Syphilis is a chronic sexually transmitted disease caused by pale treponema. The causative agent is a pale treponema, having the form of a thin spiral-shaped filament with a length of 4 to 14 microns with small uniform curls. Outside the body, treponema live and retain virulence in a humid environment for several hours; they quickly die when dried, heated (at t 55 ° C for 15 minutes), under the influence of disinfectants, acids, alkalis. They are not very sensitive to cooling: when frozen, they remain viable for 2 to 3 days, which explains the cases of syphilis infection from a corpse.
Syphilis infection occurs in close contact of a healthy person with a patient with infectious manifestations of syphilis. The most common route of infection is sexual, but so-called syphilis is possible when the infection occurs with a kiss, using household items (such as a toothbrush, spoon) that the patient previously used, smoking cigarettes with the patient. The most dangerous in relation to the contagious manifestations of the primary and secondary periods of syphilis. Manifestations of the late (tertiary) period are practically not contagious due to the insignificant amount of treponemas in the lesion foci. In exceptional cases, the patient's blood may be the source of infection (transfusion syphilis - transmission of infection pathogens with the blood of a donor).
Pale treponema penetrate the skin or mucous membrane through the smallest damage - abrasions, cracks, etc. With the penetration of pale treponemas in the body, complex changes of an immunological nature occur. Throughout the disease, pale treponemas spread throughout all tissues and organs. Repeated (after cure) infections with syphilis (the so-called reinfection) are possible, since persistent immunity is not formed.
The clinical picture . The incubation period lasts an average of 3-4 weeks, but can be extended 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 the alternation of 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, central nervous system, etc. The primary, secondary and tertiary periods of syphilis are distinguished.
The primary period of syphilis lasts an average of 6 - 7 weeks. It is characterized by the occurrence of primary affect - hard chancre at the site of the introduction of pale treponemas and regional lymphadenitis. Frequent localization of solid chancre - genitals. The solid chancre, or primary syphiloma, is a small erosion (0.5 - 1 cm) or ulcer, round or oval in shape, with smooth edges and a dense infiltrate at the base, with a smooth shiny red surface, painless; inflammatory phenomena in its circle are absent. The formation of an atypical chancre is possible - a massive, painless indurative edema. With out-of-sex infection, the hard chancre is most often localized on the lips, chin, palatine tonsils (chancre-amygdalitis), fingers (chancre-panaritium).
5-7 days after the appearance of the solid chancre, the lymph nodes closest to it increase. They are dense (scleradenitis), with a diameter of up to 2-3 cm, painless, not welded to the skin and between each other, the skin above them is not changed. By the end of the primary period, lymph nodes of all groups increase (polyadenitis).
Secondary infection may join primary syphilis. With the localization of solid chancre on the inner sheet of the foreskin or in the crown of the glans penis, phimosis can occur. A more rare complication of solid chancre is paraphimosis , balanoposthitis, etc.
The primary period of syphilis is divided into primary seronegative, when the results of standard serological reactions (complement binding reaction, Wassermann reaction, Kahn reaction, Sachs-Vitebsky reaction) are negative, and primary seropositive, occurring on average 3-4 weeks after the appearance of solid chancre, when indicated serological reactions, and a little earlier - the immunofluorescence reaction becomes positive. Serological reactions remain positive for a long time.
By the end of the initial period, patients may experience general (prodromal) phenomena: malaise, fever, bone pain , headache . The solid chancre is scarred or epithelized, however, by the beginning of the secondary period, this process is usually not yet complete.
The secondary period of syphilis lasts an average of 3 to 4 years. There is a generalization of the process with damage to the skin and mucous membranes in the form of characteristic rashes (syphilis), a violation of the general condition of the body (malaise, weakness, low-grade fever, headaches, etc.), changes in the blood (positive serological reactions mentioned above; leukocytosis , anemia , increased ESR, etc.); lesions of the internal organs, bone and nervous systems are possible.
There are fresh, latent (latent) and recurrent secondary syphilis. Secondary fresh syphilis occurs after the initial period of syphilis and is characterized by an abundant, generalized (usually roseolous or papular) rash, polyadenitis and the presence of residues of hard chancre. Without treatment, after 2 to 4 months, the disease passes into secondary latent syphilis, in which all clinical manifestations disappear, however, 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 mild grouped rash of a papular, roseolous or pustular nature, alopecia, leukoderma, which is again replaced by secondary latent syphilis. Such relapses may be 2-4 or more.
