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Lecture notes, cheat sheets
Dermatovenerology. Syphilis (most important)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE No. 10. Syphilis Syphilis is a chronic infectious disease that is caused by pale treponema and is characterized by a systemic lesion of the body and a staged progressive course. 1. Ways of infection Despite successful laboratory experiments on infecting animals, under natural conditions, animals are not susceptible to syphilis. Transmission of infection in a natural way is possible only from person to person. As a source of infection, patients pose the greatest danger in the first 2 years of the disease. After 2 years of infection, the contagiousness of patients decreases, infection of contact persons occurs less frequently. A necessary condition for infection is the presence of an entrance gate - damage (microtrauma) of the stratum corneum of the epidermis or the epithelium of the mucous membrane. There are three ways of infection transmission: contact, transfusion and transplacental. The most common infection with syphilis occurs by contact. contact way Infection can occur through direct (direct) contact with a sick person: sexual and non-sexual (domestic). The most common infection occurs through direct sexual contact. The direct non-sexual route of infection is rarely realized in practice (as a result of a kiss, a bite). In domestic conditions, young children are at particular risk of infection if their parents have active forms of syphilis. Be sure to carry out preventive treatment of children who were in close contact with patients with syphilis. Cases of direct professional infection of medical workers (dentists, surgeons, obstetricians-gynecologists, pathologists) when examining patients with syphilis, performing medical procedures, contact with internal organs during operations, autopsies are rare. Infection can occur through indirect (mediated) contact - through any objects contaminated with biological material containing pathogenic treponema. Most often, infection occurs through objects that come into contact with the oral mucosa - glasses, spoons, toothbrushes. The risk of household infection with syphilis is real for people who are in close household contact with the patient: family members, members of closed groups. Indirect infection in medical institutions through reusable medical instruments is excluded if it is properly processed. A patient with syphilis is contagious during all periods of the disease, starting with incubation. The greatest danger is posed by patients with primary and especially secondary syphilis, who have weeping rashes on the skin and mucous membranes - erosive or ulcerative primary syphilomas, macerated, erosive, vegetative papules, especially when located on the oral mucosa, genitals, and also in skin folds. Dry syphilides are less contagious. Treponema is not found in the content of papulo-pustular elements. The manifestations of tertiary syphilis are practically not contagious, since they contain only single treponemas located deep in the infiltrate. The saliva of patients with syphilis is contagious in the presence of rashes on the oral mucosa. Breast milk, semen and vaginal secretions are contagious even in the absence of rashes in the mammary glands and genitals. The secret of the sweat glands, lacrimal fluid and urine of patients do not contain treponema. In patients with early forms of syphilis, any non-specific lesions are contagious, leading to a violation of the integrity of the skin and mucous membranes: herpetic eruptions, erosion of the cervix. Transfusion route Transfusion syphilis develops during the transfusion of blood taken from a donor with syphilis, and in practice it is realized extremely rarely - only in the case of direct transfusion. Drug users are at real risk of infection by sharing intravenous syringes and needles. With the transfusion route of transmission, the pathogen immediately enters the bloodstream and internal organs, so syphilis manifests on average 2,5 months after infection with immediately generalized rashes on the skin and mucous membranes. At the same time, there are no clinical manifestations of the primary period of syphilis. Transplacental route In a pregnant woman with syphilis, intrauterine infection of the fetus can occur with the development of congenital syphilis. In this case, treponemas penetrate the placenta immediately into the bloodstream and internal organs of the fetus. With congenital infection, the formation of a chancre and other manifestations of the primary period are not observed. Transplacental infection usually occurs no earlier than the 16th week of pregnancy, after the completion of the formation of the placenta. 2. Pathogenesis The following variants of the course of syphilitic infection have been established: classical (staged) and asymptomatic. Syphilis is characterized by a staged, undulating course with alternating periods of manifestation and a latent state. Another feature of the course of syphilis is progression, i.e., a gradual change in the clinical and pathomorphological picture in the direction of increasingly unfavorable manifestations. 