Malignant syphilis. Latent, malignant and “decapitated” syphilis

Syphilis is caused by a bacterium called Treponema pallidum.

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

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

How is syphilis transmitted?

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

The cause of infection can be not only vaginal, but also anal and oral-vaginal contact. The second way of transmitting syphilis is through household modern world became less widespread.

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

Signs

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

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

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

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

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

Signs of tertiary syphilis:

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

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

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

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

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

On average, the first signs of syphilis can be noticed after 3-4 weeks, but sometimes this period can last up to 6 months.
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In the vast majority of cases, the onset of the disease is indicated by the appearance of primary syphilis - chancre. This is a small, painless ulcer of a round or oval shape, with a dense base.

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

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

In men

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

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

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

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

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

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

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

Primary signs

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

Reversible manifestations

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

Irreversible manifestations

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

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

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

Does syphilis affect hair?

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

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

However, the hair in these areas does not completely fall out, and the overall picture resembles “moth-eaten fur.”
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The second type of baldness due to syphilis is “diffuse” baldness, that is, uniform damage to the entire scalp. This symptom occurs not only with syphilis, but also with many other diseases (pyoderma of the scalp, systemic lupus erythematosus, seborrhea and others).

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

In addition, rashes on the scalp often become covered with a greasy crust and appearance very reminiscent of seborrhea.

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

Can eyebrows or eyelashes be affected by syphilis?

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

Are teeth affected by syphilis?

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

Can acne be a symptom of syphilis?

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

They are quite difficult to distinguish from ordinary acne.

You should suspect syphilis if:

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

Is there discharge from the genital tract with syphilis?

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

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

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

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

Incubation period

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

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

Primary stage of syphilis and its symptoms

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

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

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

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

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

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

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

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

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

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

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

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

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

Hard chancre on the genitals

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

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

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

Syphilis occurs in three clinical periods:

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

Third stage

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

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

Stage of primary syphilis

Congenital syphilis

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

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

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

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

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

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

Fortunately, syphilis during pregnancy is treatable.

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

Early congenital syphilis

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

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

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

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

Secondary syphilis

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

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

In addition, with secondary syphilis there may be:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

— elevated temperature;

— headache;

- decreased appetite;

- dizziness;

- increased fatigue and malaise;

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lenticular rash with secondary recurrent syphilis

Pustular (pustular) rash with secondary syphilis

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

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

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

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

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

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

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

How is syphilis diagnosed?

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

It is for this reason that doctors diagnose the disease itself using a visual examination of the patient, detection on the body characteristic symptoms and through laboratory testing.

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

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

In addition, doctors conduct various tests:

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

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

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

Possible consequences

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

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

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

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

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

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

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

Late stage complications include:

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

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

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

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

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

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

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

Treatment of syphilis

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

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

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

Video - Consequences, complications and prevention of syphilis

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

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

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

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

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

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

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

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

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

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

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

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

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

) It should be noted that at the early stage of syphilis, antibacterial treatment is most effective and leads to complete cure.
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During the course of treatment, the attending physician can adjust the treatment regimen and, if necessary, prescribe a second course of antibiotic therapy.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Follow-up

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

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

Diagnostics

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How to recognize syphilis on different active and chronic stages, the doctor knows. If you suspect a disease, you should contact a dermatovenerologist.

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

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

Possible complications

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

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

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

Pregnant mothers and newborns

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

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

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

Neurological problems

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

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

Cardiovascular problems

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

HIV infection

Prevention of syphilis

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

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

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

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

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

Without fail, all sexual and household contacts of the patient must be identified, examined and sanitized in order to prevent the possibility of the spread of infection among the population.
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During the entire period of clinical observation, patients who have had syphilis are required to abstain from sexual intercourse, and they are also prohibited from being blood donors.

Public prevention measures are considered to be:

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

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

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Syphilis is a chronic infectious venereal disease characterized by damage to the skin, mucous membranes, internal organs, bones and nervous system.

Causes of syphilis : the causative agent of syphilis is Treponema pallidum. Its typical representatives are thin spiral-shaped microorganisms 0.2 microns wide and 5-15 microns long. To identify pallidum treponema, a dark field microscope or immunofluorescent staining is used. The spirals are so thin that they are difficult to detect.

The causative agent of syphilis is an unusual microorganism in its structure, physiology and nature of interaction with the microorganism. Considering the duration of untreated syphilis, it can be assumed that treponemes manage to overcome the body's defenses. The patient's immune system cannot completely neutralize the pathogen if treatment is not adequate. Then viable treponemes remain in the body for a long time, for years. The presence of factors that weaken the immune system can lead to syphilis returning even after “full” treatment. Serological and clinical relapses are often accompanied by: HIV infection, radiation exposure, drug addiction, and occupational hazards.

Under unfavorable living conditions (exposure to antibiotics, lack of nutrition, etc.), treponemes can form “survival forms”

Transmission routes

Syphilis is transmitted mainly through sexual contact. Infection occurs through small genital or extragenital skin defects or through the epithelium of the mucous membrane upon contact with erosive or ulcerative chancroid, erosive papules on the skin and mucous membranes of the genital organs, oral cavity, hypertrophic papules (condylomas lata) containing a significant amount of syphilis pathogens - pale Treponem.

Rarely, infection can occur through close household contact, in exceptional cases - through household items or through contact with experimental animals.

There are cases of infection of newborn children while feeding with milk from a wet nurse who had manifestations of syphilis in the nipple area. Infection is also possible through the milk of a nursing woman with syphilis, who has no clinical signs of damage to the nipple of the mammary gland. It is possible that in this case specific elements are located along the excretory ducts of the mammary glands.

Treponema pallidum can be found in saliva only when there are specific rashes on the oral mucosa, so infection through kisses and bites is likely.

Infection is possible through the sperm of a patient who does not have any visible changes in the genitals. In this case, obviously, erosions are located along the urethra (there are known cases of chancre formation in the urethra). When blood is transfused from donors with syphilis, recipients develop transfusion syphilis.

Possible infection medical personnel when examining patients with syphilis, performing medical procedures and manipulations, coming into contact with the internal organs of patients (during surgical intervention), during autopsies of corpses, especially newborns with early congenital syphilis.

Intrauterine infection of the fetus through transplacental transmission of the causative agent of syphilis from an infected mother has been noted. Infection can also occur at the time of birth when the fetus passes through the birth canal infected with syphilis.

It is now considered proven that patients with early forms of syphilis can be sources of infection for 3-5 years. Patients with late forms of syphilis (with a disease duration of more than 5 years) are usually non-contagious.

Treponema pallidum enters the human body through damaged areas of the epidermis. However, intact mucous membranes can also serve as entry points for infection. In some cases, the damage may be so minor that it remains invisible to the eye or is located in places inaccessible for examination. Although infection does not occur in all cases, due to the lack of reliable tests for determining infection, there cannot be complete confidence that infection has not occurred. Therefore, for practical reasons, persons who have been in close contact with patients with syphilis over the past 4 months. and do not have pronounced clinical and serological manifestations of infection, preventive treatment is recommended.

The reaction to the introduction of the syphilis pathogen is complex and diverse. After contact with a patient with syphilis, infection may not occur, or a classic or long-term asymptomatic course of infection may occur. Sometimes late forms of acquired syphilis develop (syphilis of the nervous system, internal organs, bones and joints).

Clinical observations and experimental studies showed that infection may not occur in cases where a small amount of the pathogen enters the body or in the blood serum of healthy people high level thermolabile, treponemostatic and treponemocidal substances that cause immobility.

During syphilis there are four periods: : incubation and three clinical (primary, secondary and tertiary), which successively replace each other. The incubation period lasts on average 3-4 weeks, but can be shortened (8-15 days). It can last up to 108 or even 190 days if the patient took antibiotics for other diseases (sore throat, pneumonia, gonorrhea, pyoderma, etc.) , which leads to an uncharacteristic course of syphilis.

Conducted electron microscopic studies made it possible to establish that the greatest damage in the skin of patients with early forms of syphilis is caused by its nervous system and vascular network, with adjacent areas of connective tissue.

The entry of the syphilis pathogen into the nervous tissue of the skin in the early stages of infection with the development of characteristic pathological changes in the peripheral nerves has practical significance. This emphasizes the importance of the fact that in the treatment of syphilis, including its early forms, certain treatment regimens are necessary.

Primary lesions in syphilis

Primary lesions in syphilis are localized on the skin and mucous membranes of the genitals. About 10% of patients have extragenital primary lesions (eg, in the oral cavity).

The primary lesion always disappears spontaneously, without treatment. However, the infection spreads throughout the body through hematogenous and lymphogenous routes, which causes various forms of manifestation of the disease.

Secondary lesions in syphilis

After 2-10 weeks. secondary lesions in the form of reddish-brown rashes are observed on the skin of the entire body. In the areas: genital, ierionic, axillary, papular syphilides are transformed into flat, weeping clusters of papules - condylomas lata. All transitional forms are also possible - from macular erythema of the mucous membrane to erosions and ulcerations. Syphilitic meningitis, tonsillitis, chorioretinitis, hepatitis, nephritis and periostitis may develop. Small patchy (“areolar”) hair loss is observed.

The manifestations of syphilis are extremely diverse, as a result of which in venereology it is called the “great imitator”.

Both primary and secondary lesions contain large numbers of pathogens and therefore represent the most common source of infection. Contagious lesions may reappear 3-5 years after infection, but in the future patients are not a source of infection.

Secondary lesions also disappear spontaneously. Syphilitic infection can occur in a subclinical form; in some cases, patients endure the primary or secondary or both stages without noticing signs of the disease. Subsequently, such patients develop tertiary lesions.

Tertiary stage of syphilis

The tertiary stage of syphilis is characterized by the development of granulomatous lesions (gummas) in the skin, bones, liver, brain, lungs, heart, eyes, etc. Degenerative changes occur (paresis, tabes dorsalis) or syphilitic lesions of cardio-vascular system(aortitis, aortic aneurysm, aortic valve insufficiency). In all tertiary forms, treponema pallidums are found extremely rarely and in small quantities, and a pronounced tissue reaction is caused by the development of hypersensitivity to them. In late forms of syphilis, treponemes can sometimes be detected in the eye

Malignant syphilis

The tertiary stage of syphilis is characterized by the development of granulomatous lesions (gummas) in the skin, bones, liver, brain, lungs, heart, eyes, etc. Degenerative changes occur (paresis, tabes dorsalis) or syphilitic lesions of the cardiovascular system (aortitis, aortic aneurysm, aortic valve insufficiency). In all tertiary forms, treponema pallidums are found extremely rarely and in small quantities, and a pronounced tissue reaction is caused by the development of hypersensitivity to them. In late forms of syphilis, treponemes can sometimes be detected in the eye.

One of the variants of clinical syphilis is malignant syphilis. It is characterized by an acute, severe course. As a rule, lesions of the skin and mucous membranes are especially pronounced. At malignant course Syphilis, the primary period is shortened, phenomena of general intoxication, deep pustular syphilides, lesions of the bones, periosteum, nervous system and internal organs, as well as orchitis (in the absence of a reaction from the lymph nodes) are observed. However, the results of serological tests are sometimes negative. This form of syphilis is now rare.

Reinfection - re-infection of a person who has had syphilis; possible due to the disappearance of immunity after the disease is cured.

Superinfection - re-infection of a patient with syphilis; occurs rarely, since it is prevented by the patient’s infectious immunity. Superinfection of syphilis is possible: in the early stages of the disease (during the incubation period, during the second week of the primary period), when there is no immunity yet; in the late tertiary period of the disease; with late congenital syphilis, since there are few foci of infection and they are not able to support immunity; when the immune system is weakened as a result of insufficient treatment, which does not ensure the destruction of Treponema pallidum, but leads to the suppression of their antigenic properties; as a result of alcoholism, malnutrition, and debilitating chronic diseases.

