received preventive treatment or not.

Children who have received specific treatment for both early and late congenital syphilis are subject to clinical and serological observation according to the same principle as adults who have received treatment for the respectively early or late stage of acquired syphilis, but for at least a year.

For children who have received treatment for acquired syphilis, clinical and serological observation is carried out in the same way as for adults.

If a clinical or serological relapse occurs, patients are subject to examination by a therapist, neurologist, ophthalmologist, or otolaryngologist; It is advisable to perform a spinal puncture. Treatment is carried out according to the methods provided for secondary and latent syphilis over 6 months old.

Seroresistance in syphilis after complete treatment is defined as a condition in which there is no decrease in reagin titer by more than 4 times in non-treponemal tests with cardiolipin antigen. In these cases, additional treatment is prescribed using appropriate techniques.

If, a year after full treatment, negativity of non-treponemal tests has not occurred, but there is a decrease in reagin titer by four or more times, then these cases will be considered

They are considered as delayed negativity, and observation is continued without additional treatment.

At the end of clinical and serological observation, a complete serological and, if indicated, clinical examination of patients is carried out (examination by a therapist, neurologist, ophthalmologist, otolaryngologist).

A cerebrospinal fluid examination upon deregistration is recommended for patients treated for neurosyphilis.

When deregistering children who have received treatment for congenital syphilis, an examination is recommended, including consultations with a pediatrician, neurologist, ophthalmologist, otolaryngologist, and non-treponemal tests.

The following should be taken into account as cure criteria:

1) the usefulness of the treatment provided and its compliance with current recommendations;

2) clinical examination data (examination of the skin and mucous membranes, if indicated, the condition of the internal organs and nervous system);

3) results of dynamic laboratory (serological and, if indicated, liquorological) examination.

Patients with syphilis are allowed to work in children's institutions and public catering establishments after discharge from the hospital, and those receiving outpatient treatment - after the disappearance of all clinical manifestations of the disease.

Children who have received treatment for acquired syphilis are admitted to children's institutions after the disappearance of clinical manifestations.

is a sexually transmitted disease that has a long, wave-like course and affects all organs. The clinical picture of the disease begins with the appearance of hard chancre (primary syphiloma) at the site of infection, enlargement of regional and then distant lymph nodes. Characteristic is the appearance of syphilitic rashes on the skin and mucous membranes, which are painless, do not itch, and occur without fever. In the future, all internal organs and systems can be affected, which leads to irreversible changes and even death. Treatment of syphilis is carried out by a venereologist; it is based on systemic and rational antibiotic therapy.

General information

(Lues) is an infectious disease that has a long, wave-like course. In terms of the extent of damage to the body, syphilis is classified as a systemic disease, and in terms of the main route of transmission it is considered a sexually transmitted disease. Syphilis affects the entire body: the skin and mucous membranes, the cardiovascular, central nervous, digestive, and musculoskeletal systems. Untreated or poorly treated syphilis can last for years, alternating periods of exacerbations and latent periods. During the active period, syphilis manifests itself on the skin, mucous membranes and internal organs; during the latent period, it practically does not manifest itself in anything.

Syphilis ranks first among all infectious diseases (including STIs), in terms of incidence, infectiousness, degree of harm to health, and certain difficulties in diagnosis and treatment.

Features of the causative agent of syphilis

The causative agent of syphilis is the microorganism pale spirochete (treponema - Treponema pallidum). The pale spirochete has the appearance of a curved spiral, is capable of moving in different ways (translationally, rotationally, flexibly and wavy), reproduces by transverse division, and is painted with aniline dyes in a pale pink color.

The pale spirochete (treponema) finds optimal conditions in the human body in the lymphatic tract and lymph nodes, where it actively multiplies, and appears in the blood in high concentrations at the stage of secondary syphilis. The microbe persists for a long time in a warm and humid environment (optimum t = 37°C, in wet underwear for up to several days), and is also resistant to low temperatures (in the tissues of corpses - viable for 1-2 days). The pale spirochete dies when dried, heated (55°C - after 15 minutes, 100°C - instantly), when treated with disinfectants, solutions of acids, alkalis.