3. Course of syphilis Periods During syphilis, four periods are distinguished - incubation, primary, secondary and tertiary. The incubation period. This period begins from the moment of infection and continues until the appearance of primary syphiloma - on average 30-32 days. The incubation period may be shortened or extended compared to the stated average duration. Incubation has been described to be shortened to 9 days and extended to 6 months. When entering the body, cells of the monocyte-macrophage system are already encountered in the area of the entrance gate of treponema, however, the processes of recognition of a foreign agent by tissue macrophages, as well as the transmission of information by T-lymphocytes in syphilis, are impaired for several reasons: glycopeptides of the treponema cell wall are similar in structure and composition to glycopeptides human lymphocytes; treponemas secrete substances that slow down the recognition process; after introduction into the body, treponema quickly penetrate into the lymphatic capillaries, vessels and nodes, thereby avoiding the macrophage reaction; even being phagocytosed, treponema in most cases does not die, but becomes inaccessible to the body's defenses. The early stages of syphilis are characterized by partial inhibition of cellular immunity, which contributes to the reproduction and spread of pathogens throughout the body. Already 2-4 hours after infection, the pathogen begins to move along the lymphatic pathways and invades the lymph nodes. From the moment of infection, treponema begins to spread by hematogenous and neurogenic routes, and in the first day the infection becomes generalized. From this time on, bacteria are found in the blood, internal organs and nervous system, but in the tissues of the sick person during this period there is still no morphological response to the introduction of pathogens. The humoral link of immunity is not able to ensure the complete destruction and elimination of pale treponema. During the entire incubation period, pathogens actively multiply in the area of the entrance gate, the lymphatic system and internal organs. At the end of incubation, the number of treponemas in the body increases significantly, so patients during this period are contagious. Primary Period. It begins with the onset of primary affect and ends with the appearance of generalized rashes on the skin and mucous membranes. The average duration of primary syphilis is 6-8 weeks, but it can be shortened to 4-5 weeks and increased to 9-12 weeks. A few days after the onset of the primary affect, an increase and thickening of the lymph nodes closest to it is observed. Regional lymphadenitis is an almost constant symptom of primary syphilis. At the end of the primary period, approximately 7-10 days before its end, groups of lymph nodes remote from the area of the entrance gate of infection increase and thicken. During the primary period of syphilis, an intense production of antitreponemal antibodies occurs. First of all, their number in the bloodstream increases. Circulating antibodies immobilize treponemas, form membrane-attacking immune complexes, which leads to the destruction of pathogens and the release of lipopolysaccharide and protein products into the blood. Therefore, at the end of the primary - the beginning of the secondary period, some patients have a prodromal period: a complex of symptoms caused by intoxication of the body with substances released as a result of mass death of treponema in the bloodstream. The level of antibodies in tissues gradually increases. When the amount of antibodies becomes sufficient to ensure the death of tissue treponemas, a local inflammatory reaction occurs, which is clinically manifested by widespread rashes on the skin and mucous membranes. Since that time, syphilis passes into the second stage. 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. Recurrences of secondary rashes can be observed 10-15 years or more after infection, while at the same time, in weakened patients, the secondary period can be shortened. In the secondary period, the wave-like course of syphilis is most pronounced, i.e., the alternation of manifest and latent periods of the disease. During the first wave of secondary rashes, the number of treponemas in the body is the largest - they multiplied in large numbers during the incubation and primary 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 reproduction 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 wavelike course of syphilis is due to the peculiarities of the relationship between pale treponema and the patient's immune system. The further course of a syphilitic infection is characterized by a continuing increase in sensitization to treponema with a steady decrease in the number of pathogens in the body. After an average of 2-4 years from the moment of infection, the tissue response to the pathogen begins to proceed according to the Arthus phenomenon type, followed by the formation of a typical infectious granuloma - an infiltrate of lymphocytes, plasma, epithelioid and giant cells with necrosis in the center. Tertiary period. This period develops in patients who have not received treatment at all or have not been treated sufficiently, usually 2-4 years after infection. The balance that exists between the pathogen and the controlling immune system during the latent course of syphilis can be disturbed under the influence of adverse factors - injuries (bruises, fractures), weakening the body of the disease, intoxication. These factors contribute to the activation (reversion) of spirochetes in any part of a particular organ. In the later stages of syphilis, the reactions of cellular immunity begin to play a leading role in the pathogenesis of the disease. These processes proceed without a sufficiently pronounced humoral background, since the intensity of the humoral response decreases as the number of treponemas in the body decreases. Malignant course of syphilis Severe comorbidities (such as tuberculosis, HIV infection), chronic intoxication (alcoholism, drug addiction), malnutrition, heavy physical labor and other causes that weaken the patient's body affect the severity of syphilis, contributing to its malignant course. 