Assessing the results of specific and nonspecific therapy, many syphilidologists recognize the possibility of two types of cure for patients: clinical-bacteriological (microbiological) and clinical. In the first case, bacteriological sterilization of the body occurs, in the second, treponema pallidum remains in the body in an inactive state, in the form of cysts. The nature of the patient’s recovery is influenced by the immunoreactive forces of the body, possibly insufficiently studied genetic characteristics, as well as the time period that has passed from the moment of infection to the start of treatment. All other things being equal, with an increase in the period from the moment of infection to the start of treatment, the number of observations of bacteriological sterilization of the body decreases and the number of cases of clinical cure increases. With the latter, there is not only no recurrence of the symptoms of early infectious syphilis, but also the likelihood of the appearance of symptoms of neuro- and viscerosyphilis, despite positive serological reactions.

Currently, among the increased number of patients with syphilis, patients with latent and malignant forms, early lesions of the nervous system, an “accelerated” course of the infectious syphilitic process, as well as with sero-resistant forms of the disease have become more common. In this regard, it is extremely important to early and adequate treatment of all identified patients, prompt and timely detection of sources of infection and contacts for appropriate therapeutic measures, as well as maintaining sexual hygiene and taking preventive measures in case of infection.

Primary syphilis - stage of the disease, characterized by the appearance of hard chancre and enlargement of regional lymph nodes.

Primary seronegative syphilis is syphilis with persistently negative serological reactions during the course of treatment.

Primary seropositive syphilis is syphilis with positive serological reactions.

Primary latent syphilis is syphilis characterized by the absence of clinical manifestations in patients who began treatment in the primary period of the disease and received inadequate therapy.

Primary syphilis begins with the appearance of chancre and lasts 6-7 weeks. until multiple rashes appear on the skin and mucous membranes. 5-8 days after chancre, nearby lymph nodes begin to enlarge (regional syphilitic scleradenitis), and inflammation of the lymphatic vessels (specific lymphangitis) may develop.

In most cases, primary syphiloma is located in the area of ​​the external genitalia, but chancre can be located anywhere skin or visible mucous membranes. Some of them appear near the anus or on the oral mucosa. Thus, for the primary period of syphilis, extragenital localization of the lesion is also possible. At the site of inoculation of pale treponema, a clearly defined erythema of a round shape initially appears, which does not bother the patient and quickly (after 2-3 days) turns into a flat papule with slight peeling and slight compaction of the base. After some time, erosion or an ulcer with a compacted base forms on the surface of the papules. In the first days after the appearance of erosion or ulcers, clinical signs do not always correspond to syphilis. However, gradually clinical picture becomes typical.

Erosive chancre is usually round or oval in shape. Its diameter is 0.7-1.5 cm, the bottom is bright red (the color of fresh meat) or the color of spoiled lard, the edges are not undermined, clearly defined, at the same level as the skin. Signs acute inflammation are not noted along the periphery. The discharge from the surface of the erosion is serous, in small quantities. At the base of the chancre, a clearly demarcated leaf-shaped or lamellar compaction is palpable. To determine it, the base of the erosion is grabbed with two fingers, slightly lifted and squeezed; At the same time, a densely elastic consistency is felt. The bottom of the erosion is smooth, shiny, as if varnished. Primary syphiloma is characterized by painlessness. After epithelization, a pigment spot remains, which soon disappears without a trace. The infiltrate at the base of the erosion persists for a longer time (several weeks, and sometimes months), but then completely resolves.

Ulcerative chancroid is less common than erosive chancroid, but in last years it is being seen more and more often. In contrast to the erosive variety, the skin defect is deeper (within the dermis), the ulcer is saucer-shaped, with sloping edges, the bottom is often dirty yellow, sometimes with small hemorrhages. The discharge is more abundant than with erosive chancre. The compaction at the base of the ulcer is more pronounced and nodular. The lesion is painless, without an inflammatory rim along the periphery. The ulcer heals with scarring (without treatment, 6-9 weeks after occurrence), it has a smooth surface, a rounded, hypochromic or narrow hyperchromic rim along the periphery. Previously, single chancre was more common. Since the middle of the last century, 30-50% of patients began to experience multiple (3-5 or more) hard chancre. They can appear on the genitals of men in the presence of scabies (multiple entrance gates). Multiple chancre may appear simultaneously or sequentially, usually within one week as a result of successive infections.

The size of primary syphiloma varies widely, often reaching 0.7-1.5 cm in diameter, sometimes the size of a five-kopeck coin or more (giant chancre), while in some patients dwarf chancre is observed 0.2-0. 3 cm. The latter are especially dangerous from an epidemiological point of view, since they go unnoticed, and patients can be a source of infection for a long time.

There are clinical types of chancre depending on the location of the process and the anatomical features of the affected areas. So, in men, on the head of the penis, the chancre is erosive, small in size, with slight lamellar compaction, in the head groove - ulcerative, large in size, with a powerful infiltrate at the base; in the area of ​​the frenulum - longitudinal in shape, bleeds during erection, with compaction at the base in the form of a cord; in the area of ​​the urethra - accompanied by pain during urination, scanty serous-bloody discharge; during healing, a cicatricial narrowing of the urethra may occur. Chancres located along the edge of the foreskin cavity are usually multiple, often linear in shape. When they are localized on the inner layer of the foreskin, when the head of the penis is slowly removed from under it, the infiltrate at the base of the chancre rolls out in the form of a plate (hinged chancre). As the process develops in the area of ​​the foreskin and scrotum, an indurative, dense, painless edema may occur, upon which pressure does not leave a hole. The skin in the lesion is cold, bluish, against this background a hard chancre sometimes appears. The chancre, located in the crown of the head, is shaped like a swallow's nest.

In women, erosive chancre is more often observed in the area of ​​the labia majora, and sometimes indurative edema; on the labia minora - erosive chancre; at the entrance to the vagina, chancres are small in size and therefore hardly noticeable; at the external opening of the urethra - with pronounced infiltration; in the area of ​​the cervix, the chancre is often located on the front lip, usually single, erosive, bright red, with clear boundaries; in the area of ​​the nipple of the mammary gland - single, often in the form of a hole, sometimes in the form of a crack.

It has been established that in homosexuals, chancre is usually localized in the folds of the anus and is detected during rectoscopy. In the area of ​​the folds of the anus, primary syphiloma has a rocket-shaped or slit-like shape, in the area of ​​the internal sphincter of the anus - oval. It is painful regardless of bowel movements. On the mucous membrane of the rectum above the internal sphincter of the anus, chancre is not found.

On the lip, primary syphiloma is usually solitary and often covered with a dense crust. Currently, chancre is almost never found on the conjunctiva and eyelids of patients. On the tonsils they are single, unilateral, slightly painful; prevails ulcerative form, somewhat less often - erosive. It is difficult to diagnose the angina-like form of chancre (the tonsil is enlarged, hyperemic, the border of redness is clear, the pain is insignificant, there is no general temperature reaction).

Chancres located in the area of ​​the periungual ridges have a crescent shape. When the infiltrate develops under the nail plate (chancre-felon), the process is accompanied by severe shooting or throbbing pain.

The second important symptom of primary syphilis is bubo - regional lymphadenitis. It is usually detected by the end of the first week after the appearance of chancre. When the bubo is localized in the genital area, the inguinal lymph nodes enlarge, on the lower lip or chin - submandibular, on the tongue - submental, on the upper lip and eyelids - preauricular, on the fingers - ulnar and axillary, on the lower extremities - popliteal and femoral, on in the cervix - pelvic (not palpable), in the area of ​​the mammary glands - axillary. The inguinal lymph nodes often change on the side of the same name, less often on the opposite side, often on both sides (the size of the lymph nodes located on the opposite side is smaller). In patients with a long incubation period who are given small doses of antibiotics soon after infection, an accompanying bubo sometimes develops before the appearance of primary syphiloma.

Regional scleradenitis is manifested by enlarged lymph nodes (sometimes to the size of a hazelnut). In this case, there are no symptoms of acute inflammation, pain, or change in skin color. The nodes of dense elastic consistency are mobile, not fused to each other or to the underlying tissues, without signs of periadenitis. In the area close to the lesion, several lymph nodes are usually enlarged; one of them, closest to the chancre, is large in size. In recent years, an accompanying bubo of small size has become more common, which is probably the result of the reduced body resistance of such patients. When primary syphiloma is complicated by a secondary infection, acute inflammation of enlarged regional lymph nodes may occur, which is accompanied by pain, periadenitis, redness of the skin, sometimes tissue melting, and ulceration.

Regional scleradenitis resolves much more slowly than chancroid regresses, so it is also found in patients with symptoms of secondary fresh syphilis.

Sometimes, simultaneously with the accompanying bubo, concomitant lymphangitis develops - damage to the lymphatic vessels coming from the area where the chancre is located to the regional lymph nodes. In this case, a dense, painless cord the thickness of a thin pencil can be felt; there are no acute inflammatory phenomena. The cord on the anterior surface of the penis (dorsal lymphatic cord) is especially pronounced. Currently, concomitant lymphangitis is rare.

The third symptom of primary syphilis is positive standard serological tests. The Wasserman reaction usually becomes positive at 6-7 weeks. after infection, i.e. after 3-4 weeks. after the appearance of hard chancre, and from this moment primary seronegative syphilis passes into the stage of primary seropositive. In recent years, some patients have experienced an increase in the period of positivity of serological reactions, sometimes up to eight, even up to nine weeks after infection. This is observed in patients who received small doses of benzylpenicillin during the incubation period for other diseases, in particular gonorrhea, tonsillitis, and pyoderma. Sometimes serological reactions in the blood become positive soon after the appearance of chancre (after 2 weeks) - usually with bipolar primary syphilomas (located simultaneously in the mouth, genital area or mammary glands). The immunofluorescence reaction becomes positive somewhat earlier than standard reactions, but its indicators are not taken into account when deciding whether a patient has seronegative or seropositive primary syphilis. Subsequently, after 5-6 weeks. after the appearance of hard chancre, symptoms appear indicating the generalization of treponemal infection. All lymph nodes enlarge, i.e. polyscleradenitis develops. The nodes have a dense elastic consistency, ovoid shape, are painless, not fused to each other or to the underlying tissues, without signs of acute inflammation. Their sizes are significantly smaller than those of concomitant regional scleradenitis. The closer the lymph nodes are to the primary syphiloma, the larger they are. Like the accompanying bubo, they dissolve slowly, even with intensive treatment. By the end of the primary period of the disease, 15-20% of patients experience other symptoms indicating generalization of the infection. Body temperature rises (sometimes up to 38.5 °C), headaches, worse at night, and painful periostitis (frontal, parietal, scapular, radial and ulnar bones, clavicle, ribs) appear. Patients complain of joint pain, general weakness, and loss of appetite.

As a result of the addition of a secondary infection, the patient’s failure to comply with hygiene rules, or irritation of the lesion in the process of self-medication, complications arise, often of an acute inflammatory nature (severe redness, swelling, pain). Sometimes corresponding changes are observed in the regional lymph nodes (pain, periadenitis, change in skin color, purulent melting). In this case, women develop vulvitis and vaginitis; in men - balanitis (inflammation of the epithelium of the glans penis), balanoposthitis (balanitis in combination with inflammation of the inner layer of the foreskin). Due to inflammation of the foreskin, phimosis (narrowing of the foreskin ring) may develop, as a result of which it is not possible to remove the head of the penis. If you forcibly remove the head of the penis with a narrow ring of the foreskin, then it is pinched, the foreskin swells sharply, and paraphimosis (“noose”) occurs. If the head of the penis is not adjusted in a timely manner, the process ends with necrosis of the foreskin ring.

Severe complications of chancroid include gangrenization and phagedenism (an ulcerative-necrotic process near the primary focus). Their occurrence is facilitated by chronic alcohol intoxication, concomitant diseases that reduce the resistance of the patient’s body, diabetes etc. Currently, such complications are rare.

With phagedenism, unlike gangrene, there is no demarcation line, and the process progresses peripherally and in depth, which leads to extensive and deep destruction tissues, sometimes accompanied by bleeding from the lesion.