A patient with syphilis is contagious during any period of illness, especially during periods of primary and secondary syphilis, accompanied by manifestations on the skin and mucous membranes. Syphilis is transmitted through contact of a healthy person with a sick person through secretions (sperm during sexual intercourse, milk - in nursing women, saliva during a kiss) and blood (through direct blood transfusion, during operations - from medical staff, using a shared straight razor, a shared syringe - from drug addicts). The main route of transmission of syphilis is sexual (95-98% of cases). Less common is an indirect household route of infection - through wet household items and personal belongings (for example, from sick parents to children). There have been cases of intrauterine transmission of syphilis to a child from a sick mother. A necessary condition for infection is the presence in the patient’s secretions of a sufficient number of pathogenic forms of pale spirochetes and a violation of the integrity of the epithelium of the mucous membranes and skin of his partner (microtraumas: wounds, scratches, abrasions).

Periods of syphilis

The course of syphilis is long-term, wave-like, with alternating periods of active and latent manifestations of the disease. In the development of syphilis, periods are distinguished that differ in the set of syphilides - various forms of skin rashes and erosions that appear in response to the introduction of pale spirochetes into the body.

• Incubation period

It begins from the moment of infection and lasts on average 3-4 weeks. Pale spirochetes spread through the lymphatic and circulatory tract throughout the body, multiply, but clinical symptoms do not appear. A person with syphilis is unaware of his illness, although he is already contagious. The incubation period can be shortened (up to several days) and extended (up to several months). Extension occurs when taking medications that somewhat inactivate the causative agents of syphilis.

• Primary syphilis

Lasts 6-8 weeks, characterized by the appearance of pale spirochetes of primary syphiloma or chancre at the site of penetration and subsequent enlargement of nearby lymph nodes.

• Secondary syphilis

Can last from 2 to 5 years. Internal organs, tissues and systems of the body are damaged, generalized rashes appear on the mucous membranes and skin, and baldness occurs. This stage of syphilis occurs in waves, with periods of active manifestations followed by periods of absence of symptoms. There are secondary fresh, secondary recurrent and latent syphilis.

Latent (latent) syphilis does not have skin manifestations of the disease, signs of specific damage to internal organs and the nervous system, and is determined only by laboratory tests (positive serological reactions).

• Tertiary syphilis

It is now rare and occurs in the absence of treatment years after the lesion. Characterized by irreversible damage to internal organs and systems, especially the central nervous system. It is the most severe period of syphilis, leading to disability and death. It is detected by the appearance of tubercles and nodes (gummas) on the skin and mucous membranes, which, when disintegrating, disfigure the patient. They are divided into syphilis of the nervous system - neurosyphilis and visceral syphilis, in which internal organs are damaged (brain and spinal cord, heart, lungs, stomach, liver, kidneys).

Symptoms of syphilis

Primary syphilis

Primary syphilis begins from the moment when primary syphiloma, chancre, appears at the site of introduction of pale spirochetes. A chancre is a single, round-shaped erosion or ulcer, which has clear, smooth edges and a shiny bluish-red bottom, painless and non-inflamed. The chancre does not increase in size, has scanty serous contents or is covered with a film or crust; a dense, painless infiltrate is felt at its base. Hard chancre does not respond to local antiseptic therapy.

Chancre can be located on any part of the skin and mucous membranes (anal area, oral cavity - lips, corners of the mouth, tonsils; mammary gland, lower abdomen, fingers), but most often it is located on the genitals. Usually in men - on the head, foreskin and shaft of the penis, inside the urethra; in women - on the labia, perineum, vagina, cervix. The size of the chancre is about 1 cm, but can be dwarf - the size of a poppy seed and gigantic (d = 4-5 cm). Chancres can be multiple, in the case of numerous small lesions of the skin and mucous membranes at the time of infection, sometimes bipolar (on the penis and lips). When a chancre appears on the tonsils, a condition resembling a sore throat occurs, in which the temperature does not rise and the throat almost does not hurt. The painlessness of chancre allows patients not to notice it and not attach any importance. Soreness is distinguished by a slit-like chancre in the fold of the anus, and a chancre - felon on the nail phalanx of the fingers. During the period of primary syphilis, complications (balanitis, gangrenization, phimosis) may occur as a result of the addition of a secondary infection. Uncomplicated chancre, depending on the size, heals after 1.5 - 2 months, sometimes before signs of secondary syphilis appear.