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 is prone to ulceration, papulo-pustular syphilides are observed. The general condition of patients is disturbed, fever, symptoms of intoxication are expressed. Often there are manifest lesions of the nervous system and internal organs. Sometimes there is a continuous recurrence, without latent periods. Treponemas in the discharge of rashes are found with difficulty. Tertiary syphilides in malignant syphilis may appear early: one year after infection (galloping course of the disease). Serological reactions in patients with malignant syphilis are often negative, but may become positive after the start of treatment. Re-infection with syphilis True, or sterile, immunity does not develop with syphilis. This means that a person who has been ill can become infected again, just like a person who has never had this disease before. Re-infection with syphilis of a person who had previously been ill and completely cured is called reinfection. The latter is regarded as convincing proof of the complete curability of syphilis. With syphilis, the so-called non-sterile, or infectious, immunity develops in the patient's body. Its essence is that a new infection is impossible while pale treponemas remain in the body. 4. Clinical manifestations Primary Period The following complex of clinical symptoms is characteristic of the primary period of syphilis: primary syphiloma, regional lymphadenitis, specific lymphadenitis, specific polyadenitis, prodromal phenomena. Primary syphiloma is the first clinical manifestation of the disease that occurs at the site of the introduction of pale treponema through the skin and mucous membranes (in the region of the entrance gate). The appearance of an erosive or ulcerative defect is preceded by the appearance of a small hyperemic inflammatory spot, which after 2-3 days turns into a papule. These changes are asymptomatic and are not noticed by either the patient or the doctor. Soon after the appearance of the papule, the epidermis (epithelium) covering it undergoes disintegration, and an erosion or ulcer is formed - the primary syphiloma itself. The depth of the defect depends on the severity and nature of the tissue reaction to the introduction of the pathogen. Clinical features of a typical primary syphiloma. 1. Primary syphiloma is an erosion or superficial ulcer. 2. Primary syphilomas are single or single (2-3 elements). 3. Primary syphiloma has round or oval outlines. 4. Primary syphiloma usually measures 5-15 mm in size. There are also dwarf primary affects with a diameter of 1-3 mm. Giant chancre with a diameter of up to 4-5 cm or more are ulcerative, covered with serous-hemorrhagic or purulent-hemorrhagic crusts and have extragenital or perigenital localization. 5. Having reached a certain size, primary syphiloma does not tend to grow peripherally. 6. The boundaries of primary syphiloma are even, clear. 7. The surface of the primary syphiloma has a bright red color (the color of fresh meat), sometimes covered with a dense coating of grayish-yellow color (the color of spoiled fat). 8. The edges and bottom of erosive syphiloma lie on the same level. The edges and bottom of the ulcerative chancre are separated from each other by the depth of the defect. 9. The bottom of the primary syphiloma is smooth, covered with scanty transparent or opalescent discharge, giving it a kind of mirror or lacquer sheen. 10. At the base of primary syphiloma there is a dense elastic infiltrate, clearly demarcated from the surrounding tissues and extending 2-3 mm beyond the syphiloma. 11. Primary syphiloma is not accompanied by subjective sensations. Soreness in the area of primary affect appears when a secondary infection is attached. 12. There are no acute inflammatory skin changes around the primary syphiloma. Localization of primary syphilomas: primary syphilomas can be located on any part of the skin and mucous membranes where the conditions for the introduction of treponemas have developed, i.e., in the area of the entrance gate of infection. By localization, primary syphilomas are divided into genital, perigenital, extragenital and bipolar. Atypical primary syphilomas. In addition to primary affects with a typical clinical picture and its many varieties, atypical chancres can be observed that do not have the characteristic signs inherent in typical syphilomas. These include indurative edema, chancre-felon, chancre-amygdalite. Atypical forms of syphilomas are rare, have a long course and often cause diagnostic errors. Indurative edema is a persistent specific lymphangitis of small lymphatic vessels of the skin, accompanied by symptoms of lymphostasis. It occurs in the genital area with a richly developed lymphatic network: in men, the foreskin and scrotum are affected, in women, the labia majora, and very rarely, the small lips, clitoris, and lips of the pharynx of the cervix. Chancre panaritium is localized on the distal phalanx of the finger and has a great resemblance to the banal panaritium. It is characterized by the formation of an ulcer on the dorsum of the terminal phalanx of the finger. Deep - down to the bone - an ulcer with uneven, tortuous and undermined edges, lunate or horseshoe-shaped. The bottom of the ulcer is pitted, covered with purulent-necrotic masses, crusts, there is abundant purulent or purulent-hemorrhagic discharge with an unpleasant odor. Chancre-amygdalite is a specific unilateral enlargement and significant thickening of the tonsil without a defect on its surface. The tonsil has a stagnant red color, but is not accompanied by diffuse hyperemia. There are the following complications of primary syphiloma: 1) impetiginization. A hyperemic corolla appears along the periphery of the syphiloma, the tissues acquire pronounced puffiness, the brightness of the element increases, the discharge becomes abundant, serous-purulent or purulent, there is a burning sensation, soreness in the area of syphiloma and regional lymph nodes; 2) balanitis and balanoposthitis - in