The primary period of syphilis ends not with the resolution of chancroid, but with the appearance of secondary syphilides. Therefore, in some patients, the healing of hard chancre, in particular ulcerative chancre, is completed already in the secondary period, while in others, erosive chancre manages to resolve even in the middle of the primary period, after 3-4 weeks. after his appearance. The diagnosis is established taking into account the medical history, confrontation with the suspected source of infection, localization of the ulcer, and detection of pale treponema in the discharge from it. Along with this, clinical data is collected, paying attention to the presence of painless (except for some localizations) erosion or ulcer with scanty discharge and compacted base, regional scleradenitis, and the absence of autoinfection. It is mandatory to confirm the diagnosis with laboratory test data: in the seronegative stage - by the detection of treponemes in the discharge from the lesions or in the punctate of regional lymph nodes, and in the seropositive stage - by serological reactions. Difficulties arise when the patient treated the lesion with disinfectants or cauterizing agents before contacting a doctor, so his serological reactions are negative. Such patients are prescribed lotions with isotonic sodium chloride solution and repeated tests are carried out (at least 2 times a day) for the presence of treponema pallidum. Confrontation (examination) of the suspected source of infection helps clarify the diagnosis, but in this case the patient may indicate it incorrectly.

At differential diagnosis it is necessary to distinguish chancre from erosions or ulcers that occur in other diseases and are located primarily in the area of ​​the external genitalia. These include: traumatic erosions, herpetic rashes, tuberculous ulcers; lesions with chancre, balanitis and balanoposthitis, chancriform pyoderma, Queyr's erythroplasia, skin carcinoma, etc.

Traumatic erosion usually has a linear form with a soft base, is accompanied by acute inflammatory phenomena, is painful, and heals quickly with the use of lotions with isotonic sodium chloride solution. Treponema pallidums are not detected in the discharge. There is no accompanying bubo. Anamnesis data are also taken into account.

Lichen vesica is often recurrent. The rash is preceded 1-2 days by itching and burning in areas of future lesions. Small grouped blisters with serous contents appear on the edematous base and hyperemic skin. Their tire soon bursts, bright red superficial erosions with micropolycyclic outlines appear, which are sometimes accompanied by regional inflammatory adenopathy and disappear without a trace.

Soft chancroid has a shorter incubation period (2-3 days), is characterized by the appearance of an inflammatory spot - papules - vesicles - pustules, the latter soon ulcerates. After the first ulcer (maternal), daughter ulcers arise as a result of autoinfection. The edges of these ulcers are swollen, bright red, undermined, the discharge is purulent, copious; patients experience severe pain. In scrapings from the bottom of the ulcer or from under its edge, Streptobacteria Ducray-Unna-Peterson, the causative agent of chancroid, is found. Regional lymph nodes are either unchanged, or there is acute inflammatory lymphadenopathy: soreness, soft consistency, periadenitis, redness of the skin, fluctuation, fistulas, thick creamy pus. Difficulties in diagnosis are noted in the presence of mixed chancre caused by a combined infection - Treponema pallidum and Streptobacter. At the same time, the time period for positivity of serological reactions can be significantly extended (up to 3-5 months); Treponema pallidum is difficult to detect.

Erosive balanitis and balanoposthitis are manifested by painful superficial bright red erosions without compaction, with copious discharge. With chancriform pyoderma (rare), an ulcer is formed, similar to ulcerative primary syphiloma, round or oval, with a dense base that extends beyond the edge of the ulcer, painless, and may be accompanied by concomitant scleradenitis. Treponema pallidums are not found in the discharge of the ulcer and the punctate lymph nodes. Serological tests for syphilis are negative. Differential diagnosis of chancriform pyoderma and primary syphiloma is sometimes very difficult. After scarring of the lesion, the patient needs long-term observation.

Chancriform scabies ecthyma is usually multiple, accompanied by acute inflammatory phenomena, severe itching and the presence of other symptoms of scabies, lack of compaction at the base of the ulcer, as well as regional scleradenitis.

Gonococcal and trichomonas ulcers are rare. They are characterized by acute inflammatory phenomena, bright red, with copious discharge, in which the corresponding pathogens are found. Sometimes they resemble chancroid ulcers, but their edges are smooth and not undermined. The lesions are somewhat painful. There is no concomitant regional scleradenitis. With ulceration of tubercular syphilide, the lesions are located in the form of rings, garlands, and have a roller-shaped edge; nearby lymph nodes are not enlarged; Treponema pallidums are not detected in the discharge. Syphilitic gumma in the area of ​​the glans penis is usually single; the appearance of an ulcer is preceded by softening, fluctuation, its gentle edges descend to the bottom, where the gummous core is visible.

A tuberculous ulcer bleeds a little, is soft, irregular in shape, often its edges are bluish, undermined; at the bottom there are yellowish small foci of decay - Trill grains. The ulcer does not scar for a long time and is usually located near natural openings. The patient also has other foci of tuberculosis infection.

Cutaneous carcinoma usually occurs in people over 50 years of age; single, slowly progresses, does not scar without appropriate treatment. With its basal cell variety, the edges of the ulcer are formed by small whitish nodules; with squamous cell - they are usually everted, the bottom is pitted, covered with foci of ichorous decay, and bleed slightly.

Keir's erythroplasia manifests itself as a slowly developing, painless small lesion located mainly on the glans penis; its edges are clearly demarcated, the surface is bright red, velvety, shiny, somewhat moist, but without discharge.

An acute ulcer on the external genitalia is observed in girls, young nulliparous women, and occurs acutely, usually with high temperature body and does not present great difficulties in diagnosis.

With all the importance, maximum early diagnosis Primary syphiloma cannot be treated without absolute confidence in the accuracy of the diagnosis, without its laboratory confirmation. In all suspicious cases, the patient should be monitored at a dispensary with examination after discharge from the hospital (due to remission of skin manifestations and lack of laboratory data) once every 2 weeks. within a month and once a month - over the next months (up to 3-6 depending on the previous clinical picture and anamnesis data, in each specific case individually).

Secondary syphilis - stage of the disease caused by the hematogenous spread of pathogens from the primary focus, characterized by polymorphic rashes (papules, spots, pustules) on the skin and mucous membranes. Secondary fresh syphilis (syphilis II recens) - a period of syphilis characterized by numerous polymorphic rashes on the skin and mucous membranes, polyadenitis; Residual signs of chancroid are often observed. Secondary recurrent syphilis (syphilis II recediva) - the period of secondary syphilis following fresh secondary; characterized by a few polymorphic clustered rashes and often damage to the nervous system. Secondary latent syphilis (syphilis II latens) is a secondary period of the disease that occurs latently.

In the secondary period of syphilis, roseolous, papular and pustular rashes appear on the skin and mucous membranes, pigmentation is disrupted, and hair loss increases. Internal organs (liver, kidneys, etc.), nervous, endocrine and skeletal systems may be affected. The lesions are functional in nature and quickly improve with specific treatment. Sometimes general phenomena are observed. The secondary period of the disease is characterized, as a rule, by a benign course. The patient has no complaints, no destructive changes are observed. Clinical signs recede even without treatment, serological tests in the blood are positive.

Usually at the beginning of the secondary period there is a profuse rash, often polymorphic, small, and not prone to fusion. Exanthems in secondary syphilis are called syphilides. They are located randomly, but symmetrically. Some patients have clinical signs of primary syphilis, in particular, ulcerative chancroid remains or traces of primary syphiloma remain (pigmented secondary spot or fresh scar) and regional scleradenitis. The most common symptom is polyadenitis. However, in recent years, in many patients it is weakly expressed, which is a consequence of the suppression of the body’s immunological reactivity. The course of the disease is variable. More often after 2-2.5 months. the rash gradually disappears and only positive serological reactions remain, traces of polyscleradenitis are noted. The secondary latent period begins. In a later period, a relapse of the disease occurs with a very varied course.

Unlike secondary fresh syphilis, at this stage of the disease the number of rashes on the skin is smaller, they are larger, prone to swelling, paler, more often located in the area of ​​large folds, in places of skin trauma, areas with increased sweating; polyadenitis is weakly expressed. Changes in the oral mucosa appear more often in patients who abuse alcoholic beverages, hot food, and in people with carious teeth. Serological reactions in the blood are positive in 98% of patients, and the titer of the Wasserman reaction is lower than with secondary fresh syphilis. In addition, there are cases of damage to internal organs, nervous and endocrine systems, sensory organs, bones, joints, which are detected using special research methods.

To establish a diagnosis, the following are important: special data from anamnesis and objective examination; laboratory analysis to detect pathogens in lesions; serological blood tests; special laboratory and functional research methods.

If secondary syphilis is suspected in patients, it is determined whether there is a non-pruritic skin rash affecting the palms and soles; generalized enlargement of lymph nodes; spontaneous hair loss; spontaneous hoarseness; the appearance of genital and intertriginous weeping “warts”; other complaints (headaches, joint pain, night bone pain, eye symptoms etc.).

The manifestations of secondary syphilis are extremely varied. Syphilides at this stage of the disease can be spotted (roseola), papular, vesicular, pustular. Syphilitic leukoderma, baldness, damage to the larynx, vocal cords, oral mucosa, nose, erosive and ulcerative syphilides on the mucous membranes are observed.

Clinical studies show that some features are currently observed in the manifestations of the secondary period of syphilis. Thus, in some patients with secondary fresh syphilis, a small number of roseolas and papules are noted, and in case of recurrent syphilis, there are abundant “monomorphic” rashes. Less common are condylomas lata and pustular syphilides. The titer of positive serological reactions is sometimes low, which complicates timely diagnosis. In some cases, it is difficult to distinguish secondary fresh syphilis from recurrent syphilis.

Spotted (roseolous) syphilide is the most common rash in the first stage of secondary fresh syphilis. The rash is located on the lateral surfaces chest, abdomen, back, front surface upper limbs, sometimes on the thighs. It is extremely rarely found on the face, hands and feet. The rash appears gradually, 10-20 roseola per day, and reaches full development within 7-10 days. With secondary fresh syphilis, the rashes are profuse, randomly and symmetrically located, focal, rarely merging. Young elements are pink, mature ones are red, old ones are yellowish-brown. Roseola is round, 8-12 mm in diameter, usually does not rise above the skin, does not peel off, does not cause subjective sensations, and disappears with diascopy (only in rare cases does it peel off and is accompanied by itching). It becomes more noticeable when the skin is cooled with a stream of cold air. With an exacerbation of the process (Herxheimer-Yarish-Lukashevich reaction) after intramuscular injection of benzylpenicillin, roseola is more pronounced, sometimes appearing in a place where it was not visible before the injection.

In secondary recurrent syphilis, roseola is larger, less bright, often ring-shaped, and prone to grouping. With a pronounced inflammatory reaction, accompanied by perivascular edema, the (“nettle” roseola) rises somewhat. Sometimes small copper-red follicular nodules (granular roseola) are visible against its background.

Lenticular papules are more often observed in patients with secondary fresh syphilis, less often in recurrent syphilis (Fig. 11). Over the course of several days, new elements appear daily. In the secondary fresh period of the disease, they are often accompanied by roseola - a polymorphic rash.

Lenticular papule - dense, round, the size of a lentil, clearly demarcated from the surrounding tissue, without an inflammatory rim, copper-red in color with a bluish tint; the surface is smooth. During resorption (1-2 months after occurrence), a small scale appears on the papule, then its central part is torn away and a rim of the undermined stratum corneum (Biette's collar) is visible along the periphery. After resorption of the papule, a pigmented spot remains, which then disappears. Syphilitic papules do not cause subjective sensations. With secondary fresh syphilis there are many papules, they are located randomly, but symmetrically, with recurrent syphilis there are fewer of them and they tend to cluster. In recent years, lenticular papules have been observed more often on the palms and soles of patients.

Coin-shaped papules are characterized by the same properties as lenticular ones. They are larger (up to 2.5 cm in diameter) and are more often observed with recurrent syphilis. Miliary syphilitic papules are small (the size of a millet grain), hemispherical, dense, red-bluish, multiple, prone to grouping, slowly resolve, leaving behind slight cicatricial atrophy.

Hypertrophic (vegetative, or wide) condylomas are usually located in the area of ​​large folds, the perineum, on the genitals, around the anus, and arise as a result of moderate prolonged irritation. They are large, rise significantly above the skin level, merge, forming plaques with scalloped outlines. They are more common in patients with secondary recurrent syphilis. Their surface is often macerated, weeping, and in some patients it is eroded or ulcerated.