5-7 days after the appearance of chancre, uneven enlargement and hardening of the lymph nodes closest to it (usually inguinal) develops. It can be unilateral or bilateral; the nodes are not inflamed, painless, have an ovoid shape and can reach the size of a chicken egg. Towards the end of the period of primary syphilis, specific polyadenitis develops - an enlargement of most subcutaneous lymph nodes. Patients may experience malaise, headache, insomnia, fever, arthralgia, muscle pain, neurotic and depressive disorders. This is associated with syphilitic septicemia - the spread of the causative agent of syphilis through the circulatory and lymphatic system from the lesion throughout the body. In some cases, this process occurs without fever or malaise, and the patient does not notice the transition from the primary stage of syphilis to the secondary stage.

Secondary syphilis

Secondary syphilis begins 2-4 months after infection and can last from 2 to 5 years. Characterized by generalization of infection. At this stage, all systems and organs of the patient are affected: joints, bones, nervous system, hematopoietic organs, digestion, vision, hearing. The clinical symptom of secondary syphilis is rashes on the skin and mucous membranes, which are widespread (secondary syphilides). The rash may be accompanied by body aches, headache, fever and may feel like a cold.

The rash appears in paroxysms: after lasting 1.5 - 2 months, it disappears without treatment (secondary latent syphilis), then appears again. The first rash is characterized by abundance and brightness of color (secondary fresh syphilis), subsequent repeated rashes are paler in color, less abundant, but larger in size and prone to merging (secondary recurrent syphilis). The frequency of relapses and the duration of latent periods of secondary syphilis vary and depend on the body’s immunological reactions in response to the proliferation of pale spirochetes.

Syphilides of the secondary period disappear without scars and have a variety of forms - roseola, papules, pustules.

Syphilitic roseolas are small round spots of pink (pale pink) color that do not rise above the surface of the skin and epithelium of the mucous membranes, which do not peel and do not cause itching; when pressed on, they turn pale and disappear for a short time. Roseola rash with secondary syphilis is observed in 75-80% of patients. The formation of roseola is caused by disturbances in the blood vessels; they are located throughout the body, mainly on the torso and limbs, in the face - most often on the forehead.

A papular rash is a rounded nodular formation protruding above the surface of the skin, bright pink in color with a bluish tint. Papules are located on the body and do not cause any subjective sensations. However, when pressing on them with a button probe, acute pain appears. With syphilis, a rash of papules with greasy scales along the edge of the forehead forms the so-called “crown of Venus.”

Syphilitic papules can grow, merge with each other and form plaques, becoming wet. Weeping erosive papules are especially contagious, and syphilis at this stage can easily be transmitted not only through sexual contact, but also through handshakes, kisses, and the use of common household items. Pustular (pustular) rashes with syphilis are similar to acne or chicken rash, covered with crust or scales. Usually occur in patients with reduced immunity.

The malignant course of syphilis can develop in weakened patients, as well as in drug addicts, alcoholics, and HIV-infected people. Malignant syphilis is characterized by ulceration of papulopustular syphilides, continuous relapses, impaired general condition, fever, intoxication, and weight loss.

Patients with secondary syphilis may experience syphilitic (erythematous) tonsillitis (severe redness of the tonsils, with whitish spots, not accompanied by malaise and fever), syphilitic seizures in the corners of the lips, and oral syphilis. There is a general mild malaise that may resemble the symptoms of a common cold. Characteristic of secondary syphilis is generalized lymphadenitis without signs of inflammation and pain.

During the period of secondary syphilis, disturbances in skin pigmentation (leukoderma) and hair loss (alopecia) occur. Syphilitic leukoderma manifests itself in the loss of pigmentation of various areas of the skin on the neck, chest, abdomen, back, lower back, and armpits. On the neck, more often in women, a “Venus necklace” may appear, consisting of small (3-10 mm) discolored spots surrounded by darker areas of skin. It can exist without change for a long time (several months or even years), despite antisyphilitic treatment. The development of leukoderma is associated with syphilitic damage to the nervous system; upon examination, pathological changes in the cerebrospinal fluid are observed.

Hair loss is not accompanied by itching or flaking; its nature is:

• diffuse - hair loss is typical of normal baldness, occurring on the scalp, in the temporal and parietal regions;
• small focal - a clear symptom of syphilis, hair loss or thinning in small patches located randomly on the head, eyelashes, eyebrows, mustache and beard;
• mixed - both diffuse and small-focal are found.

With timely treatment of syphilis, the hairline is completely restored.

Skin manifestations of secondary syphilis accompany lesions of the central nervous system, bones and joints, and internal organs.