men, vulvitis and vulvovaginitis - in women. High humidity, constant temperature, the presence of a nutrient medium in the form of smegma in the preputial sac contribute to the reproduction of microorganisms and the development of clinical manifestations of balanitis - inflammation of the skin of the glans penis. In women, secondary infection contributes to vulvovaginitis; 3) phimosis. In men who have not undergone circumcision, the inflammatory process of the skin of the preputial sac due to the developed lymphatic network often leads to phimosis - narrowing of the foreskin ring. Inflammatory phimosis is characterized by a bright diffuse hyperemia, mild swelling and an increase in the volume of the foreskin, as a result of which the penis acquires a cone-shaped shape, becomes painful; 4) paraphimosis, which is an infringement of the glans penis by a narrowed ring of the foreskin, drawn to the coronal sulcus. Occurs as a result of forced exposure of the head during phimosis. This leads to a violation of the blood and lymph flow, aggravation of the edema of the preputial ring and severe pain in the penis; 5) gangrenization. Syphiloma undergoes necrotic decay, which is clinically expressed by the formation of a scab of a dirty gray, brown or black color, tightly soldered to the underlying tissues and painless; 6) phagedenism, which begins with the appearance of a larger or smaller area of necrosis against the background of an ulcer. But the necrotic process is not limited to the chancre and extends not only in depth, but also beyond the syphiloma. Regional lymphadenitis. It is an enlargement of the lymph nodes that drain the site of primary syphiloma. This is the second clinical manifestation of primary syphilis. specific lymphangitis. It is an inflammation of the lymphatic vessel from a hard chancre to regional lymph nodes. This is the third component of the clinical picture of primary syphilis. Specific polyadenitis. At the end of the primary period of syphilis, patients develop a specific polyadenitis - an increase in several groups of subcutaneous lymph nodes remote from the area of the entrance gate of infection. Prodromal syndrome. Approximately 7-10 days before the end of the primary period and during the first 5-7 days of the secondary period, general symptoms are observed due to intoxication as a result of the massive presence of treponemes in the bloodstream. It includes fatigue, weakness, insomnia, decreased appetite and performance, headache, dizziness, irregular fever, myalgia, leukocytosis and anemia. Secondary period The secondary period of syphilis is characterized by a complex of such clinical manifestations as spotted syphilis (syphilitic roseola), papular syphilis, papulo-pustular syphilis, syphilitic alopecia (baldness), syphilitic leucoderma (pigmented syphilis). Spotted syphilide, or syphilitic roseola. This is the most common and earliest manifestation of the secondary period of the disease. The roseate rash appears gradually, in spurts, 10-12 elements per day. The rash reaches full development in 8-10 days, lasts on average 3-4 weeks without treatment, sometimes less or more (up to 1,5-2 months). The roseate rash resolves without leaving a trace. Syphilitic roseola is a hyperemic inflammatory spot. The color of roseola varies from pale pink to deep pink, sometimes with a bluish tint. Most often it has a pale pink, faded color. Long-existing roseola acquires a yellowish-brown tint. The size of the spots ranges from 2 to 25 mm, with an average of 5-10 mm. The outlines of roseola are round or oval, the boundaries are unclear. The spots do not grow peripherally, do not merge, and are not accompanied by subjective sensations. There is no peeling. Roseolous rash is localized mainly on the lateral surfaces of the trunk, chest, in the upper abdomen. Rashes can also be observed on the skin of the upper thighs and flexor surface of the forearms, rarely on the face. In addition to the typical roseolous syphilis, its atypical varieties are distinguished: elevating, confluent, follicular and scaly roseola. Elevating (towering) roseola, urticarial roseola, exudative roseola. In this form, the spots appear to rise slightly above the level of the skin and become similar to an urticarial rash with urticaria. Drain roseola. It occurs with a very abundant rash of spots, which, due to the abundance, merge with each other and form continuous erythematous areas. Follicular roseola. This variety is a transitional element between roseola and papule. Against the background of a pink spot, there are small follicular nodules in the form of dotted granularity of copper-red color. Flaky roseola. This atypical variety is characterized by the appearance of lamellar scales on the surface of the spotty elements, resembling crumpled tissue paper. The center of the element appears somewhat sunken. Papular syphilide. Occurs in patients with secondary recurrent syphilis. Papular syphilide also occurs with secondary fresh syphilis; in this case, papules usually appear 1-2 weeks after the onset of roseola rash and are combined with it (maculopapular syphilide). Papular syphilides appear on the skin in spurts, reaching full development in 10-14 days, after which they exist for 4-8 weeks. The primary morphological element of papular syphilis is a dermal papule, sharply delimited from the surrounding skin, regularly rounded or oval in shape. In shape, it can be hemispherical with a truncated top or pointed. The color of the element is initially pink-red, later becoming yellowish-red or bluish-red. The consistency of the papules is densely elastic. Elements are located in isolation, only when localized in folds and irritation, there is a tendency for their peripheral growth and merging. There are no subjective sensations, but when pressing on the center of a newly