Psoriasiform papules are usually localized on the palms and soles, are characterized by pronounced peeling, and are more common in secondary recurrent syphilis. Seborrheic papules are covered with greasy yellowish scales and are found in places where there are many sebaceous glands. Cracks often form on papules in the corners of the mouth, near the eyes, and in the interdigital folds - ragadiform syphilide. Syphilitic papules must be distinguished from papules in various dermatoses. Thus, lenticular papules are differentiated from rashes with lichen planus (dense, flat, polygonal, with a pearlescent sheen, umbilical indentation in the center of the papules, red-brown or bluish, accompanied by itching, often located on the anterior surface of the forearms), with guttate parapsoriasis (soft , slightly raised above the skin, variegated red-brownish in color, covered with scales in the form of a wafer; when scratched, pinpoint hemorrhages appear on the surface of the papules and on the skin near it; the disease lasts for years, is difficult to treat), psoriasis (red-pink in color, covered with whitish spots). scales; when scraped, the phenomena of stearin stain, terminal film, pinpoint bleeding are observed, the elements tend to grow peripherally, predominantly on the back surface of the elbow joints, forearms and the front surface of the legs, knee joints, in the area of ​​the sacrum, scalp), with pseudosyphilitic papules (hemispherical, the color of normal skin, with a shiny dry surface, without signs of acute inflammation, localized on the upper edge of the labia majora), papulonecrotic tuberculosis of the skin (reddish-bluish pauliform-like elements with necrosis in the central part are located symmetrically, mainly on the posterior surface of the upper and anterior surface of the lower extremities, on the fingers, sometimes on the face, false evolutionary polymorphism is noted, stamped scars after regression of the elements, tuberculosis of internal organs, bones, joints or lymphatics is often observed; nodes, positive Mantoux test, negative serological reactions in blood tests for syphilis); with molluscum contagiosum (small, pea- or lentil-sized, hemispherical papules, with an umbilical indentation in the center, whitish-pearl-colored, shiny, without an inflammatory rim along the periphery; when squeezed from the sides, a whitish thick mass is released from the mollusk - a mollusc body).

The most common manifestations of secondary syphilis on the mucous membranes are papular rashes. They are similar to papules on the skin: dense, flat, round, clearly demarcated, without a peripheral inflammatory rim, deep red in color, and usually do not bother the patient. Due to their maceration central part soon becomes whitish with a grayish or yellowish tint (opal). Papules can hypertrophy (condylomas lata), merge, and form large plaques with scalloped outlines. After some time they dissolve and disappear without a trace. With chronic irritation (smoking, mucopurulent vaginal discharge), they can erode or ulcerate, while maintaining a dense papular base.

Most often, syphilitic papular tonsillitis occurs; papules appear on the mucous membrane of the mouth, tongue, lips, in the area of ​​the external genitalia, anus, and less often in the pharynx, vocal cords and nasal mucosa. Papules located in the pharynx are sometimes accompanied by slight pain, and ulcerated ones are sometimes accompanied by pain when swallowing. When the vocal cords are damaged, coughing, hoarseness appear, and when the cords become hyperplastic, even aphonia. If the papules become ulcerated, the voice impairment becomes irreversible. Papules on the nasal mucosa cause the same sensations as catarrhal lesions, but they are more clearly defined. With deep ulceration of papules on the mucous membrane of the nasal septum, perforation can occur, sometimes with subsequent deformation of the nose.

Syphilitic papular tonsillitis is differentiated from a number of diseases. A common sore throat is accompanied by body temperature, severe swelling and hyperemia of the pharynx, tonsils, arches, soft palate, unclear boundaries of the lesion, and severe pain; there are no signs of syphilis. With diphtheria, along with the above symptoms, a dirty-gray, smooth, slightly shiny, tightly fitting fibrinous coating appears on the tonsils, and toxicosis is often observed. Simonovsky-Plaut-Vincent angina is characterized by acute inflammatory phenomena, severe pain, necrotic decay, putrid breath, regional lymphadenitis with periadenitis in the absence of signs of syphilis and negative serological reactions in the blood.

The differential diagnosis of syphilitic papules on the mucous membrane and papules in lichen planus is important. The latter are dense, almost do not rise above the level of the surrounding tissues, small, whitish, with a shiny surface, polygonal, sometimes merge to form plaques. Some of them are located in the form of lace, arcs, rings, linearly on the oral mucosa at the level of the closure of the molars. There is no itching, some patients experience a slight burning sensation. At the same time, typical skin rashes are detected (the anterior surface of the forearms and wrist joints), serological tests for syphilis are negative.

Aphthous stomatitis begins acutely. Painful, round, small (3-5 mm in diameter) yellowish erosions with a bright red rim appear on the mucous membrane of the gums and lower lip, and sometimes under the tongue. They do not merge, after 7-10 days they disappear without a trace, and often recur.

Flat leukoplakia develops gradually, slowly progresses, taking on the appearance of slightly raised milky-white spots with a rough, dry surface, without any inflammatory phenomena. In some patients, warty growths (leukokeratosis) or erosions appear on their surface. With soft leukoplakia, the grayish-white plaque in the lesions is easily torn off when scraped.

Syphilitic papules on the tongue are differentiated from “geographic tongue” (desquamative glossitis), in which slightly raised, grayish, round, garland- or arcuate lesions are observed, bordered by red flattened areas with atrophied papillae. Usually they merge, creating the impression of a geographical map. Their outlines change quickly.

Smooth plaques on the tongue are round, red, shiny, devoid of papillae, painless, persistent, sometimes resembling syphilitic papules. A thorough examination of the patient, the absence of any symptoms of syphilis, medical history, and negative serological reactions in the blood help establish the correct diagnosis.

Syphilitic lesions of the larynx, vocal cords, and nasal mucosa are recognized on the basis of the clinical picture (painlessness, duration of existence, absence of acute inflammatory changes, resistance to conventional treatment, other symptoms of syphilis, positive serological reactions in the blood).

Erosive and ulcerative syphilides on the mucous membranes develop on a papular background, they are usually deep, various shapes(round or oval), sometimes painful, their bottom is covered with tissue decay products, there are no acute inflammatory phenomena. At the same time, other symptoms of syphilis are detected, serological reactions in the blood are positive.

In some cases, in the secondary period of syphilis, damage to bones and joints is observed. Clinical signs of damage to bones and joints are usually limited to pain. Characterized by night pain in the long tubular bones of the lower extremities, arthralgia in the knee, shoulder and other joints. Sometimes the disease can manifest itself with a typical pattern of lesions (periostitis, osteoperiostitis, hydrarthrosis), which are more characteristic of the tertiary period of syphilis.

Tertiary syphilis - stage following secondary syphilis; characterized by destructive lesions of internal organs and the nervous system with the appearance of gummas in them. There are active tuberculate, or gummous, tertiary syphilis (syphilis III activa, seu manifesta, tuberculosa, seu gummosa), characterized by an active process of formation of tubercles, resolved by necrotic decay, the formation of ulcers, their healing, scarring and the appearance of uneven pigmentation (mosaic), and latent tertiary syphilis (syphilis III latens) - a period of illness in persons who have suffered active manifestations of tertiary syphilis.

Usually after 5-10 years, and sometimes later, after infection with syphilis, the tertiary period of the disease begins. However, it is not the inevitable end of the disease, even if the patient did not receive full treatment or was not treated at all. Research data show that the frequency of transition of syphilis to the tertiary stage varies widely (from 5 to 40%). In recent decades, tertiary syphilis has been observed rarely.

It is believed that the main reasons for the appearance of signs of tertiary syphilis are severe concomitant diseases, chronic intoxication, trauma, overwork, malnutrition, alcoholism, immunodeficiency states, etc.

In the tertiary period, the skin, mucous membranes, nervous and endocrine system, bones, joints, internal organs (heart, aorta, lungs, liver), eyes, sensory organs.

There are a manifest (active) stage of tertiary syphilis and a latent (latent) stage. The manifest stage is accompanied by obvious signs of syphilis, the latent stage is characterized by the presence of residual signs (scars, bone changes, etc.) of active manifestations of the disease.

During this period of syphilis, the lesions practically do not contain the pathogen, so they are not contagious. Usually there are tubercles or gummas that are prone to decay and ulceration. They leave behind scars or cicatricial atrophy. Tertiary syphilides are located in groups in one area and are not accompanied by lymphadenitis. Superficially located tubercles in the skin can be grouped in the form of arcs, rings, garlands and, regressing, leave behind characteristic atrophic scars (brown spots with signs of atrophy) with a bizarre pattern reminiscent of a mosaic. Deeply located tubercles (gummas) emanating from the subcutaneous tissue reach a large size. They can resolve, but more often they disintegrate, turning into deep, irregular ulcers. Gummas can appear in any organ.

Proving the presence of a previous syphilitic infection is more difficult than it might seem at first glance. It is rarely possible to directly detect Treponema pallidum. The clinical picture is of considerable importance in making a diagnosis. With pronounced clinical signs, diagnosis is not difficult. In cases of insufficient severity of symptoms, it is difficult and becomes possible in combination with data from serological reactions, histological studies, and potassium iodide tests.

Classic serological reactions are positive in most cases, but fluctuating in titer. They can be negative in 35% of patients with tertiary syphilis. Specific serological reactions are almost always positive. After treatment, CSRs rarely become completely negative, and specific serological tests almost never become negative. Histological studies are essential. A specific granulomatous inflammation is detected - a syphilitic granuloma, which is often extremely difficult to differentiate from tuberculous and other granulomas. In addition, a test with potassium iodide is also useful: with oral therapy with potassium iodide, a specific reverse development of skin manifestations of tertiary syphilis occurs within 5 days. Before starting the test, pulmonary tuberculosis, as well as syphilitic aortic aneurysm, MUST be excluded, since under the influence of potassium iodide, exacerbation of the tuberculosis process and perforation of the aneurysm are possible.

Tuberous syphilides are characterized by rashes on limited areas of the skin of dense, bluish-red, painless grouped tubercles ranging in size from lentils to peas, lying at different depths of the dermis and not merging with each other.

The rash appears in waves. Therefore, when examining a patient, fresh, mature elements, tubercles in a state of decay, ulcers, and in some cases scars are visible. Their pronounced tendency to group is noted - in some patients they are crowded, in others - in the form of incomplete rings, half-arcs, garlands, which merge to form continuous lesions. There are several clinical varieties of tubercular syphilide - grouped, diffuse, serpinginating, dwarf. The most common is grouped tubercular syphilide; in which the tubercles are located close to each other, focally, do not merge, usually there are 10-20 of them in one area. Sometimes they are randomly scattered. May be at different stages of development (evolutionary polymorphism). The resulting tubercle (small in size, dense, hemispherical, red-bluish in color) can resolve, leaving behind scar atrophy, or ulcerate. The ulcer is round, has a dense, roll-shaped, red-bluish edge, rising above the surrounding skin and gradually descending to the bottom of the ulcer, where necrotic, molten tissue of a dirty yellow color (necrotic core) is located. The depth of the ulcer is not the same in different areas and depends on the location of the tubercle. After a few weeks, the necrotic core is rejected; the ulcer is granulated and scarred. The scar is dense, deep, star-shaped, and relapses of tubercles are never observed on it. Gradually it becomes discolored. Diffuse tubercular syphilide (tubercular platform syphilide) is characterized by the fusion of tubercles. A solid, compacted dark red plaque appears, sometimes with slight peeling. Individual tubercles are not visible. The lesion can be the size of a coin or more (almost the size of a palm), of various shapes, with polycyclic outlines. Resolves by resorption (cicatricial atrophy remains) or ulceration with subsequent scar formation.

Seriinginating tubercular syphilide appears as a small focus of fused tubercles. Gradually the process progresses along the periphery, and regresses in the center. Extensive lesions appear with a characteristic scar in the central zone (a mosaic scar in old areas is depigmented, in more recent areas it is bluish-red, red-brown, pale brown, depending on the time of its appearance, having a heterogeneous relief in accordance with the depth of individual tubercles ). Along the periphery there are young tuberculate elements at different stages of development (infiltrates, ulcerations), forming a kind of ridge with scalloped outlines. If left untreated, the disease progresses and can affect large areas of the skin.

