SYPHILIS

SYPHILIS is a chronic venereal disease caused by pale treponema. Pathogen - pale treponema, having the form of a thin spiral-shaped filament from 4 to 14 microns in length with fine uniform curls. Outside the body treponema live and retain virulence in a humid environment for several hours; They quickly die on drying, heating (at t 55 ° C for 15 min), under the influence of disinfectants, acids, alkalis. Cooling is not very sensitive: during freezing, they remain viable for 2 to 3 days, which explains the cases of syphilis infection from the corpse.

Infection with syphilis occurs with close contact of a healthy person with a patient who has infectious manifestations of syphilis. The most frequent way of sexual infection, however, is the so-called common syphilis, when infection occurs when kissing, using household items (such as a toothbrush, spoon), which the patient used before, smoking one with a sick cigarette. The manifestations of the primary and secondary periods of syphilis are most dangerous with respect to infectiousness. The manifestations of the late (tertiary) period are almost not contagious due to the small number of treponemes in the lesions. In exceptional cases, the source of infection may be the patient's blood (transfusion syphilis - transmission of infectious agents with donor blood).

Pale treponemes penetrate the skin or mucous membrane through the smallest damage - abrasions, cracks, etc. With the penetration of pale treponem in the body there are complex changes in the immunological nature. Throughout the disease, pale treponema spreads to all tissues and organs. Possible repeated (after treatment) infection with syphilis (the so-called reinfection), since no permanent immunity is formed.

Clinical picture . The incubation period lasts an average of 3-4 weeks, but it can lengthen if during this period the patient takes antibiotics for another disease. In rare cases, the incubation period is shortened to 8-15 days.

The course is characterized by alternating periods of active (active syphilis) and latent (latent syphilis) manifestations. The clinical picture of the disease is gradually becoming more pronounced, up to the development of severe irreversible changes in the cardiovascular system, the central nervous system, etc. There are primary, secondary and tertiary periods of syphilis.

The primary period of syphilis lasts an average of 6 to 7 weeks. It is characterized by the emergence of a primary affect - a solid chancre at the site of the introduction of pale treponem and regional lymphadenitis. Frequent localization of a solid chancre is the genitals. Hard chancre, or primary syphilloma, is a small erosion (0.5-1 cm) or ulcer, round or oval in shape, with even margins and a dense infiltrate at the base, with a smooth shiny surface of red, painless; There are no inflammatory phenomena in its circumference. Perhaps the formation of atypical chancre - a massive painless indurative edema. With extra-viral infection, the hard chancre is most often localized on the lips, chin, palatine tonsils (chancre amygdalitis), fingers (chancre-panaricium).

After 5 - 7 days after the appearance of a solid chancre, the nearest lymph nodes increase. They are dense (scleradenitis), up to 2 - 3 cm in diameter, painless, not soldered to the skin and between themselves, the skin over them is not changed. By the end of the primary period, the lymph nodes of all groups (polyadenitis) increase.

A secondary infection can join the primary syphilis. With the localization of a solid chancre on the inner leaf of the foreskin or in the crown of the glans penis, phimosis may occur. A more rare complication of a solid chancre is paraphimosis , balanoposthitis, and others.

The primary period of syphilis is divided into primary seronegative, when the results of standard serological reactions (complement fixation reaction, Wasserman reaction, Kahn reaction, Sachs-Vitebsky reaction) are negative, and primary seropositive, occurring on average 3 to 4 weeks after the appearance of chancre, when these Serological reactions, and somewhat earlier - the reaction of immunofluorescence become positive. Serological reactions remain positive for a long time.

By the end of the primary period, patients may experience general (prodromal) events: malaise, fever, bone pain , headache . The hard chancre is cicatrized or epithelialized, but by the beginning of the secondary period this process is usually not completely completed.

The secondary period of syphilis lasts an average of 3 to 4 years. Generalization of the process with skin and mucous membrane damage in the form of characteristic rashes (syphilids), a violation of the general state of the organism (malaise, weakness, subfebrile body temperature, headaches, etc.), changes in blood (positive serological reactions mentioned above, leukocytosis , anemia , Increased ESR, etc.); Possible lesions of internal organs, bone and nervous systems.

There are fresh, latent (latent) and recurrent secondary syphilis. Secondary fresh syphilis follows the primary period of syphilis and is characterized by a plentiful, generalized (more often roseous or papular) rash, polyadenitis, and the presence of the remains of a solid chancre. Without treatment, after 2-4 months, the disease becomes secondary latent syphilis, in which all clinical manifestations disappear, but serological reactions remain positive. The duration of secondary latent syphilis is 1-3 months or more. Then there is a secondary recurrent syphilis, characterized by a non-unified grouped rash of papular, roseous or pustular nature, alopecia, leukoderma, which again gives way to secondary latent syphilis. Such relapses can be 2-4 or more.