appeared papule with a blunt probe, pain is noted. Depending on the size of the papules, four types of papular syphilis are distinguished. Lenticular papular syphilide. This is the most common variety, which is characterized by a rash of papules with a diameter of 3-5 mm, observed in both secondary fresh and recurrent syphilis. Miliary papular syphilis. This variety is extremely rare, its appearance is considered evidence of a severe course of the disease. The morphological element is a cone-shaped papule of dense consistency with a diameter of 1-2 mm, located around the mouth of the hair follicle. The color of the elements is pale pink, as a result of which they stand out slightly against the surrounding background. Nummular papular syphilide. This manifestation of the disease occurs mainly in patients with secondary recurrent syphilis. The rashes appear in small numbers and are usually grouped. The morphological element is a hemispherical papule with a flattened apex with a diameter of 2-2,5 cm. The color of the elements is brownish or bluish-red, rounded in outline. When nummular papules resolve, pronounced skin pigmentation remains for a long time. Plaque papular syphilis. It occurs very rarely in patients with secondary recurrent syphilis. It is formed as a result of peripheral growth and fusion of nummular and lenticular papules that are exposed to external irritation. Most often, plaque-like syphilis is formed in the area of large folds - on the genitals, around the anus, in the inguinal-femoral fold, under the mammary glands, in the armpits. Papulo-pustular syphilis. It is observed in debilitated patients suffering from alcoholism, drug addiction, severe concomitant diseases, and indicates a severe, malignant course of syphilis. The following clinical varieties of papulopustular syphilis are distinguished: acneiform (or acneiform), smallpox (or varioliform), impetigo-like, syphilitic ecthyma, syphilitic rupee. Superficial forms of papulo-pustular syphilis - acne-like, pox-like and impetigo-like - are most often observed in patients with secondary fresh syphilis, and deep forms - syphilitic ecthyma and rupee - are observed mainly in secondary recurrent syphilis and serve as a sign of a malignant course of the disease. All varieties of pustular syphilides have an important feature: they have a specific infiltrate at their base. Pustular syphilides arise as a result of the collapse of papular infiltrates, so it is more correct to call them papulo-pustular. Syphilitic alopecia. There are three clinical varieties of alopecia: diffuse, small-focal and mixed, which is a combination of small-focal and diffuse varieties of alopecia. Diffuse syphilitic alopecia is characterized by an acute general thinning of the hair in the absence of any skin changes. Hair loss usually starts at the temples and spreads to the entire scalp. In some cases, other areas of the hairline are also subject to baldness - the areas of the beard and mustache, eyebrows, eyelashes. The hair itself also changes: it becomes thin, dry, dull. The severity of diffuse alopecia varies from barely noticeable hair loss, slightly exceeding the size of the physiological change, to complete loss of all hair, including vellus. Small focal syphilitic alopecia is characterized by the sudden, rapidly progressive appearance on the scalp, especially in the area of the temples and the back of the head, of many randomly scattered small foci of hair thinning with a diameter of 0,5-1 cm. Bald spots have irregularly rounded outlines, do not grow along the periphery and do not merge with each other. The hair in the affected areas does not fall out completely, only a sharp thinning occurs. Syphilitic leukoderma, or pigment syphilide. This is a kind of skin dyschromia of unknown origin that occurs in patients with secondary, mainly recurrent, syphilis. A typical localization of leukoderma is the skin of the back and sides of the neck, less often - the anterior wall of the armpits, the area of the shoulder joints, the upper chest, and back. Diffuse yellowish-brown hyperpigmentation of the skin first appears on the affected areas. After 2-3 weeks, whitish hypopigmented spots with a diameter of 0,5 to 2 cm of round or oval shape appear on the hyperpigmented background. All spots are approximately the same size, located in isolation, and are not prone to peripheral growth and fusion. There are three clinical varieties of pigmented syphilis: spotted, mesh (lace) and marbled. In spotted leukoderma, hypopigmented patches are separated from each other by wide layers of hyperpigmented skin, and there is a pronounced difference in color between hyper- and hypopigmented areas. With a mesh form, hypopigmented spots are in close contact with each other, but do not merge, remaining separated by thin layers of hyperpigmented skin. At the same time, narrow areas of hyperpigmentation form a grid. In leukoderma marble, the contrast between hyper- and hypopigmented areas is negligible, the boundaries between the white patches are indistinct, and the overall impression is of dirty skin. Damage to the nervous system. Neurosyphilis is usually divided into early and late forms, depending on the nature of the pathomorphological changes observed in the nervous tissue. Early neurosyphilis is a predominantly mesenchymal process affecting the meninges and vessels of the brain and spinal cord. It usually develops in the first 5 years after infection. Early neurosyphilis is characterized by the predominance of exudative-inflammatory and proliferative processes. Damage to internal organs. Syphilitic lesions of internal organs in early syphilis are inflammatory in nature and are similar in morphological pattern to changes occurring in the skin. Damage to the musculoskeletal system. Lesions of the skeletal system, mainly in the form