Tertiary syphilis

If a patient with syphilis was not treated or the treatment was incomplete, then several years after infection he develops symptoms of tertiary syphilis. Serious violations of organs and systems occur, the patient’s appearance is disfigured, he becomes disabled, and in severe cases, death is likely. Recently, the incidence of tertiary syphilis has decreased due to its treatment with penicillin, and severe forms of disability have become rare.

There are tertiary active (if there are manifestations) and tertiary latent syphilis. Manifestations of tertiary syphilis are a few infiltrates (tubercles and gummas), prone to decay, and destructive changes in organs and tissues. Infiltrates on the skin and mucous membranes develop without changing the general condition of patients; they contain very few pale spirochetes and are practically not infectious.

Tubercles and gummas on the mucous membranes of the soft and hard palate, larynx, and nose ulcerate and lead to disorders of swallowing, speech, breathing (perforation of the hard palate, “failure” of the nose). Gummy syphilides, spreading to bones and joints, blood vessels, and internal organs, cause bleeding, perforations, scar deformities, and disrupt their functions, which can lead to death.

All stages of syphilis cause numerous progressive lesions of internal organs and the nervous system, the most severe form of which develops with tertiary (late) syphilis:

• neurosyphilis (meningitis, meningovasculitis, syphilitic neuritis, neuralgia, paresis, epileptic seizures, tabes dorsalis and progressive paralysis);
• syphilitic osteoperiostitis, osteoarthritis,

  Diagnosis of syphilis

  Diagnostic measures for syphilis include a thorough examination of the patient, taking an anamnesis and conducting clinical studies:

  1. Detection and identification of the causative agent of syphilis by microscopy of serous discharge from skin rashes. But in the absence of signs on the skin and mucous membranes and in the presence of a “dry” rash, the use of this method is impossible.
  2. Serological tests (nonspecific, specific) are performed with serum, blood plasma and cerebrospinal fluid - the most reliable method for diagnosing syphilis.

  Nonspecific serological reactions are: RPR - rapid plasma reagin reaction and RW - Wasserman reaction (compliment binding reaction). Allows the determination of antibodies to spirochete pallidum - reagins. Used for mass examinations (in clinics, hospitals). Sometimes they give a false-positive result (positive in the absence of syphilis), so this result is confirmed by performing specific tests.

  Specific serological reactions include: RIF - immunofluorescence reaction, RPHA - passive hemagglutination reaction, RIBT - immobilization reaction of treponemal pallidum, RW with treponemal antigen. Used to determine species-specific antibodies. RIF and RPGA are highly sensitive tests that become positive at the end of the incubation period. Used in the diagnosis of latent syphilis and to recognize false-positive reactions.

  Serological reactions become positive only at the end of the second week of the primary period, therefore the primary period of syphilis is divided into two stages: seronegative and seropositive.

  Nonspecific serological reactions are used to assess the effectiveness of treatment. Specific serological reactions in a patient who has had syphilis remain positive for life; they are not used to test the effectiveness of treatment.

  Treatment of syphilis

  Treatment for syphilis begins after a reliable diagnosis is made, which is confirmed by laboratory tests. Treatment of syphilis is selected individually, carried out comprehensively, recovery must be determined in a laboratory. Modern methods of treating syphilis, which venereology has today, allow us to talk about a favorable prognosis for treatment, subject to correct and timely therapy that corresponds to the stage and clinical manifestations of the disease. But only a venereologist can choose a therapy that is rational and sufficient in terms of volume and time. Self-medication of syphilis is unacceptable! Untreated syphilis becomes a latent, chronic form, and the patient remains epidemiologically dangerous.

  The treatment of syphilis is based on the use of penicillin antibiotics, to which the pale spirochete is highly sensitive. If the patient has allergic reactions to penicillin derivatives, erythromycin, tetracyclines, and cephalosporins are recommended as an alternative. In cases of late syphilis, iodine and bismuth preparations, immunotherapy, biogenic stimulants, and physiotherapy are additionally prescribed.

  It is important to establish sexual contacts of a patient with syphilis, and be sure to carry out preventive treatment of possibly infected sexual partners. At the end of treatment, all previously patients with syphilis remain under dispensary observation with a doctor until the result of a complex of serological reactions is completely negative.

  In order to prevent syphilis, examinations are carried out among donors, pregnant women, workers in children's, food and medical institutions, and patients in hospitals; representatives of risk groups (drug addicts, prostitutes, homeless people). Blood donated by donors must be tested for syphilis and canned.