In the secondary period of syphilis, roseous, papular, pustular rashes can be observed simultaneously. Roseolous rashes are pale pink, rounded spots with signs of inflammation, usually not peeling, not merging with each other and not accompanied by subjective sensations. Roseolous rash with secondary fresh syphilis is small, profuse, generalized; it is localized on the chest, abdomen, back, limbs. In secondary recurrent syphilis, the rash is large, scanty, usually grouped on the lateral surfaces of the chest, abdomen.
Papules with syphilis have a dark red (copper red) color, are clearly delimited, tight to the touch, the size of lentils (lenticular syphilis). Less common is the rash in the form of small ones, with millet grain, papules (miliary syphilis) and papules the size of a coin (coin-shaped syphilis). At the stage of resolution on the papules, a characteristic peeling is revealed: starting in the center, it then moves to the periphery, forming the so-called Beetta collar. With secondary fresh syphilis, the papular rash is plentiful, widespread; in case of secondary recurrent syphilis, it is grouped, large, scarce, more often localized on the chest, palms, soles, face, along the border of the scalp (the “Venus crown”), as well as in the region of the anus, genitals, where weeping, erosive are often formed and vegetative papules - wide warts. A large number of pale treponemas are found in their discharge. With pustular syphilis (a rare form), the rash consists of pustules with a dense infiltrate at the base. When the pustules dry, a crust forms. Distinguish between superficial forms of pustular syphilis (syphilitic impetigo , acne syphilis) and deep (syphilitic ecthyma, etc.).
On the mucous membranes there are erythematous and papular syphilis, which are sharply delimited from a healthy mucous membrane. Papules quickly become opal white due to swelling and maceration of the epithelium and are easily eroded. Secondary syphilis of the mucous membranes is extremely contagious. Papular rashes in the area of the vocal cords (folds) cause hoarseness of the voice. Often there is a specific sore throat as a result of papular rashes on the tonsils.
In the first months of the secondary period, temporary loss of hair on the head can occur, leading to general thinning of the hair, and in the secondary recurrent period of syphilis, small focal alopecia (see Alopecia). At the same time, syphilitic leukoderma usually appears: against the background of more pigmented skin on the back and side surfaces of the neck, much less often on the chest and back rounded depigmented spots are unsharp, the number of which is gradually increasing; subjective sensations are absent.
The tertiary period of syphilis develops after 3 to 4 years in patients who have not received full treatment. This period is characterized by damage to the skin and mucous membranes, internal organs (visceral syphilis; most often syphilitic aortitis), bones, and also the nervous system - neurosyphilis (syphilitic meningitis , spinal cord, progressive paralysis , etc.).
On the skin, mucous membranes and in other tissues, dense small formations (tubercles) or large (gum) appear, prone to decay and ulceration.
With tuberous syphilis in a limited area of the skin or mucous membrane, tubercles appear from hemp grain to dark red pea, dense to the touch, hemispherical in shape, not merging with each other and grouped into rings, arches, and garlands. They exist for a long time and then in some cases flatten and disappear, leaving areas of atrophy, and in others they undergo necrosis with the formation of ulcers, healing by scars surrounded by a pigmented border. Gummous syphilis is one, less often several isolated nodes (gum) located in the dermis and hypodermis. They are dense, on average the size of a walnut, and the skin above them is dark red. More often, gumma decays, starting from its central part and leading to the formation of a deep ulcer with sheer dense edges, the bottom of which is covered with necrotic decay (gummy rod). At the site of the ulcer, a rounded shape scar is formed, retracted, with a smooth or star-shaped surface. Less often, gumma resorption or its transformation into a dense fibrous node.
With damage to the mucous membrane of the nasal septum, hard and soft palate, slightly painful gummous infiltrates of bluish-red color develop. They quickly decompose and ulcerate, destroying bone and cartilage. The formation of perforations in the nasal septum, in the soft and hard palate causes severe respiratory failure, speech, makes eating difficult.
There are active and latent periods of tertiary syphilis. There are patients who immediately detect late tertiary skin lesions in the absence of data on previous infection with syphilis (the so-called unknown syphilis). It is assumed that the primary and secondary periods occur secretly or the initial manifestations of syphilis, as well as relapses of the secondary period of syphilis, were slightly expressed, and early skin manifestations were not seen by patients.