Dwarf tubercular syphilide is manifested by small tubercles, usually located in groups. They never ulcerate, resemble papules, but leave behind cicatricial atrophy. It should be differentiated from lupus vulgaris, papulonecrotic tuberculosis of the skin, basal cell carcinoma, small-nodular benign sarcoid, tuberculoid leprosy.

Unlike syphilis, with lupus the tubercles have a soft consistency, red in color with a yellowish tint, when pressing on them with a button-shaped probe, a hole (mark of indentation) remains, with diascopy the phenomenon of apple jelly is noted, the ulcer lasts a long time, does not show a tendency to scarring, is superficial, soft, with yellowish-red flaccid granulations, uneven edges, bleeding slightly. The resulting scar is soft, smooth, superficial, and there are recurrences of tubercles; Mantoux reaction is positive.

With papulonecrotic tuberculosis, the rashes are located symmetrically, mainly on the posterior surface of the upper and anterior surface of the lower extremities, scattered, abundant, with necrosis in the center. Subsequently, stamped scars are formed. The patient also has other foci of tuberculous lesions (in the internal organs); Mantoux reaction is positive.

Basal cell carcinoma is usually solitary, most often localized on the face, and has a distinct ridge-like edge consisting of small whitish nodules. In the center there is an erosion that bleeds slightly when touched and progresses slowly without showing a tendency to scarring.

Small-nodular benign sarcoid is expressed in multiple dense red-brown nodules that are not prone to ulceration; with diascopy, against a background of pale yellow color, small dots (in the form of grains of sand) are visible, colored more intensely.

With tuberculoid leprosy, the tubercles are red-brown, shiny, ring-shaped, hair falls out in the lesion, there is no sweating, and sensitivity is impaired. Gummy syphilides are now rare. They appear as separate nodes or diffuse gummous infiltration. Occur in the subcutaneous base or deeper tissues. At this stage, they are clearly demarcated, dense, painless formations without inflammation, easily moving under the skin. Gradually, the node increases and reaches the size of a nut, and sometimes a chicken egg, fuses with the surrounding tissues and skin, which gradually turns red, then softening of the gum occurs, and fluctuation is determined. From the small fistula that forms as a result of thinning and breaking of the skin, a small amount of viscous liquid of a dirty yellow color is released. Gradually, the fistula opening increases and turns into a deep ulcer with dense roll-like edges, gradually descending to the bottom, where the gummous core (dirty yellow necrotic tissue) is located (Fig. 19). After its rejection, the bottom of the ulcer is filled with granulations, then scarring occurs (Fig. 20). The scar is initially red-brown, later acquires a brownish tint and gradually becomes depigmented; deep, retracted, star-shaped, dense. The evolution of gumma lasts from several weeks to several months. Typically, gumma does not cause subjective sensations, except when it is located directly above the bone, near the joints, corner of the mouth, tongue, or external genitalia. If the patient begins to be treated in a timely manner (before the gumma begins to disintegrate), its resorption may occur without the formation of an ulcer, after which cicatricial atrophy remains. With good body resistance, the gummous infiltrate can be replaced by connective tissue, undergoes fibrosis with subsequent deposition of calcium salts in it. With such changes, “periarticular nodularity” appears at the anterior and posterior surfaces of large joints (knees, elbows, etc.). Usually they are solitary, less often 2-3 gummas are observed. In isolated cases, the lesion consists of several fused gummas and is large in size (6-8 and 4-6 cm or more). Such gumma can erupt in several places, which leads to the formation of extensive ulcers with an uneven bottom and polycyclic outlines.

Gummous ulcers may be complicated by secondary infection, erysipelas. Sometimes the focus grows in depth and along the periphery (gum irradiation). Due to the deep location of the infiltrate, involvement of lymphatic vessels in the process, and impaired lymphatic drainage, elephantiasis appears. Most often, gummas appear in the area of ​​the legs, less often - on the upper extremities, then on the head, chest, abdomen, back, lumbar region, etc.

Standard serological reactions for syphilitic gummas are positive in 60-70% of patients, RIBT and RIF - somewhat more often. To clarify the diagnosis, sometimes (when serological reactions are negative and clinical manifestations are typical for tertiary syphilis) a trial treatment is carried out.

Before the disintegration of syphilitic gumma, it must be distinguished from lipoma or fibrolipoma (usually multiple subcutaneous softer nodes, the size of which does not change for a long time or increases very slowly; they have a lobular structure, the skin over them is not changed), atheroma (slowly progressing cyst of the sebaceous gland of the dense elastic consistency, with clear boundaries, sometimes suppurates; upon puncture, foul-smelling cheesy contents are extracted from it), compacted Bazin's erythema (dense, slightly painful nodes, in young women or girls, located mainly on the legs; over the lesions the skin is red-bluish, sometimes they ulcerate, exist for a long time; exacerbations occur in the cold season, the Mantoux test is positive, serological reactions, RIBT, RIF are negative).

After ulceration of the gumma, it must be distinguished from colliquative tuberculosis of the skin (subcutaneous nodes, gradually increasing in size, adhere to the skin, which becomes cyanotic). The nodes soften in the center, and then ulcers with soft bluish, undermined edges form. The bottom of the ulcer is covered with flaccid granulations and bleeds slightly; the course is long, subsequently soft scars are formed with papillae at the edges and “bridges” of healthy skin; the Mantoux reaction is positive. It is necessary to differentiate gumma from a malignant ulcer (irregular in shape, woody-dense edges and base, pitted bottom, covered with ichorous decay, bleeds easily, constantly progresses, usually there is one focus). In rare cases, differential diagnosis of syphilitic gumma and leprosy nodes, deep mycoses (deep blastomycosis, sporotrichosis), actinomycosis, and chronic nodular pyoderma is carried out. A peculiar manifestation of this period of the disease is tertiary syphilitic erythema in the form of large red-bluish spots located in an arcuate manner, mainly on the lateral surface of the body. Does not cause subjective sensations, lasts a long time (up to a year or more). The size of the lesion is large (10-15 cm), sometimes it is combined with dwarf tubercular syphilide. After regression of the erythema, no traces remain, but in some cases small areas of cicatricial atrophy are noted (Ge's symptom). Tertiary syphilitic erythema must be distinguished from trichophytosis or microsporia of smooth skin (bubbles in the peripheral zone of erythematous lesions, slight peeling, detection of spores and mycelium of the fungus in the scales, rapid effect with antimycotic treatment), pityriasis versicolor, pityriasis rosea Zhibera, seboreid.

Lesions of the mucous membranes in the tertiary period of the disease are relatively common. On the lips, especially the upper, limited nodes (gummas) or diffuse gummous infiltrations are observed. The same type of lesions are observed in the tongue area. With gummous glossitis, 2-3 gummas the size of a small one are formed in the thickness of the tongue. Walnut which ulcerate without treatment. With diffuse sclerogummous glossitis, the tongue is sharply enlarged in volume, with smoothed folds, dense, red-bluish, easily injured, its mobility is severely impaired. After resorption of the infiltrate, the tongue wrinkles, bends, loses its mobility, and is very dense due to the formation of scar tissue.

Tuberous and gummous rashes may be located on the soft and hard palate. They ulcerate, lead to tissue destruction, sometimes to rejection of the uvula, and after scarring - to deformation of the soft palate. Small gummous nodes or diffuse gummous infiltration sometimes appear in the pharynx. After their ulceration, pain and functional disorders appear. Tertiary syphilides of the larynx can cause perichondritis, damage to the vocal cords (hoarseness, hoarseness, aphonia), cough with the discharge of dirty yellow thick mucus. As a result of scarring of the ulcers, the vocal cords do not close completely, and the voice remains hoarse forever. There may be persistent difficulty breathing.

Gummous lesions of the nasal mucosa are most often located in the septum area, at the border of the cartilaginous and bone parts, but can also occur in other places. In some patients, the process begins directly in the nose, sometimes moves from neighboring areas (skin, cartilage, bones) and manifests itself in limited nodes or diffuse gummous infiltration. Subjective sensations are usually absent. The mucus from the nose after the formation of an ulcer becomes purulent. At the bottom of the ulcer, a probe can often identify dead bone. When the process passes to the bone of the nasal septum, its destruction may occur and, as a result, deformation of the nose (saddle nose).

Syphilitic tubercles - gummas of the mucous membranes must be distinguished from tuberculous lesions (soft, more superficial lesions, irregularly shaped ulcers that bleed slightly, flaccid granulations with Trela ​​grains: torpid course, painful, concomitant tuberculous lesions lungs; positive Mantoux reaction; negative serological standard reactions for syphilis, as well as RIBT and RIF), from malignant tumors(often preceded by leukoplakia, leukokeratosis; single lesions; an irregularly shaped ulcer with everted, woody-dense edges, very painful, its bottom bleeds; metastases are observed; a biopsy confirms the diagnosis).

Gummous lesions of the lymph nodes are very rare. Their current is torpid. Unlike the changes in colliquative tuberculosis, they are denser and do not bother patients. After ulceration, a typical gummous syphilitic ulcer develops. The Mantoux reaction is negative. Serological standard reactions are positive in 60-70% of patients, and the percentage of positive RIBT and RIF is even higher.

Tertiary syphilis of bones and joints manifests itself in the form of osteoperiostitis or osteomyelitis. Osteoperiostitis can be limited and diffuse. Limited osteoperiostitis is a gumma, which in its development either ossifies or disintegrates and turns into a typical gummatous ulcer. Diffuse osteoperiostitis is a consequence of diffuse gummous infiltration. It usually ends with ossification with the formation of rachic calluses. With osteomyelitis, the gumma either ossifies or a sequester forms in it. Sometimes sequestration leads to the development of a gummous ulcer. Damage to joints in the tertiary period of syphilis in some cases is caused by diffuse gummous infiltration of the synovial membrane and joint capsule (hydrarthrosis), in others this is accompanied by the development of gummas in the epiphysis of bones (osteoarthritis). The most commonly affected joints are the knee, elbow, or wrist joints. An effusion appears in the joint cavity, which leads to an increase in its volume. Typical for hydrarthrosis and osteoarthritis in tertiary syphilis are the almost complete absence pain and preservation of motor function.

In the tertiary period of syphilis, lesions of the musculoskeletal system occur more often than in the secondary (in 20-20% of patients), are much more severe and are accompanied by destructive changes, mainly in the bones of the legs, skull, sternum, collarbone, ulna, nasal bones, etc. The process involves the periosteum, cortical, spongy and medulla. Patients complain of pain that worsens at night and when the affected bones are tapped. The radiograph shows a combination of osteoporosis and osteosclerosis. Limited gummous osteoperiostitis is more often detected - single gummas are located in the cortical layer, which form a node with a dense bone ridge. As a result of their decay, an ulcer appears with a gummous core in the center. After some time, sequestration appears; less often, the bone gum becomes ossified. Typically, healing ends with the formation of a deep, retracted scar.

With diffuse gummous periostitis, osteoperiostitis, the changes are similar, but more widespread, in the form of a fusiform, tuberous thickening. They are especially noticeable in the middle part of the crest of the tibia and ulna.

Syphilitic osteomyelitis is observed when the spongy and medullary substance of the bone is damaged, in the case of destruction of the central part of the lesion and the occurrence of reactive osteosclerosis along the periphery. Subsequently, the cortical layer of bone, periosteum, soft fabrics, a deep ulcer forms, bone sequesters are released, the bone becomes brittle, and a pathological fracture may occur.

In case of tertiary syphilis of bones and joints, it is necessary to carry out differential diagnosis with bone tuberculosis, osteomyelitis of another etiology, with bone sarcoma, etc. It should be taken into account that:

1) bone lesions in tuberculosis often develop in childhood, are multiple, and last a long time. In this case, the pineal gland is primarily involved in the process. Severe pain occurs, as a result of which the patient limits the movements of the limb, which leads to atrophy without active muscles. Fistulas do not heal for a long time. The general condition is disturbed. There are no signs of osteosclerosis on the radiograph, the periosteum is not changed;

2) osteomyelitis caused by pyogenic microbes, characterized by the presence of sequesters, the absence of osteosclerosis, and is sometimes located in the metaphysis (Brodie’s abscess);

3) bone sarcoma often affects proximal part metaphysis, single, painful, characterized by progressive growth, minor phenomena of reactive osteosclerosis, splitting of the periosteum.