of ossalgia, less often - periostitis and osteoperiostitis, are localized mainly in the long tubular bones of the lower extremities, less often - in the bones of the skull and chest. Tertiary period Damage to the skin and mucous membranes in tertiary active syphilis is manifested by tuberculous and gummy rashes. Tubercular syphilide. It can be located on any part of the skin and mucous membranes, but the typical places of its localization are the extensor surface of the upper limbs, torso, face. The lesion occupies a small area of the skin, is located asymmetrically. The main morphological element of tubercular syphilis is a tubercle (a dense, hemispherical, cavityless formation of a rounded shape, densely elastic consistency). The tubercle is formed in the thickness of the dermis, sharply demarcated from apparently healthy skin, has a size of 1 mm to 1,5 cm. The color of the tubercles is first dark red or yellowish-red, then becomes bluish-red or brownish. The surface of the elements is at first smooth, shiny, later on it appears small-lamellar peeling, and in case of ulceration - crusts. There are no subjective sensations. Fresh elements appear along the periphery of the focus. The following clinical varieties of tubercular syphilis are distinguished: grouped, serping (creeping), tubercular syphilis with a platform, dwarf. Grouped tubercular syphilide is the most common type. The number of tubercles usually does not exceed 30-40. The tubercles are at different stages of evolution, some of them have just appeared, others have ulcerated and become crusty, and others have already healed, leaving scars or cicatricial atrophy. Due to the unequal growth of the tubercles and the different depths of their occurrence in the dermis, individual small scars differ in color and relief. Serping tubercular syphilis. The lesion spreads over the surface of the skin either eccentrically or in one direction, when fresh bumps appear at one pole of the lesion. In this case, the individual elements merge with each other into a dark red horseshoe-shaped roller raised above the level of the surrounding skin with a width of 2 mm to 1 cm, along the edge of which fresh tubercles appear. Tuberous syphilide platform. Individual tubercles are not visible; they merge into plaques 5-10 cm in size, of bizarre shape, sharply demarcated from the unaffected skin and rising above it. The plaque has a dense texture, brownish or dark purple color. The regression of the tubercular syphilis with a platform occurs either dry, with the subsequent formation of cicatricial atrophy, or through ulceration with the formation of characteristic scars. Dwarf tubercular syphilide. Rarely observed. It has a small size of 1-2 mm. The tubercles are located on the skin in separate groups and resemble lenticular papules. Gummous syphilide, or subcutaneous gumma. This is a node that develops in the hypodermis. The characteristic places of localization of gums are the shins, head, forearms, sternum. There are the following clinical varieties of gummy syphilis: isolated gums, diffuse gummous infiltrations, fibrous gums. Isolated gumma. Appears in the form of a painless node measuring 5-10 mm, spherical in shape, densely elastic consistency, not fused to the skin. Gradually increasing, the subcutaneous gum adheres to the surrounding tissue and skin and protrudes above it in the form of a hemisphere. The skin over the gumma first becomes pale pink, then brownish-red, purple. Then a fluctuation appears in the center of the gumma, and the gumma opens. When opened, 1-2 drops of sticky, yellow liquid with crumbly inclusions are released from the gummosa node. Hummous infiltrations. They arise independently or as a result of the merger of several gums. Hummous infiltrate disintegrates, ulcerations merge, forming an extensive ulcerative surface with irregular, large-scalloped outlines, healing with a scar. Fibrous gums, or periarticular nodules, are formed as a result of fibrous degeneration of syphilitic gums. Fibrous gummas are localized mainly in the area of the extensor surface of large joints in the form of formations of a spherical shape, very dense consistency, ranging in size from 1 to 8 cm. They are painless, mobile, the skin above them is not changed or slightly pinkish. Late neurosyphilis. It is a predominantly ectodermal process affecting the nervous parenchyma of the brain and spinal cord. It usually develops after 5 years or more from the moment of infection. In late forms of neurosyphilis, degenerative-dystrophic processes predominate. The actual late forms of neurosyphilis include: dorsal tabes - the process of destruction of the nervous tissue and its replacement with connective tissue, localized in the posterior roots, posterior columns and membranes of the spinal cord; progressive paralysis - degenerative-dystrophic changes in the cerebral cortex in the frontal lobes; taboparalysis - a combination of symptoms of dorsal tabes and progressive paralysis. In the tertiary period, lesions of the meninges and blood vessels can still be observed. Late visceral syphilis. In the tertiary period of syphilis, limited gummas or diffuse gummous infiltrations can occur in any internal organ, and various dystrophic processes can also be observed. The morphological basis of lesions in late visceral syphilis is an infectious granuloma. Damage to the musculoskeletal system. In the tertiary period, the musculoskeletal system may be involved in the process. The main forms of bone damage in syphilis. 1. Hummous osteoperiostitis (lesion of spongy bone): 1) limited; 2) diffuse. 2. Hummous osteomyelitis (damage to spongy bone and bone marrow): 1) limited; 2) diffuse. 