In case of syphilitic bone lesions, it is radiologically detected. Bone damage due to syphilis
Osteomyelitis is a disease whose name comes from the Greek language and literally means “inflammation of the bone marrow.” It is characterized by a varied course - from asymptomatic and sluggish to fulminant. For this reason, a patient with suspected osteomyelitis should be carefully examined, receive timely appropriate treatment and be under the vigilant supervision of medical personnel.
Osteomyelitis can affect any bone in the body, but statistically most often osteomyelitis occurs in the femur, tibia and humerus. Men are most predisposed to this disease.
Treatment of osteomyelitis is a complex and not always successful process, since it includes several components, which are based on surgical intervention. The prognosis largely depends on the condition of the patient’s body and the quality of medical care provided. According to statistics, the percentage of complete recovery without subsequent relapses ( repeated exacerbations) is 64%. Relapses occur in another 27% of patients over the next 5 years. 6% fail treatment and the remaining 3% develop fulminant osteomyelitis and die.
Bone Anatomy
The human musculoskeletal system consists of a rigid frame, which is the bones, and a moving component, the muscles. Depending on heredity, the human body can consist of 200 – 208 bones. Each bone is a separate organ with a unique shape and structure determined by the function that the bone performs. Like any organ, bone has its own metabolism, subject to the metabolism of the skeletal system as a whole and the metabolism of the whole organism. In addition, the internal structure of the bone is not constant and changes depending on the total vector of loads over the past few days. When injured, the bone regenerates like any other organ, over time completely restoring the impaired function. Skeletal bones are classified according to shape into the following types:
- long and short tubular ( femurs, humeri, phalanges);
- flat ( scapula, calvarial bones);
- mixed ( sternum, vertebrae, etc.)
Bone consists of two-thirds inorganic minerals and one-third organic. The main inorganic substance is calcium hydroxyapatite. Among organic substances, various proteins, carbohydrates and small amounts of fats are distinguished. In addition, bone contains in small quantities almost all the elements of the periodic table of chemical elements. Water is an integral component of bone and to a certain extent determines its flexibility. Children have a higher water content, so their bones are more elastic than those of adults and, especially, older people. The balance between calcium and phosphorus ions is also of certain importance. Maintaining this balance is maintained by a constant balance of the hormonal influence of parathyroid hormone and somatostatin. The more parathyroid hormone enters the blood, the more calcium is washed out of the bones. The resulting gaps are filled with phosphorus ions. As a result, the bone loses strength but gains some flexibility.
Different types of bones have different structures. Osteomyelitis can develop in any bone, but according to statistics, in more than two thirds of cases it develops in long tubular bones. This is facilitated by certain features of vascularization ( provision of blood vessels) bones of this type, which will be described in the section “mechanism of development of osteomyelitis”. Based on this, the closest attention should be paid to the structure of the long tubular bones.
Tubular bone consists of a body ( diaphysis) and two ends ( epiphyses). A small strip of tissue up to 2 - 3 centimeters wide, which is located between the diaphysis and epiphyses, is called the metaphysis. The metaphysis is responsible for the growth of bone in length.
When cut, the bone looks like this. In the center of the diaphysis there is a cavity - the medullary canal, in which the red bone marrow is located. The amount of red bone marrow can vary significantly depending on the intensity of hematopoietic processes. Around the medullary canal there is bone substance itself, which is divided into two types - spongy and compact substance. Closer to the center and at the ends of the bone there is a spongy substance. According to its name, its structure contains a large number of interconnected cavities in which yellow bone marrow is located. It is believed that it does not perform special functions, but is a precursor of red bone marrow and is converted into it when there is a need to enhance hematopoiesis. The main supporting function of the bone is performed by the compact substance. It is located around the spongy substance, mainly in the diaphysis. In the area of the epiphyses and metaphyses, the spongy substance is organized in the form of septa ( partitions). These partitions are located parallel to the vector of the greatest constant load on the bone and are able to be rebuilt depending on the need to strengthen or weaken the bone.