In the tertiary period of the disease, acute syphilitic polyarthritis is extremely rare. They can arise as a result of irradiation of the pathological process from the metaphyseal gum. The joint is enlarged in volume, there is a crunch during movements that are difficult and painful.

Chronic syphilitic synovitis is formed primarily, proceeds torpidly, without pain, with normal joint function and good general condition of the patient. There are no pronounced inflammatory phenomena. Gummy synovitis leads to the formation of perisynovitis and is difficult to treat.

With syphilitic gummous osteoarthritis, not only the joint capsule is affected, but also cartilage and bones. Multiple gummas are located in the epiphysis of the bone, destroying it. An effusion appears in the joint, its deformation occurs, movements in it are preserved, and pain is almost not felt. The patient's general condition is good. Sometimes the surrounding soft tissues are also affected. The process develops slowly, without acute inflammatory phenomena.

In rare cases, syphilitic myositis occurs (swelling of the long muscle of the limb, hardening and pain of the lesion, disruption of its function). Sometimes gummous myositis occurs, more often of the sternocleidomastoid muscle, less often of the muscles of the limbs and tongue.

The diagnosis of lesions of the movement apparatus in syphilis is established on the basis of clinical and radiological data, the results of a serological examination (standard reactions, RIBT, RIF), and sometimes trial antisyphilitic treatment.

The disease may be accompanied by damage to vital important organs(large vessels, liver, kidneys, brain, etc.), pronounced changes in the nervous system are often encountered. Tertiary syphilis can lead to disability (deafness, loss of vision due to atrophy optic nerves) and even death.

Hidden syphilis - syphilis, in which serological reactions are positive, but there are no signs of damage to the skin, mucous membranes and internal organs. Early latent syphilis (syphilis latens praecox) - latent syphilis, less than 2 years have passed since infection. Late latent syphilis (syphilis latens tarba) - 2 years or more have passed since infection. Unspecified latent syphilis (syphilis ignorata) is a disease whose duration cannot be determined.

Latent syphilis - this term refers to a type of syphilis that takes a latent course from the moment of infection, without clinical signs of the disease, with positive serological reactions in the blood. There are early and late latent syphilis. Early forms include acquired forms of syphilis with a duration of infection of up to two years, late - more than two years.

In the last decades of the 20th century, the proportion of patients with latent forms of syphilis increased significantly. As detailed epidemiological, clinical and laboratory studies have shown, early latent syphilis is one of the forms of infectious syphilis, and late latent syphilis is one of the forms of late non-infectious syphilis. In cases where it is impossible to distinguish early syphilis from late latent syphilis, they speak of latent unspecified syphilis. Such a diagnosis should be considered preliminary, subject to clarification during treatment and observation.

The difference in personal and social characteristics of patients with early and late forms of latent syphilis is very noticeable. Most patients with early latent syphilis are people under the age of 40, many of them have no family. In the anamnesis of sexual life, one can find evidence that they easily enter into sexual relations with unfamiliar and unfamiliar persons, which indicates a high probability of contact with patients with sexually transmitted diseases. During the period of 1-2 years, some of them had erosions, ulcers in the genital area, anus, perineum, oral cavity, and rashes on the skin of the torso. In the past, these patients (according to them) took antibiotics for gonorrhea or other infectious diseases. There may be cases when the sexual partners of such patients show signs of infectious syphilis or early latent syphilis.

Unlike people with early forms of latent syphilis, late latent syphilis affects mainly people over 40 years of age, most of them are married. In 99% of cases, the disease is detected during mass preventive examinations of the population, and only 1% of patients with late latent syphilis are detected during examination of family contacts of patients with late forms of syphilis. In such cases, infection apparently occurred when one of the spouses had infectious syphilis; the infection was not recognized in a timely manner and the spouses developed late forms of the disease. However, this should not be regarded as a possible contagiousness of patients with late forms of syphilis.

Only some patients with late latent syphilis indicate that they could have been infected 2-3 years ago. As a rule, they do not know exactly when they could have become infected, and they have not noticed any manifestations similar to the symptoms of infectious syphilis. Some of these patients belong to decreed groups of the population; for many years they have been systematically subjected to clinical and serological examination in medical preventive rooms. Clinically and serologically, their syphilis was asymptomatic.

A careful examination of patients with suspected early latent syphilis can reveal scars, induration, pigmentation at the sites of resolved syphilis, and enlarged inguinal lymph nodes. Early latent syphilis is accompanied by positive serological reactions.

The diagnosis of early latent syphilis is confirmed by the appearance of an exacerbation reaction at the beginning of treatment and a relatively rapid, as in patients with primary and secondary syphilis, negativity of standard serological reactions.

In all cases, clinical examination of patients with late latent syphilis does not reveal traces of resolved syphilis on the skin and visible mucous membranes, as well as specific pathology of the nervous system, internal and other organs. The disease is detected by serological blood testing. Typically, classical serological reactions in 90% of patients are positive in low titers (1:5-1:20) or in an incomplete complex. In rare cases, they are positive in high titers (1:160-1:480). Specific serological reactions are always positive.

Diagnosis of latent syphilis is often difficult. Thus, the need to make a decision on the final diagnosis based on the results of serological blood tests in the absence clinical symptoms illness, negative data from confrontation and anamnesis determines the special responsibility of the doctor when diagnosing latent syphilis. It is important to consider the possibility of developing false-positive serological reactions, which can be acute or chronic. Acute - observed in children, general infections, poisoning, in women during menstruation, in the last months of pregnancy, etc. With the disappearance of the main cause, they become negative (within 2-3 weeks, sometimes 4-6 months). Chronic reactions are observed in chronic infections, severe systemic diseases, metabolic disorders; Often the cause of their occurrence cannot be determined. Very persistent chronic false-positive serological reactions are observed for many months and even years. They can be positive in high titer and in full complex, including positive RIF and RIBT in individuals. Their frequency increases markedly in older people.

In this regard, the doctor must be well aware of individual methods, their diagnostic capabilities, the principles of diagnosing latent syphilis, the need to take into account the general condition of patients, their social and personal characteristics.

It's important to anticipate possible dangers and complications that may be associated with misdiagnosis. Based on this, young patients with suspected early latent syphilis must be hospitalized to clarify the diagnosis. Elderly patients who do not have extramarital affairs, with negative results of examination of their family contacts, in case of suspicion of late latent syphilis, must be subjected to a thorough, repeated (over 5-6 months or more) clinical and serological examination on an outpatient basis with mandatory RIF , RIBT. The more and more often there are coincidences in the complex of serological reactions, the more confidently one can make a diagnosis of latent syphilis.

Considering the high percentage of false positives in elderly and old age As a rule, they have no history and clinical manifestations of syphilis on the skin and visible mucous membranes, changes in the nervous system, internal organs; based on positive serological blood reactions alone, specific treatment is not prescribed to such patients.

Unspecified latent syphilis. In cases where it is impossible to distinguish early syphilis from late latent syphilis, they speak of latent unspecified syphilis. Such a diagnosis should be considered preliminary, subject to clarification during treatment and observation.

Congenital syphilis - syphilis, infection of which occurred from a sick mother during intrauterine development. Congenital syphilis refers to the presence of treponemal infection in a child, starting from its intrauterine development.

Treponema pallidum enters the fetus through the umbilical vein and lymphatic slits umbilical vessels, with maternal blood through the damaged placenta, starting from the 10th week of pregnancy. Typically, intrauterine infection with syphilis occurs at 4-5 months. pregnancy. In pregnant women with secondary syphilis, infection of the fetus occurs in almost 100% of cases; intrauterine infection occurs less frequently in patients with late forms of syphilis and very rarely in patients with primary syphilis.

The placenta of women with syphilis is increased in size and weight. Normally, the ratio of the weight of the placenta to the body weight of the child is 1:6, in sick children - 1:3; 1:4. They experience edema, connective tissue hyperplasia, and necrotic changes, more pronounced in the embryonic part of the placenta.

In all doubtful cases, the obstetrician-gynecologist is obliged to carefully examine the condition of the placenta, weigh it and refer it for histological examination its embryonic (children's) part.

Some infected fetuses die; in other cases, the child is born at term, but still dead. Some children are born alive, however, already in childhood they show signs of congenital syphilis: interstitial keratitis, Hutchinson's teeth, saddle nose, periostitis, various anomalies of the central nervous system.

Reagin titers in the child’s blood increase during the active stage of the disease; with passive transfer of antibodies from the mother, they decrease over time. Correct treatment mother during pregnancy prevents the development of congenital syphilis.

According to the currently accepted WHO classification, early congenital syphilis is distinguished from characteristic features and early congenital latent syphilis - without clinical manifestations, with seropositive blood reactions and cerebrospinal fluid. Late congenital syphilis includes all signs of congenital syphilis, specified as late or appearing 2 years or more after birth, as well as late congenital syphilis, latent, without clinical symptoms, accompanied by positive serological reactions and normal composition of the cerebrospinal fluid.

Damage to internal organs with congenital syphilis can be detected already in the first months of a child’s life. More often the liver and spleen are affected (they increase in size and become dense). Interstitial pneumonia develops in the lungs, and less commonly, white pneumonia. There is anemia, increase in ESR. Diseases of the heart, kidneys, digestive tract for syphilis in children infancy are rare.

When the central nervous system is damaged, the vessels and membranes of the brain, less often the spinal cord, are involved in the process, meningitis, meningoencephalitis, and cerebral syphilis with characteristic polymorphic symptoms develop. In some cases, hidden meningitis may occur, detected only by examining the cerebrospinal fluid.

Early congenital syphilis childhood(from 1 year to 2 years) according to their own clinical signs does not differ from secondary relapse. In the 2nd year of a child’s life, the clinical symptoms of congenital syphilis are less diverse. Papular elements are observed on the skin and mucous membranes, and rarely roseola. Robinson-Fournier scars, periostitis, phalangitis, bone gummas, orchitis, chorioretinitis, liver, spleen, and central nervous system lesions such as meningitis, meningoencephalitis, and cerebral vascular syphilis may be observed.

Currently, active manifestations of early congenital syphilis on the skin and internal organs are rare. This is mainly due to the early detection and timely treatment of this disease in pregnant women, which became possible thanks to the widespread introduction of their double wassermanization, as well as, apparently, the use of antibiotics during pregnancy for intercurrent diseases and the generally milder course of syphilis observed in recent years .

It is important to emphasize that early congenital syphilis occurs predominantly latently or with scanty symptoms (osteochondritis of I-II degrees, periostitis, chorioretinitis). The diagnosis of latent, erased forms is established on the basis of data from a serological study (KSR, RIBT, RIF), opinions of doctors of related specialties, and radiography of long tubular bones. When assessing positive serological reactions in children in the first months of life, it is necessary to take into account the possibility of transplacental transfer of antibodies and reagins from mother to child. When conducting differential diagnosis early latent congenital syphilis and passive transmission of antibodies are important quantitative reactions. To diagnose syphilis, the child's antibody titers must be higher than those of the mother. Monthly serodiagnosis is also required. In healthy children, titers decrease within 4-5 months. spontaneous negativity of serological reactions occurs. In the presence of infection, antibody titers are persistent or increased. Passive transmission from mother to child is possible only for low-molecular-weight IgG, and large IgM molecules penetrate the child’s body only when the barrier function of the placenta is disrupted or are actively produced by the child’s body when he or she becomes ill with syphilis. This gives grounds for using the RIF IgM reaction in the diagnosis of early congenital syphilis.

Therefore, children (in the absence of clinical, radiological, ophthalmological symptoms of syphilis) born to mothers who were fully treated before and during pregnancy or who completed basic treatment but did not receive prophylactic treatment should not be diagnosed with early latent congenital syphilis if they have titres antibodies are lower than those of the mother. Such children should be given preventive treatment. If after 6 months. If they have a positive RIBT or RIF, then it should be concluded that there was congenital latent syphilis. It should be taken into account that due to the peculiarities of the reactivity of the newborn’s body (increased lability of blood proteins, lack of complement and natural hemolysin, insufficient levels of antibodies in the blood serum) in the first days of the child’s life, serological reactions can be negative, despite the presence of syphilis. Therefore, they are not recommended in the first K) days after the birth of the child.