In the secondary period of syphilis can be observed simultaneously rozoleoznye, papular, pustular eruptions. Roseolaotic eruptions - pale pink, rounded spots with signs of inflammation, usually not flaking, not merging with each other and not accompanied by subjective sensations. Roseolous rash with secondary fresh syphilis small, abundant, generalized; It is localized on the chest, abdomen, back, limbs. With secondary recurrent syphilis, the rash is large, lean, usually grouped on the lateral surfaces of the chest, abdomen.

Papules with syphilis have a dark red (copper-red) color, clearly delineated, dense to the touch, the size of a lentil (lenticular syphilide). Less common is a rash in the form of small, with millet grains, papules (miliary syphilids) and papules the size of a coin (coin syphilis). At the stage of resolution on the papules, characteristic peeling emerges: beginning in the center, it then retreats to the periphery, forming the so-called collar of Biett. With secondary fresh syphilis, the papular rash is abundant, common; With secondary recurrent syphilis, it is grouped, large, scanty, more often localized on the chest, palms, soles, face, along the border of the scalp ("crown of Venus"), as well as in the anus, genitalia, where often damp, erosive And vegetative papules - wide condylomata. In their detachable are a large number of pale treponem. With pustular syphilis (a rare form), the rash consists of pustules with a dense infiltrate at the base. When the pustules dry out, a crust is formed. There are surface forms of pustular syphilidae (syphilitic impetigo , acne-like syphilidae) and deep (syphilitic ectima, etc.).

On the mucous membranes there are erythematous and papular syphilis, which are sharply delimited from the healthy mucosa. Papules quickly take opal-white color due to swelling and maceration of the epithelium and are easily eroded. Secondary syphilis mucous membranes are extremely contagious. Papular eruptions in the area of ​​the vocal cords (folds) cause hoarseness of the voice. Quite often there is a specific angina as a result of papular eruptions on palatine tonsils.

In the first months of the secondary period, temporary hair loss on the head may occur, leading to general hair thinning, and in the secondary recurrent period of syphilis - small-frontal baldness (see Alopecia). At the same time, syphilitic leukoderma usually appears: against the backdrop of more pigmented skin on the posterior and lateral surfaces of the neck, the rounded depigmented spots are less prominent on the chest and back, the number of which gradually increases; Subjective sensations in this case are absent.

The tertiary period of syphilis develops after 3 to 4 years in patients who have not received adequate treatment. This period is characterized by damage to the skin and mucous membranes, internal organs (visceral syphilis, most often - syphilitic aortitis), bones, and the nervous system - neurosyphilis (syphilitic meningitis, dorsal, progressive paralysis, etc.).

On the skin, mucous membranes and other tissues appear dense small formations (tubercles) or large (gum), prone to decay and ulceration.

With tubercular syphilis on a limited area of ​​the skin or mucous membrane, there are tubercles ranging from hemp seeds to peas of dark red color, dense to the touch, hemispherical, not merging with each other and grouped into rings, arcs, garlands. They exist for a long time and then in some cases become flattened and disappear, leaving areas of atrophy, while in others they are necrotic with the formation of ulcers that heal with scarring surrounded by a pigment rim. Hummous syphilide - one, rarely several isolated nodes (gumm), located in the dermis and hypodermis. They are dense, the size of an average walnut, the skin over them is dark red. More often the decay of gum begins, beginning with its central part and leading to the formation of a deep ulcer with steep, dense edges, the bottom of which is covered with necrotic decay (gummy rod). At the site of an ulcer, a scar of rounded outline is formed, drawn, with a smooth or stellate surface. Less common is the absorption of gum or the transformation of it into a dense fibrous node.

When lesions of the mucous membrane of the nasal septum, the hard and soft palate develop malignant gummy infiltrates of bluish-red color. They quickly decompose and ulcerate, destroying bone and cartilaginous tissue. The formation of perforations in the nasal septum, in the soft and hard sky, causes severe breathing disorders, speech, and difficulty in eating.

There are active and latent periods of tertiary syphilis. There are patients who discover immediately late tertiary skin lesions in the absence of data on the previous infection with syphilis (the so-called unknown syphilis). It is assumed that the primary and secondary periods are hidden or the initial manifestations of syphilis, as well as relapses of the secondary period of syphilis, were negligible, and early skin manifestations were not noticed by patients.