The bone shell consists of periosteum in the area of the diaphysis and articular cartilage in the area of the epiphyses. The periosteum is a thin piece of plastic capable of producing young bone cells - osteoblasts. It is this that ensures the growth of bones in thickness and actively regenerates ( is being restored) for fractures. The periosteum contains several openings through which blood vessels penetrate the bone. Under the periosteum, these vessels form an extensive network, one part of the branches of which nourishes the periosteum itself, and the second penetrates deep into the bone and, in the form of tiny capillaries, penetrates both bone marrows, and also enters the spongy and compact substance of the bone, providing their nutrition. The vessels that pass through the bone marrow are fenestrated, meaning they have holes in their walls. Through these holes, newly formed red blood cells in the bone marrow enter the bloodstream.
To further describe the mechanism of development of hematogenous osteomyelitis, it is necessary to pay attention to the metaphysis, which in most cases is the place from which inflammation begins. As stated earlier, the metaphysis is the area that allows bone to grow in length. Growth implies high metabolic activity in this area, which is unimaginable without appropriate nutrition. It is for this reason that the most extensive capillary network is located in the metaphyses, providing the necessary blood supply to this area of the bone.
The articular surfaces located at the edges of the bone are covered with hyaline cartilage. Cartilage is nourished both by intraosseous blood vessels and by synovial fluid located in the joint cavity. The functional integrity of cartilage lies in its shock-absorbing function. In other words, cartilage softens the natural vibrations and shocks of the body, thus preventing damage to bone tissue.
Causes of osteomyelitis
The immediate cause of osteomyelitis is the entry of pathogenic bacteria into the bone with the development of a purulent inflammatory process. The most common causative agent of osteomyelitis is Staphylococcus aureus. Less commonly, osteomyelitis develops due to intraosseous invasion of Proteus, Pseudomonas aeruginosa, hemolytic streptococcus and Escherichia coli. Based on the number of types of pathogens that cause osteomyelitis, they are distinguished:
- monoculture;
- mixed culture;
- lack of growth of the pathogen on nutrient media.
Predisposing factors for the development of osteomyelitis are:
- foci of latent infection ( tonsils, caries, adenoids, boils, etc.);
- increased allergic background of the body;
- weak immunity ;
- physical exhaustion;
- long fasting.
- injury;
- respiratory viral infection ( ARVI);
- lifting weights;
- acute reaction to stress, etc.
Mechanism of development of osteomyelitis
The mechanism of development of osteomyelitis has not been fully disclosed, despite the fact that this disease has been known to doctors for a long time. Today, there are several generally accepted theories that describe the development of osteomyelitis in stages, but each of them has both advantages and disadvantages, and therefore cannot be considered the main one. The following theories of the development of osteomyelitis are distinguished:
- vascular ( embolic);
- allergic;
- neuro-reflex.
Vascular ( embolic) theory
Intraosseous vessels form a wide network. As the number of capillaries increases, their total lumen increases, which ultimately affects a decrease in the speed of blood flow in them. This is especially pronounced in the metaphysis area, where the capillary network is most pronounced. A decrease in blood flow speed leads to an increased risk of thrombosis and subsequent necrosis. Attachment of bacteremia ( circulation of microorganisms in the blood) or pyaemia ( circulation of pus clots in the blood) is practically equivalent to the development of purulent osteomyelitis. Another fact in favor of this theory is that the relatively high incidence of development of the primary focus of osteomyelitis in the epiphyses of bones is explained by the blind completion of the vessels feeding the articular cartilage. Therefore, in some injuries, bone necrosis does not develop in the area of the cartilage itself, which is nourished in two ways and is therefore more resistant to ischemia ( insufficient blood flow), and under the cartilage, where the lowest blood flow velocity is observed.Allergic theory
As a result of a series of animal experiments, it was found that bacterial clots themselves entering the bone developed inflammation in approximately 18% of cases. However, when the body of experimental animals was sensitized with the serum of another animal, osteomyelitis developed in 70% of cases. Based on the data obtained, it was concluded that an increase in the allergic background of the body greatly increases the risk of developing osteomyelitis. Presumably this is due to the fact that with increased sensitization of the body, any minor injury can cause aseptic inflammation in the perivascular tissue. This inflammation compresses the blood vessels and significantly slows down blood circulation in them until it stops completely. Stopping blood circulation further aggravates inflammation due to the cessation of oxygen supply to bone tissue. The swelling progresses, compressing new vessels and leading to an increase in the area of the affected bone. Thus, a vicious circle is formed. The entry of at least one pathogenic microbe into the site of aseptic inflammation leads to the development of purulent osteomyelitis.In addition to an attempt to describe the mechanism of development of osteomyelitis, this theory ensured the fulfillment of another important task. Thanks to it, the key role of increased intraosseous pressure in the maintenance and progression of inflammation was proven. Thus, the main therapeutic measures should primarily be aimed at reducing intraosseous pressure through medullary canal puncture or bone trepanation.