Serological tests may also be negative in the first 4-12 weeks. life of a newborn whose mother became infected in late dates pregnancy. According to the relevant instructions, such children also need to undergo 6 courses of preventive treatment.

Late congenital syphilis. The clinical symptoms of the disease are highly variable. Pathognomonic, unconditional, and probable symptoms of late congenital syphilis are distinguished. Natognomonic symptoms include Hutchinson's triad: parenchymal keratitis, specific labyrinthitis, changes in the permanent upper central incisors (Hutchinson's teeth). With parenchymal keratitis, redness and clouding of the cornea, photophobia, and lacrimation appear. The process is usually bilateral: first one eye gets sick, and after some time the second one is affected.

Vascular forms of keratitis are observed, in which clouding of the cornea develops without redness of the eyes and photophobia. Such forms of keratitis were also encountered in the clinic of the Institute of Dermatology and Venereology of the Academy of Medical Sciences of Ukraine. In parenchymal keratitis, episcleral and scleral vessels grow into the cornea. There is clouding of the cornea of ​​varying severity. Often it covers almost the entire cornea in the form of a milky or grayish-red “cloud”. The cloudiness is most intense in the center of the cornea. In milder cases, it is not diffuse in nature, but is represented by individual small cloud-like spots. The injection of the basal vessels and conjunctival vessels is significantly expressed. Parenchymal keratitis may be accompanied, moreover, by iridocyclitis and chorioretinitis. The period between the disease of one and the second eye, despite the treatment, can often range from several weeks to 12 months, and according to some authors, even several years. The outcome of keratitis depends on the severity and location of the area of ​​opacification. With a small degree of turbidity and timely rational treatment The child's vision can be completely restored. There are also cases of almost complete loss of vision. With insufficient treatment, relapses are possible. After resolution of parenchymal keratitis, corneal opacities and empty vessels, which are detected by ophthalmoscopy using a slit lamp, remain for life, as a result of which the diagnosis of previous parenchymal keratitis can always be made retrospectively. This is very important, since parenchymal keratitis is the most common and perhaps the only symptom of Hutchinson's triad. Develops between the ages of 5-15 years. It also happens at a later age. Thus, M.P. Frishman (1989) described a case of parenchymal keratitis in a patient aged 52 years.

Syphilitic labyrinthitis and the resulting deafness are caused by the development of periostitis in the bony part of the labyrinth and damage to auditory nerve. The process is usually two-way. Deafness occurs suddenly. Sometimes it is preceded by dizziness, noise and ringing in the ears. Develops between the ages of 7-15 years. At early occurrence, before the child develops speech, deaf-muteness may be observed. Labyrinthine deafness is resistant to treatment.

There is degeneration of two permanent upper central incisors (Hutchinson's teeth). The main symptom is crown atrophy, as a result of which the tooth at the neck is wider than at the cutting edge. The teeth are usually chisel or screwdriver shaped with a lunate notch along the cutting edge. The axes of the teeth converge towards the midline; sometimes one central incisor may have characteristic changes.

Before the eruption of permanent teeth, these changes are revealed on an x-ray. Hutchinson's triad is rarely detected. Parenchymal keratitis and Hutchinson's teeth or one of these symptoms are more commonly observed. In addition to pathognomonic, i.e., unconditional, signs, the detection of even one of which allows one to diagnose late congenital syphilis without a doubt, there are probable signs, the presence of which allows one to suspect congenital syphilis, but to confirm the diagnosis additional data is needed: concomitant clinical manifestations or results of examination of members families.

Most authors include the following as probable signs of late congenital syphilis: radial scars around the lips and on the chin (Robinson-Fournier scars), some forms of neurosyphilis, syphilitic chorioretinitis, a buttock-shaped skull formed before one year of life, a “saddle” nose, dystrophy of teeth in the form of purse-shaped large molars and fangs, “saber-shaped” shins, symmetrical scnovites of the knee joints. A probable sign is also considered to be the Ausitidian-Higumenakis sign - thickening of the sternal end of the clavicle (usually the right one). While N.A. Torsuev (1976), Yu.K. Skripkin (1980) attribute this symptom to dystrophies, that is, to manifestations observed not only in late congenital syphilis, but also in other diseases. However, if they are detected, it is necessary to conduct a thorough examination of the child and his parents for the presence of syphilis. Dystrophies include: high (Gothic) hard palate, infantile little finger, absence of the xiphoid process of the sternum, the presence of a fifth tubercle on the chewing surface of the first large molar of the upper jaw (Corabelli tubercle), diastom, microdentism, “Olympic” forehead, enlarged frontal and parietal tubercles, etc. The detection of several dystrophies, their combination with one of the iatognomonic signs or several probable ones, with positive serological reactions in the child and his parents are the basis for making a diagnosis of late congenital syphilis.

Severe changes, often leading to disability, are observed with damage to the central nervous system in patients with late congenital syphilis. The development of specific meningitis and vascular lesions is manifested by cerebrospinal fluid hypertension, persistent headache, speech disorder, hemiparesis and hemiplegia, dementia, secondary atrophy of the optic nerves, and Jacksonian epilepsy. These children develop tabes dorsalis early, progressive paralysis with frequent primary atrophy of the optic nerves. M. P. Frishman (1989) observed a 10-year-old boy with tabes dorsalis and atrophy of the optic nerves, which led to complete blindness. Before pregnancy, the child's mother underwent one course of specific treatment for secondary recurrent syphilis and was not treated again. If there are no irreversible scar changes due to damage to the nervous system, specific treatment is quite effective.

Lesions of internal organs with late congenital syphilis are observed less frequently than with early congenital syphilis. The liver often suffers, which is enlarged, dense, and lumpy. Splenomegaly, albuminuria, paroxysmal hematuria, metabolic diseases (nanism, infantilism, obesity, etc.) are observed. Specific damage to the cardiovascular system rarely develops.

With late congenital syphilis, standard serological tests are positive in 70-80% of patients and in almost 100% of patients with parenchymal keratitis. RIBT and RIF are positive in 92-100% of cases. After full treatment, standard serological reactions (especially RIBT and RIF) remain positive for many years, which, however, does not indicate the need for additional treatment. We observed a patient with late congenital syphilis, who, after eight full courses of treatment with novarsenol and bismuth, gave birth to three healthy children. During pregnancy she received prophylactic treatment with benzylpenicillin. Standard serological reactions during subsequent examinations, RIBT and RIF remained consistently positive for her for 20 years or more.

Diagnosis of late congenital latent syphilis presents certain difficulties, for which, according to international classification, characterized by the absence of clinical manifestations of congenital syphilis and normal cerebrospinal fluid. When differentially diagnosing late congenital latent syphilis and late latent acquired syphilis, it is necessary to take into account the results of examination of the patient’s semen, the duration of the mother’s disease, the presence and nature of manifestations of late congenital syphilis in brothers and sisters. At the same time, the detection of syphilis in the mother does not always serve as evidence that the child being examined has congenital syphilis. The following clinical case is indicative.

A 14-year-old girl was diagnosed with late congenital syphilis, the manifestations of which were dementia, infantility, Hutchinson teeth, chorioretinitis, and positive serological reactions in the blood. Her older sister, 17 years old, physically and mentally well developed, in the absence of any signs of congenital syphilis, tested positive for CSR, RIF and RIBT. Cerebrospinal fluid is normal. It was established that after the birth of her first daughter, the mother separated from her husband and began to abuse alcohol and become a vagrant. A few years after the birth of her second daughter, she died. Apparently, during her period of vagrancy she was infected with syphilis. She gave birth to a younger daughter, who was subsequently diagnosed with severe manifestations of late congenital syphilis, and infected her healthy older daughter. This assumption is supported by the generally accepted position that the activity of syphilitic infection in relation to the fetus decreases depending on the duration of the mother’s illness. If the eldest daughter had congenital syphilis, the process would be more difficult than with the younger one. Therefore, the eldest daughter was diagnosed with late latent acquired syphilis.

Early congenital syphilis - congenital syphilis in the fetus and in children under 2 years of age, manifested by syphilitic pemphigus, diffuse papular infiltration of the skin, damage to the mucous membranes, internal organs, bone tissue, nervous system, eyes. Late congenital syphilis (syphilis congenita tarda) is congenital syphilis in children over 2 years of age, manifested by Hutchinson’s triad, as well as damage to the skin, internal organs and bones like tertiary syphilis.

Latent congenital syphilis - congenital syphilis, in which there are no clinical manifestations and laboratory parameters of the cerebrospinal fluid are normal.

Syphilis of the nervous system - uh This concept includes a large number of diseases that differ both pathogenetically and morphologically, as well as clinical course. The main role in the development of neurosyphilis is played by the absence or insufficient previous antisyphilitic treatment, trauma (especially traumatic brain injury), intoxication, chronic infections, and disorders of the immune status of the patient’s body. From a clinical point of view, it is advisable to distinguish between: syphilis of the central nervous system, syphilis of the peripheral nervous system, functional nervous and mental disorders in syphilis.

Syphilis of the central nervous system. This disease is closely associated with a wide variety of (localized or diffuse) syphilitic processes in the brain or spinal cord. They can be either vascular or localized in the medulla. A combination of such processes is often observed, often without clear distinctions and with scattered symptoms. Their pathogenesis is very diverse. IN early periods they can be acute or subacute inflammatory, in later periods - limited or diffuse inflammatory or gummous, and in some cases inflammatory-degenerative (for example, with vascular lesions).

Clinically, syphilis of the central nervous system can manifest itself as a picture of meningitis, meningoencephalitis. meningomyelitis, endarteritis or gummous processes that give symptoms of a tumor in the brain or medulla oblongata. The pathomorphosis of modern neurosyphilis is an increase in the number of erased, low-symptomatic ones. atypical forms. Its expressed forms are rare, the symptoms of progressive paralysis have changed, gummas of the brain and spinal cord, as well as syphilitic cervical pachymeningitis, are very rarely observed.

The classification of central nervous system lesions in syphilis is imperfect. Currently, clinical and morphological classification is used for practical purposes. There are early syphilis of the nervous system, or early neurosyphilis (up to 5 years from the moment of infection, mainly in the first 2-3 years), and late, or late neurosyphilis (not earlier than 6-8 years after infection). Early neurosyphilis is called mesenchymal, since the membranes and blood vessels of the brain are affected, the mesenchymal reaction predominates; sometimes parenchymal elements are involved in the process, but secondary. Late neurosyphilis is called parenchymal due to damage to neurons, nerve fibers, as well as neuroglia. The changes are inflammatory-dystrophic in nature, the mesenchymal reaction is not expressed. This division of neurosyphilis is conditional; In recent decades, a significant lengthening of the latent period has been observed, and cerebral vascular syphilis, like meningovascular syphilis, is registered 10-15 years or more after infection.

Syphilis visceral - syphilis, which affects internal organs (heart, brain and/or spinal cord, lungs, liver, stomach, kidneys).

This term refers to syphilis, which affects internal organs. Siphatotic lesions can develop in any organ, but more often they occur in internal organs with the greatest functional load (heart, brain and spinal cord, lungs, liver, stomach). There are early and late forms of visceral syphilis. The former develop in early forms of syphilis, and, as a rule, only the function of the affected organs is impaired. However, some patients with primary and secondary syphilis may experience more pronounced damage to internal organs (inflammatory, degenerative). At the same time, the clinic is not distinguished by specific symptoms characteristic only of syphilitic infection. Early lesions of internal organs by syphilis develop more often than are diagnosed, since they cannot be identified during a routine clinical examination of patients. Late forms of visceral syphilis are characterized by changes in the internal organs; they are accompanied by focal lesions that manifest themselves as destructive changes.

Household syphilis - syphilis, which is transmitted through extrasexual contact.

Syphilis decapitated - infection occurs when the pathogen enters directly into the bloodstream (through a wound, during a blood test); characterized by the absence of chancre.

Syphilis transfusion - infection occurs as a result of blood transfusion of a patient.