The diagnosis . In the presence of any erosion on the genitals, it is necessary to conduct a microscopic examination (dark-field microscopy): pale treponema is easily detected in the detachable solid chancre, weeping papule, or broad condyloma by characteristic movements (rotational, flexion, pendulum-like). If the test result is negative, it is repeated after 24 hours, during which lotions with sterile isotonic sodium chloride solution are used. With repeated negative microscopy results and a continuing suspicion of syphilis, punctured lymph nodes are taken for examination. Serological reactions in the initial period of syphilis do not have a decisive diagnostic value, since they become positive only 3 to 4 weeks after the appearance of hard chancre. The differential diagnosis is carried out with a soft chancre, tumors, vesicular lichen, chanciform pyoderma, acute ulcer of the vulva, etc. Importance is given to the clarification of sexual contacts.
In the secondary period, serological reactions are positive (Wassermann, sedimentary, Caen, Sachs-Vitebsky, immunofluorescence, immobilization of pale treponemal reactions). Treponema pallidum is usually easily detected by microscopic examination of the discharge of erosive papules, broad warts. The differential diagnosis is carried out with toxidermia, psoriasis, pink lichen, parapsoriasis, aphthae, hemorrhoids, pityriasis versicolor, alopecia, etc. In the tertiary period, it is difficult to detect pale treponema in the separated tubercles and gum. The diagnosis is confirmed by the positive results of serological reactions. However, it must be borne in mind that the Wassermann reaction during this period can give a negative result. A differential diagnosis is carried out with lupus tuberculosis, inductive skin tuberculosis, vasculitis and other diseases.
Congenital syphilis. Occurs with intrauterine infection of the fetus 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 fetal syphilis, the placenta is usually large. If the infection of the fetus occurs at the V-VI months of pregnancy, premature birth can occur. The fetus is born dead, macerated, with damage to the liver, spleen, lungs. If the mother is infected in the last months of pregnancy, the baby may show signs of syphilis in a few weeks, and a positive Wasserman reaction - at the 3rd month of life.
Syphilis in infants is a direct continuation of fetal syphilis. The child is anxious, sluggishly sucking his chest, there is a pained facial expression, pale gray skin, slight increase in body weight, sweating, causeless increase in body temperature, digestive upset. In some cases, syphilitic pemphigus is observed, which, unlike the epidemic pemphigus of newborns, is found at birth or in the first days of life and is localized mainly on the soles and palms. Bubbles ranging in size from a pea to a cherry on an inflamed base appear, filled with serous-purulent or hemorrhagic fluid with a large number of pale treponemes. When opening the bubbles, erosion is formed, epithelizing as the infiltrate resolves. Diffuse skin tightening (Hochsinger infiltration) occurs in 60-65% of patients at 8-10 weeks of life. On the face, scalp, buttocks, soles and palms, the skin is infiltrated, has a brownish-red color, glistens. The lips are thickened, swollen, in cracks. Scars remain around the mouth for life. Infiltration of the scalp, eyelashes and eyebrows ends with hair loss. At the 4-8th week of life, a papular rash of brown-red color, sharply delimited from the surrounding skin, may appear on the face, outer surface of the limbs and soles.
A relatively common symptom is syphilitic runny nose. From birth, the baby’s nose is stuffed up, then mucopurulent or successive discharge appears, shrinking into crusts. Breathing is very difficult, sucking is impossible. In advanced cases, the destruction of the cartilaginous septum of the nose and the hard palate (saddle nose, Gothic sky) may occur. When the larynx is affected, the voice is hoarse, aphonic. Specific bone changes, most often osteochondritis, are systemic in nature. The liver and spleen are almost always affected, they are enlarged, dense. The abdomen is swollen, ascites and jaundice are possible. In the lungs, diffuse proliferation of connective tissue in the circumference of the alveoli and small vessels is noted - the so-called white pneumonia , which manifests itself as cyanosis, shortness of breath, is protracted and has a tendency to abscess formation. Possible damage to the kidneys, gastrointestinal tract, central nervous system (meningitis, hydrocephalus), heart (endomyocarditis).
The predominant symptom of syphilis in early childhood are condylomas of the anus. On the skin, dense nodes (gum) and weeping papules in folds are possible, hair often falls out, bones, testicles, central nervous system (mental retardation, optic atrophy, epilepsy , meningitis) are affected. Gumma can occur in the brain.