The diagnosis . In the presence of any erosion on the genitals it is necessary to conduct a microscopic examination (darkfield microscopy): pale treponema is easily detected in the separated chancre, papules, or wide condyloma by characteristic movements (rotational, flexural, pendulum). If the test is negative, it is repeated after 24 hours, during which lotions with a sterile isotonic sodium chloride solution are used. With repeated negative results of microscopy and persisting suspicion of the presence of syphilis, a punctate of the lymph node is taken for examination. Serological reactions in the primary period of syphilis do not have a decisive diagnostic value, since they become positive only 3 to 4 weeks after the appearance of a solid chancre. Differential diagnosis is carried out with mild chancroid, tumors, bladderwort, chancreiform pyoderma, acute ulcer of the vulva, etc. Importance is attached to clarifying sexual contacts.

In the secondary period, positive serological reactions (Wassermann's reactions, sedimentary, Kana, Zaksa-Vitebsk, immunofluorescence, immobilization of pale treponemes). Pale treponema is usually easily detected by microscopic examination of detachable erosive papules, wide condylomas. Differential diagnosis is carried out with toxidermy, psoriasis, pink lichen, parapsoriasis, aphthae, hemorrhoids, pityriasis, alopecia, etc. In the Tertiary period, it is difficult to detect pale treponema in detached tubercles and hum. The diagnosis is confirmed by positive results of serological reactions. However, it must be taken into account that Wasserman's reaction in this period can give a negative result. Differential diagnosis is performed with tuberculous lupus, inducible skin tuberculosis, vasculitis and other diseases.

Congenital syphilis. Occurs when the fetus is prenatal from a sick mother. There are congenital syphilis of the fetus, syphilis of infants, syphilis of early childhood (from 1 year to 4 years) and late congenital syphilis (from 4 to 17 years).

With syphilis of the fetus, the placenta is usually large. If fetal infection occurs during V-VI months of pregnancy, premature birth may occur. The fetus is born dead, macerated, with damage to the liver, spleen, lungs. When a mother is infected in the last months of pregnancy, the symptoms of syphilis in a child may appear in a few weeks, and the positive reaction of Wasserman is at the 3rd month of life.

Syphilis in infants is the direct continuation of syphilis of the fetus. The child is restless, sluggishly sucks his chest, there is a painful look on his face, pale gray color of the skin, slight increase in body weight, sweating, unreasonable fever, digestive upset. In a number of cases, syphilitic pemphigus is observed, which unlike epidemical pemphigus of newborns is detected at birth or in the first days of life and is localized mainly on the soles and palms. Bubbles appear as large as pea to cherry on the inflamed base, filled with a serous-purulent or hemorrhagic fluid with a large number of pale treponemes. When the blisters are opened, erosions are formed, epithelizing as the infiltrate dissolves. Diffusive firming of the skin (Hochsinger infiltration) occurs in 60-65% of patients at the 8-10th week of life. On the face, hairy part of the head, buttocks, soles and palms, the skin is infiltrated, has a brownish-red color, shines. Lips thickened, edematous, in cracks. Around the mouth for life scars remain. Infiltration of the scalp, eyelashes and eyebrows ends with hair loss. At the 4th-8th week of life, a papular rash of brownish-red color, sharply delimited from the surrounding skin, may appear on the face, the outer surface of the limbs and soles.

A relatively common symptom is a syphilitic runny nose. Since the birth of the child's nose is laid, then there are mucopurulent or suprascal discharges, which shrink into the crusts. Breathing is hampered, sucking is impossible. In neglected cases, destruction of the cartilaginous septum of the nose and hard palate (saddle nose, Gothic sky) may occur. When the larynx is affected, the voice is hoarse, aphonic. Specific changes in bones, most often osteochondritis, are systemic in nature. Almost always the liver and spleen are affected, they are enlarged, dense. The stomach is swollen, ascites and jaundice are possible. In the lungs there is a diffuse proliferation of connective tissue in the circumference of the alveoli and small vessels - the so-called white pneumonia , which manifests itself as cyanosis, dyspnea, is protracted and tends to abscess. Possible damage to the kidneys, gastrointestinal tract, central nervous system (meningitis, hydrocephalus), heart (endomyocarditis).

The predominant symptom of syphilis of early childhood is the condylomas of the anus. On the skin tight knots (gum) and wet papules in the folds are possible, hair often falls out, bones, testicles, CNS are affected (mental retardation, optic nerve atrophy, epilepsy , meningitis ). Gums can appear in the brain.