Malignant syphilis - severe syphilis with massive damage to internal organs and the nervous system, characteristic of tertiary syphilis in the 1st year of the disease.

Experimental syphilis - syphilis that occurred in experimental animals (monkeys, rabbits) as a result of their artificial infection.

Diagnosis of syphilis

To establish a diagnosis, the following are important: special anamnesis data; data from an objective examination of the patient; laboratory analysis for the detection of pathogens in erosive-ulcerative, papular elements in the genital area, oral cavity, serological tests of blood, cerebrospinal fluid; in some cases - other research methods (potassium iodide test, probe phenomenon, histological analysis).

Based on materials Medical encyclopedia Professor Ivan Ivanovich Mavrov. “Sexual diseases” 2002

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

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

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

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

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

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

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

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

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

Hidden syphilis. It is characterized by the fact that the presence of a syphilitic infection is proven only by positive serological reactions, while clinical signs of the disease, neither specific lesions of the skin and mucous membranes, nor pathological changes in the nervous system, internal organs, bones and joints can be identified. In such cases, when the patient knows nothing about the time of his infection with syphilis, and the doctor cannot determine the period and timing of the disease, it is customary to diagnose “latent unspecified syphilis.”

In addition, the group of latent syphilis includes patients with a temporarily or long-term asymptomatic course of the disease. Such patients already had active manifestations of syphilitic infection, but they disappeared spontaneously or after the use of antibiotics in doses insufficient to cure syphilis. If less than two years have passed since infection, then, despite the latent course of the disease, patients with such early latent syphilis are very dangerous in epidemiological terms, since they can expect another relapse of the secondary period with the appearance of infectious lesions on the skin and mucous membranes. Late latent syphilis, when more than two years have passed since the disease, is epidemiologically less dangerous, since the activation of infection will, as a rule, be expressed either in damage to internal organs and the nervous system, or in low-infectious tertiary syphilides of the skin and mucous membranes.

Syphilis without chancre (“decapitated syphilis”). When infected with syphilis through the skin or mucous membranes, primary syphiloma is formed at the site of introduction of pale treponema - chancre. If treponema pallidum enters the body bypassing the skin and mucous barrier, then a generalized infection may develop without previous primary syphiloma. This is observed if infection occurs, for example, from deep cuts, injections or during surgical operations, which is practically extremely rare, as well as when blood is transfused from a donor with syphilis ( transfusion syphilis). In such cases, syphilis is detected immediately in the form of generalized rashes characteristic of the secondary period. Rashes usually appear 2.5 months after infection and are often preceded by prodromal phenomena in the form of headache, pain in bones and joints, and fever. The further course of “decapitated syphilis” does not differ from the course of classical syphilis.

Malignant syphilis. This term refers to a rare form of syphilitic infection in the secondary period. It is characterized by pronounced disturbances general condition and destructive rashes on the skin and mucous membranes, occurring continuously over many months without hidden periods.

Primary syphiloma in malignant syphilis, as a rule, does not differ from that in the normal course of the disease. In some patients, it has a tendency to grow and undergo deep decay. After the primary period, sometimes shortened to 2-3 weeks, in patients, in addition to the usual rashes for the secondary period (roseola, papule), special forms of pustular elements appear, followed by ulceration of the skin. This form of syphilis is accompanied by more or less severe general symptoms and high fever.

Along with skin lesions in malignant syphilis, deep ulcerations of the mucous membranes, damage to the bones, periosteum, and kidneys can be observed. Damage to internal organs and the nervous system is rare, but is severe.

In untreated patients, the process does not tend to go into a latent state and can occur in separate outbreaks, following one after another, for many months. Prolonged fever, severe intoxication, painful destructive rashes - all this exhausts patients and causes loss of body weight. Only then does the disease begin to gradually subside and enter a latent state. The subsequent relapses are usually of a normal nature.

61) Hidden form of syphilis.
Latent syphilis from the moment of infection takes a latent course and is asymptomatic, but blood tests for syphilis are positive.
In venereological practice, it is customary to distinguish between early and late latent syphilis: if the patient became infected with syphilis less than 2 years ago, they speak of early latent syphilis, and if more than 2 years ago, then late.
If it is impossible to determine the type of latent syphilis, the venereologist makes a preliminary diagnosis of latent unspecified syphilis; during examination and treatment, the diagnosis can be clarified.

The reaction of the patient's body to the introduction of Treponema pallidum is complex, diverse and insufficiently studied. Infection occurs as a result of penetration of Treponema pallidum through the skin or mucous membrane, the integrity of which is usually compromised.

Many authors provide statistical data according to which the number of patients with latent syphilis has increased in many countries. For example, latent (latent) syphilis is detected in 90% of patients during preventive examinations, in antenatal clinics and somatic hospitals. This is explained by both a more thorough examination of the population (i.e., improved diagnosis) and a true increase in the number of patients (including due to the widespread use of antibiotics by the population for intercurrent diseases and manifestations of syphilis, which are interpreted by the patient himself not as symptoms of a sexually transmitted disease, but as, for example, the manifestation of allergies, colds, etc.).
Latent syphilis is divided into early, late And unspecified.
Latent late syphilis in epidemiological terms, it is less dangerous than earlier forms, since when the process is activated, it manifests itself either by damage to internal organs and the nervous system, or (with skin rashes) by the appearance of low-infectious tertiary syphilides (tubercles and gummas).
Early latent syphilis in time corresponds to the period from primary seropositive syphilis to secondary recurrent syphilis inclusive, only without active clinical manifestations of the latter (on average up to 2 years from the moment of infection). However, these patients may experience active, contagious manifestations of early syphilis at any time. This forces patients with early latent syphilis to be classified as an epidemiologically dangerous group and vigorous anti-epidemic measures to be carried out (isolation of patients, thorough examination of not only sexual but also household contacts, compulsory treatment if necessary, etc.). Like the treatment of patients with other early forms of syphilis, the treatment of patients with early latent syphilis is aimed at quickly sanitizing the body from a syphilitic infection.

62. The course of syphilis in the tertiary period . This period develops in patients who have not received any or insufficient treatment, usually 2–4 years after infection.

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

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 consistency, brownish or dark purple color.

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.

Gummy syphilide, or subcutaneous gumma. This is a node that develops in the hypodermis. Typical localization sites for gummas are the legs, head, forearms, and sternum. The following clinical types of gummous syphilide are distinguished: isolated gummas, diffuse gummous infiltrates, fibrous gummas.

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.

Gummous infiltration. The gummous infiltrate disintegrates, the ulcerations merge, forming an extensive ulcerative surface with irregular large scalloped outlines, healing with a scar.

Fibrous gummas, or periarticular nodules, are formed as a result of fibrous degeneration of syphilitic gummas.

Late neurosyphilis. It is a predominantly ectodermal process involving the neural parenchyma of the brain and spinal cord. It usually develops 5 years or more from the moment of infection. In late forms of neurosyphilis, degenerative-dystrophic processes predominate.

Late visceral syphilis. In the tertiary period of syphilis, limited gummas or diffuse gummatous infiltrations may occur in any internal organ.

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. Gummy osteoperiostitis:

2. Gummy osteomyelitis:

3. Non-gummous osteoperiostitis.

63. Tubercular syphilide of the skin. Tuberous syphilide. Typical places of its localization are the extensor surface of the upper limbs, torso, and face. The lesion occupies a small area of ​​skin and is located asymmetrically.

The main morphological element of tubercular syphilide is a tubercle (a dense, hemispherical, cavityless formation of a round shape, dense elastic consistency).

Grouped tubercular syphilide is the most common type. The number of tubercles usually does not exceed 30–40. The tubercles are located on different stages evolution.

Serpiginating tubercular syphilide. In this case, the individual elements merge with each other into a dark red horseshoe-shaped ridge, 2 mm to 1 cm wide, raised above the level of the surrounding skin, along the edge of which fresh tubercles appear.

Definition. Syphilis (Syphilis, Lues)- general infection, caused by treponema pallidum and affects all human organs and tissues, among which the most common are the skin and mucous membranes.

29.1. HISTORY OF SYPHILIS STUDY

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

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

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

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

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

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

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

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

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

29.2. ETIOLOGY

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

1) translational (forward and backward);

2) rotational;

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

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

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

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

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

29.3. CONDITIONS AND ROUTES OF INFECTION

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

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

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

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

29.4. GENERAL PATHOLOGY

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

29.5. CLASSIFICATION OF SYPHILIS

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

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

29.6. CLINICAL PICTURE OF THE PRIMARY PERIOD OF SYPHILIS

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

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

Special varieties of chancre also include:

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

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

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

3) herpetiform chancre, reminiscent of genital herpes.

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

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

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

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

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

At the end of the primary period, polyadenitis develops.

Differential diagnosis The solid Shancra is carried out with the following diseases: balanight and balanopostitis, genital herpes, scabies ectima, shancriform pyoderma, gonococcal and trichomonal ulcers, soft chancre, tuberculosis ulcer, diphtheria ulcer, acute vulva ulcer, fixed toxicoderma, venereal lymphogranuloma Fire cancer of the skin. Differential diagnosis is based on the characteristics of the clinical picture, medical history, detection of Treponema pallidum and the results of serological reactions.

29.7. CLINICAL PICTURE OF SECONDARY

SYPHILIS PERIOD

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

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

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

3. Polymorphism.

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

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

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

5. Absence of acute inflammatory phenomena.

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

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

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

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

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

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

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

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

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

Elements resolve very slowly, even under the influence of treatment. Miliary syphilide is considered a rare manifestation of secondary syphilis.

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

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

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

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

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

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

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

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

With diffuse alopecia, uniform hair thinning is noted.

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

Pigmentary syphilide (syphilitic leukoderma,

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

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

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

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

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

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

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

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

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

Syphilitic lesions of internal organs in

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

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

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

29.8. CLINICAL PICTURE OF THE TERTIARY PERIOD OF SYPHILIS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

With osteomyelitis, the gumma either ossifies or a sequester forms in it.

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

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

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

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

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

Syphilis of the nervous system. Most often among clinical forms Late neurosyphilis causes progressive paralysis, tabes dorsalis, and cerebral gummas.

29.9. CLINICAL PICTURE OF CONGENITAL SYPHILIS

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

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

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

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

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

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

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

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

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

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

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

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

trophies resulting from specific damage to the endocrine glands.

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

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

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

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

Possible signs include the following:

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

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

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

4) syphilitic chorioretinitis;

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

6) syphilitic gonitis;

7) damage to the nervous system.

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

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

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

29.10. LABORATORY DIAGNOSIS OF SYPHILIS

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

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

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

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

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

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

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

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

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

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

Serological diagnosis of syphilis

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

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

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

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

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

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

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

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

1. Immunofluorescence reaction (RIF).

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

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

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

Indications for performing RIF-abs.:

Elimination of false positive results of treponemal tests;

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

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

Indications for this reaction are:

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

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

2. Immobilization reaction of Treponema pallidum (RIBT,

RIT).

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

3. Enzyme-linked immunosorbent assay (ELISA).

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

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

4. Passive hemagglutination reaction (RPHA).

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

For various types examinations for syphilis recommend the following serological diagnostic methods:

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

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

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

29.11. BASIC PRINCIPLES OF TREATING PATIENTS WITH SYPHILIS

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

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

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

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

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

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

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

and etc.).

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

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

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

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

cidal concentration of penicillin for 2-3 weeks; injections of extensillin and retarpen are carried out once a week, bicillin-1 - once every 5 days. Bicillin-3 and bicillin-5 can also be used in outpatient treatment.

Three-component domestic bicillin-3 consists of dibenzylethylenediamine, novocaine and sodium salts of penicillin in a ratio of 1:1:1. Injections of this drug at a dose of 1.8 million units are given 2 times a week. Two-component bicillin-5 consists of dibenzylethylenediamine and novocaine salts of penicillin in a ratio of 4: 1. Injections of this drug in a dose of 1,500,000 units are made once every 4 days.

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

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

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

1) priority of outpatient treatment methods;

2) reduction of treatment time;

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

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

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

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

7) reducing the time of clinical and serological control.

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

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

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

Clinical and serological control after completion of treatment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The following should be taken into account as cure criteria:

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

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

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

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

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