Late congenital syphilis is a relapse of syphilis, transferred and not cured in early childhood. Reliable and probable signs of late congenital syphilis are distinguished. Reliable signs include the so-called Getchinson triad: barrel-shaped teeth with a half-moon recess along the chewing edge (Getchinson's teeth), keratitis , deafness as a result of the defeat of the labyrinth. The probable signs are saber-shaped tibia, buttock-shaped skull, Gothic palate, absence of the xiphoid process of the sternum, etc. Syphilis on the skin, lesions of the liver, spleen, cardiovascular and endocrine systems are possible; speech impairment, mental retardation.
A child with active manifestations of syphilis on the skin and mucous membranes is contagious to others, so when caring for him, the staff should work in rubber gloves and disinfect their hands. All children with early congenital syphilis should be reported to children's counseling centers. If congenital syphilis is suspected, the child’s blood is sent for a serological examination. A sick child is placed for treatment in a hospital of a skin and venereologic dispensary.
The treatment of syphilis is complex. Prescribe antibiotics, bismuth and iodine preparations (according to the schemes); to increase the body's resistance to infection - pyrogenal, prodigiosan, etc .; autohemotherapy, B vitamins, biogenic stimulants (aloe, vitreous, etc.). A full-fledged treatment, especially begun in the early periods of the disease, provides a cure for patients.
With congenital syphilis, systematic treatment from the 1st month of life can lead to a complete recovery.
Preventive treatment is given to children born to mothers with syphilis who have not previously been treated or have not been sufficiently treated, even if the children do not have clinical symptoms and negative serological reactions. At the end of treatment, children remain under the supervision of the dispensary for 5 years.
Public and personal prevention of syphilis is carried out according to the general rules for combating sexually transmitted diseases and includes the following measures.
1) full-fledged roll-call of patients with sexually transmitted diseases For a patient with a first established diagnosis of a 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, an emergency notification is sent within 24 hours to the district epidemiologist, who is obliged to monitor the timeliness of hospitalization of the patient, examination of his family members and those who had close contact with him or her, and identification and treatment of the person who was the source of infection;
2) compulsory hospitalization of all patients with infectious syphilis within 24 hours upon diagnosis in the skin and venereologic hospital or department of the somatic hospital (district, district) in a separate ward. Pregnant women and children with syphilis are also subject to treatment in a hospital;
3) urgent involvement of the sick family members in the examination. Patients identified in this case, as well as patients who served as a source of infection, are treated according to approved schemes. The remaining people who were in close contact with patients receive preventive treatment. Calls for examination are carried out by patronage sisters: in this case, the rules of deontology should be strictly observed without disclosing information about the patient;
4) systematic monitoring of the accuracy of treatment (reminders, calls through a foster sister or a closed letter). In cases of changing the patient’s place of residence, it is necessary to notify the venereological department of the new place of residence about this. The patient is deregistered at the old place of residence only after receiving notice of his registration at the new place of residence;
5) examination of children admitted to child care facilities by a pediatrician. If a sexually transmitted disease is suspected, they are referred for consultation to a dermatologist. The staff of children's institutions undergo a physical examination at least 1 time in 6 months. Children suffering from contagious syphilis can only be admitted to child care facilities after two courses of treatment, subject to systematic medical supervision. Children with congenital syphilis (seropositive), in the absence of clinical manifestations, can be admitted to institutions after one course of specific treatment, subject to follow-up. Children entering children's homes, orphanages, boarding schools undergo clinical and serological examinations;
6) preventive measures against 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; establishing a close relationship between the venereological institution, antenatal care and the maternity ward for the purpose of mutual notification of patients;
7) hygienic education of the population.
In gynecological, urological and dental offices, it is necessary to thoroughly sterilize the instruments. In all cases of suspicion of syphilis (erosion and ulcers in the genital area, rashes on the oral mucosa, etc.), patients should be referred for examination by a venereologist; it is impossible to prescribe antibiotics even locally, as this dramatically complicates the detection of pale treponemas; before referral to a doctor, one should confine oneself to lotions with isotonic sodium chloride solution only.
A large role belongs to personal prevention. In case of accidental sexual intercourse, it is recommended immediately after sexual intercourse to thoroughly wash the genitals and adjacent areas of the body with warm water and soap, treat with gibitana. In case of suspected infection with syphilis, you must contact the venereological care center or the nearest medical institution where the urethra is washed with a solution of potassium permanganate, a solution of protargol is instilled into the urethra and rubbed into the skin with 33% calomel ointment.