Late congenital syphilis is a relapse of syphilis, suffered and not cured in early childhood. There are significant and probable signs of late congenital syphilis. Reliable attributes include the so-called Gatchinson triad: barrel-shaped teeth with a semilunar notch on the chewing edge (getschinonski teeth), keratitis, deafness as a result of the defeat of the labyrinth. Probable signs are saber-shaped shins, a buttock-like skull, a Gothic sky, the absence of a xiphoid process of the sternum, etc. Syphilis on the skin, lesions of the liver, spleen, cardiovascular and endocrine systems are possible; Speech disturbance, mental retardation.

A child with active manifestations of syphilis on the skin and mucous membranes is contagious to others, so when caring for him, staff should work in rubber gloves, disinfect their hands. All children who are sick with early congenital syphilis should be informed of the child's consultations at the place of residence. If a suspected congenital syphilis is suspected, the child's blood is sent for serological examination. A sick child is placed for treatment in the hospital of a dermatological-venereologic dispensary.

Treatment of syphilis is complex. Prescribe antibiotics, preparations of bismuth and iodine (according to the schemes); To increase the body's resistance to infection - pyrogenal, prodigiozan, etc .; Autohemotherapy, vitamins of group B, biogenic stimulators (aloe, vitreous body, etc.). Complete treatment, especially begun in the early periods of the disease, provides a cure for patients.

With congenital syphilis, systematic treatment from the first month of life can lead to complete recovery.

Preventive treatment is given to children born to mothers with syphilis who have not previously been treated or treated adequately, even in the absence of clinical symptoms and negative serological responses in children. After the treatment, the children remain under the supervision of the dispensary for 5 years.

Public and personal prophylaxis of syphilis is carried out according to the general rules for combating venereal diseases and includes the following activities.

1) a full-fledged register of patients with sexually transmitted diseases. On the patient with a newly diagnosed venereal disease, the doctor who established this diagnosis, regardless of his specialty, fills out a special notice. When an infectious form of syphilis is established within 24 hours, emergency notification is sent to the district epidemiologist, who is obliged to monitor the timeliness of hospitalization of the patient, the examination of members of his family and persons who were with him in close personal or sexual contact, the identification and treatment of the person who was the source of infection;

2) obligatory hospitalization of all patients with infectious forms of syphilis within 24 hours upon diagnosis in the dermatovenerologic hospital or department of the somatic hospital (district, district) into a separate ward. Pregnant and children suffering from syphilis are also treated in hospital;

3) urgent involvement in the examination of family members of the sick person. The patients, as well as the patients, who were the source of infection, are treated according to the approved schemes. The remaining persons, who were in close contact with the patients, receive preventive treatment. Calls for examination are carried out by visiting patrons: at the same time, the rules of deontology should be strictly observed, without disclosing information about the patient;

4) systematic monitoring of the accuracy of the treatment (reminders, calls through a visiting nurse or closed letter). In cases of a change in the place of residence of the patient, it is necessary to notify the venereological department about this at the new place of residence. The patient is removed from the record of the old place of residence only after receiving a notice of taking him on record at the new place of residence;

5) examination of children admitted to children's institutions by a pediatrician. When suspected of a venereal disease, they are referred for consultation to a dermatologist. The personnel of children's institutions are subjected to a medical examination at least once every 6 months. Children infected with infectious forms of syphilis, only after two courses of treatment can be admitted to children's institutions subject to systematic medical supervision. Children with congenital syphilis (seropositive), in the absence of their clinical manifestations, can be admitted to children's institutions after one course of specific treatment, provided that they receive dispensary follow-up. Children entering children's homes, orphanages, boarding schools, undergo a clinical and serological examination;

6) preventive measures for congenital syphilis: clinical and serological examination of pregnant women (in the first and second half of pregnancy); Investigation of each case of early congenital syphilis; Establishment of a close relationship between the venereological institution, the women's consultation and the maternity home for the purpose of mutual notification of patients;

7) hygienic education of the population.

In gynecological, urological and dental offices, it is necessary to carefully sterilize the instruments. In all cases of suspected syphilis (erosion and ulcers in the genital area, rashes on the oral mucosa, etc.), patients should be referred for examination to a venerologist; It is not possible to prescribe antibiotics even locally, as this makes it very difficult to detect pale treponemes; Before going to the doctor should be limited to only lotions isotonic sodium chloride solution.

A big role belongs to personal prevention. In case of accidental sexual intercourse, immediately after sexual intercourse, it is recommended to thoroughly wash the genitals and adjacent areas of the body with warm water and soap, and treat with gibitane. In case of suspected infection with syphilis, it is necessary to go to the venereological department or to the nearest medical institution where the urethra is washed with a solution of potassium permanganate, a solution of protargolum is injected into the urethra and 33% calomel ointment is rubbed into the skin.