3. Non-gummous osteoperiostitis. Most often, the tibia is affected, less often the bones of the forearm, collarbone, sternum, skull bones, and vertebrae. Damage to muscles in the form of gummous myositis and joints in the form of acute or chronic synovitis or osteoarthritis in the tertiary period are rare. 5. Latent syphilis Latent syphilis is diagnosed on the basis of positive results of serological reactions in the absence of active manifestations of the disease on the skin and mucous membranes, signs of a specific lesion of the nervous system, internal organs, and the musculoskeletal system. Latent syphilis is divided into early (with a disease duration of up to 1 year), late (more than 1 year) and unspecified, or unknown (it is not possible to determine the timing of infection). This time division is due to the degree of epidemiological danger of patients. 6. Congenital syphilis Congenital syphilis occurs as a result of infection of the fetus during pregnancy through the transplacental route from a mother with syphilis. A pregnant woman with syphilis can transmit Treponema pallidum through the placenta, starting from the 10th week of pregnancy, but usually intrauterine infection of the fetus occurs in the 4-5th month of pregnancy. Congenital syphilis is most often observed in children born to sick women who have not been treated or received inadequate treatment. The likelihood of congenital syphilis depends on the duration of the infection in a pregnant woman: the fresher and more active the syphilis in the mother, the more likely the unfavorable ending of pregnancy for the unborn child. The fate of a fetus infected with syphilis may be different. Pregnancy may end in stillbirth or live birth with disease manifestations occurring immediately after delivery or somewhat later. It is possible to give birth to children without clinical symptoms, but with positive serological reactions, who subsequently develop late manifestations of congenital syphilis. Mothers who have had syphilis for more than 2 years can give birth to a healthy baby. Syphilis of the placenta With syphilis, the placenta is hypertrophied, the ratio of its mass to the mass of the fetus is 1:4-1:3 (normally 1:6-1:5), the consistency is dense, the surface is lumpy, the tissue is fragile, flabby, easily torn, the color is motley. It is difficult to find treponema in placental tissue, so to detect the pathogen, material is taken from the umbilical cord, where treponema is always found in large quantities. Fetal syphilis The changes that have occurred in the placenta make it functionally defective, unable to ensure normal growth, nutrition and metabolism of the fetus, resulting in its intrauterine death in the 6-7th month of pregnancy. The dead fruit is expelled on the 3rd or 4th day, usually in a macerated state. A macerated fetus, compared to a normally developing fetus of the same age, is significantly smaller in size and weight. The skin of stillborns is bright red, folded, the epidermis is loosened and easily slides off in large layers. Due to the massive penetration of pale treponema, all internal organs and the skeletal system of the fetus are affected. A huge number of treponema found in the liver, spleen, pancreas, adrenal glands. Early congenital syphilis If a fetus affected by a syphilitic infection does not die in utero, then the newborn may develop the next stage of congenital syphilis - early congenital syphilis. Its manifestations are detected either immediately after birth or during the first 3-4 months of life. In most cases, newborns with severe manifestations of early congenital syphilis are not viable and die in the first hours or days after birth due to functional inferiority of internal organs and general exhaustion. Clinical signs of early congenital syphilis are detected on the part of the skin, mucous membranes, internal organs, musculoskeletal system, nervous system, and generally correspond to the period of acquired syphilis. The appearance of a newborn with early congenital syphilis is almost pathognomonic. The child is poorly developed, has a small body weight, the skin due to the lack of subcutaneous tissue is flabby, folded. The face of the infant is wrinkled (senile), the skin is pale earthy or yellowish, especially on the cheeks. Due to hydrocephalus and due to premature ossification of the skull bones, the size of the head is sharply increased, the fontanel is tense, and the skin veins of the head are dilated. The child's behavior is restless, he often screams, develops poorly. Lesions of the skin and mucous membranes can be represented by all varieties of secondary syphilides and special symptoms characteristic only of early congenital syphilis: syphilitic pemphigoid, diffuse skin infiltrations, syphilitic rhinitis. Massive bone stratification on the anterior surface of the tibia as a result of repeatedly recurring osteoperiostitis ending in ossification leads to the formation of a falciform protrusion and the formation of false saber tibiae. Periostitis and osteoperiostitis of the skull bones can lead to various changes in its shape. The most typical are the buttock-shaped skull and the Olympian forehead. In patients with early congenital syphilis, various forms of damage to the nervous system can be observed: hydrocephalus, specific meningitis, specific meningoencephalitis, cerebral meningovascular syphilis. The most typical form of damage to the organ of vision is damage to the retina and choroid - specific chorioretinitis. With ophthalmoscopy, mainly along the periphery of the fundus, small light or yellowish spots are found, alternating with dotted pigment inclusions. The visual acuity of the child does not suffer. Late congenital syphilis This form occurs in patients who previously had signs of early congenital syphilis, or in children with a long asymptomatic course of congenital syphilis. Late congenital syphilis refers to symptoms that appear 2 years or more after birth. Most often they develop between 7 and 14 years, after 30 years they rarely occur. The clinical picture of active late congenital syphilis is generally similar to acquired tertiary syphilis: tuberculous and gummous syphilis, lesions of the nervous system, internal organs, and the musculoskeletal system, as in tertiary syphilis, can be observed. But along with this, with late congenital syphilis, there are special clinical signs that are divided into reliable, probable and dystrophies. Reliable signs of late congenital syphilis, resulting from the direct impact of treponema on the child's organs and tissues, include parenchymal keratitis, specific labyrinthitis, and Hutchinson's teeth. Probable signs of late congenital syphilis include Robinson-Fournier radial perioral striae, true saber tibia, saddle nose, buttock-shaped skull, syphilitic gonitis. Probable signs are taken into account in combination with reliable or in combination with data from a serological examination, anamnesis. Dystrophies (stigmas) arise as a result of the indirect effect of the infection on the organs and tissues of the child and are manifested by their abnormal development. They acquire diagnostic value only when the patient simultaneously reveals reliable signs of late congenital syphilis, positive serological reactions. The most characteristic dystrophies are the following: a sign of Avsitidia - a thickening of the thoracic end of the clavicle, more often the right one; axifoidia (Keira's symptom) - the absence of the xiphoid process of the sternum; Olympic forehead with very convex frontal tubercles; high (Gothic) hard palate; symptom of Dubois - Gissar, or infantile little finger, - shortening and curvature of the little finger inward due to hypoplasia of the fifth metacarpal bone; hypertrichosis of the forehead and temples. 7. Diagnosis of syphilis The main diagnostic criteria: 1) clinical examination of the patient; 2) detection of pale treponema in the serous discharge of weeping syphilides of the skin and mucous membranes by examining the native drug crushed drop by dark-field microscopy; 3) results of serological reactions; 4) confrontation data (survey of sexual partners); 5) results of trial treatment. This diagnostic method is rarely used, only in late forms of syphilis, when other methods of confirming the diagnosis are not possible. With early forms of syphilis, trial treatment is unacceptable. 8. Principles of syphilis therapy Early forms of syphilis are completely curable if the patient is given therapy that is adequate to the stage and clinical form of the disease. In the treatment of late forms of the disease, in most cases, clinical recovery or stabilization of the process is observed. A specific treatment can only be given to a patient if the diagnosis of syphilis is clinically justified and confirmed in accordance with the criteria listed above. There are the following exceptions to this general rule: 1) preventive treatment, which is carried out in order to prevent the development of the disease to persons who have had sexual or close household contact with patients with early forms of syphilis, if no more than 2 months have passed since the contact; 2) prophylactic treatment prescribed for pregnant women who are ill or have had syphilis, but not taken off the register, in order to prevent congenital syphilis in a child, as well as children born to mothers who did not receive prophylactic treatment during pregnancy; 3) trial treatment. It can be prescribed for the purpose of additional diagnostics in case of suspected late specific damage to the internal organs, nervous system, sensory organs, musculoskeletal system in cases where it is not possible to confirm the diagnosis with laboratory tests, and the clinical picture does not allow to exclude the possibility of a syphilitic infection. The drugs of choice for the treatment of syphilis are currently antibiotics of the penicillin group: 1) durant (extended) penicillin preparations - the group name of benzathine benzylpenicillin (retarpen, extensillin, bicillin-1), ensuring that the antibiotic stays in the body for up to 18-23 days; 2) drugs of medium duration (procaine-benzylpenicillin, novocaine salt of benzylpenicillin), which ensure the stay of the antibiotic in the body for up to 2 days; 3) preparations of water-soluble penicillin (benzylpenicillin sodium salt), ensuring that the antibiotic remains in the body for 3-6 hours; 4) combination preparations of penicillin (bicillin-3, bicillin-5), ensuring that the antibiotic remains in the body for 3-6 days. The most effective preparations are water-soluble penicillin, the treatment of which is carried out in a hospital in the form of round-the-clock intramuscular injections or intravenous drip. The volume and duration of therapy depend on the duration of the syphilitic infection. Therapeutic concentration of penicillin in the blood is 0,03 IU / ml and above. In case of intolerance to drugs of the penicillin group, treatment of patients with syphilis is carried out with reserve antibiotics that have a wide spectrum of action - semi-synthetic penicillins (ampicillin, oxacillin), doxycycline, tetracycline, ceftriaxone (rocephin), erythromycin. Specific treatment for syphilis should be complete and vigorous. Medicines should be prescribed in strict accordance with the approved instructions for the treatment and prevention of syphilis - in sufficient single and course doses, observing the frequency of administration and the duration of the course. At the end of treatment, all patients are subject to clinical and serological monitoring. During observation, patients undergo a thorough clinical examination and serological examination every 3-6 months. Author: Sitkalieva E.V. << Back: Lichen planus >> Forward: Lupus
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