Neuro-reflex theory
To confirm this theory, experiments were also conducted in which experimental animals were divided into two groups. The first group was administered antispasmodic drugs, while the second group was not administered. Next, both groups were exposed to various provocative influences with the aim of developing artificial osteomyelitis in them. The experiment revealed that animals that took antispasmodics were 74% less likely to develop osteomyelitis than animals that did not receive such premedication.The explanation for this pattern is as follows. Any adverse effect on the body, such as stress, illness or injury, causes a reflex spasm of blood vessels, including those in bone tissue. According to the mechanism described above, vascular spasm leads to bone necrosis. However, if the reflex spasm is eliminated with the help of medications, then there will be no deterioration in the blood supply and, as a result, osteomyelitis will not develop, even with slight bacteremia.
All of the above theories represent different options for describing the initial mechanisms of the onset of inflammation. Subsequently, the active development of pathogenic microflora in the bone marrow canal occurs, accompanied by an increase in intraosseous pressure. When certain critical pressure values are reached, the pus eats away at the bone tissue along the path of least resistance. When pus spreads towards the epiphysis, it breaks into the joint cavity with the development of purulent arthritis. The spread of pus towards the periosteum is accompanied by severe pain. The pain is caused by the accumulation of pus under the periosteum with its gradual detachment. After a certain time, the pus melts the periosteum, breaking into the soft tissue around it with the formation of intermuscular phlegmon. The final stage is the release of pus onto the skin with the formation of a fistula tract. At the same time, pain and temperature decrease, and acute osteomyelitis becomes chronic. This option for self-resolution of osteomyelitis is the most favorable for the patient.
Less successful resolution of osteomyelitis occurs when purulent inflammation spreads to the entire bone. In this case, melting of bone tissue and periosteum is observed in several places. As a result, an extensive periosteal phlegmon is formed, opening on the skin in several places. The outcome of such phlegmon is pronounced destruction of muscle tissue with massive adhesions and contractures.
The most dramatic outcome of the disease occurs when the infection generalizes from the source to the entire body. At the same time, a huge number of pathogenic microorganisms penetrate into the blood. They spread throughout the body, forming metastatic foci of infection in other bones and internal organs. The consequence of this is the development of osteomyelitis of the corresponding bones and insufficiency of the function of the affected organs. Some of the microbes are destroyed by the immune system. As the microbes break down, they release a substance called endotoxin into the blood, which in small quantities causes a rise in body temperature, and in extreme quantities leads to a sharp drop in blood pressure and the development of a state of shock. Unlike other types of shock, septic shock is the most irreversible because it is practically untreatable with medications prescribed for this condition. In most cases, septic shock is fatal.
The process of sequestration formation deserves special attention. A sequestrum is a section of bone freely floating in the cavity of the medullary canal, separated from the compact or spongy substance due to purulent melting. It is one of the signs, when determined, one can confidently say that the patient has osteomyelitis. When a fistulous tract has formed, sequester can be released from it along with pus. The sizes of sequesters may vary depending on the depth of bone tissue damage. In children, resorption may occur ( resorption) formed sequestration in the acute phase of the disease. When it becomes chronic, a protective capsule forms around it, which prevents both its resorption and its attachment to a healthy bone. With age, the ability of sequesters to resolve on their own decreases. Thus, in adults, resorption occurs extremely rarely and only small sequestrations, and in elderly and elderly people it does not occur at all.
Sequestration is detected by x-ray or computed tomography of the affected bone. Its detection is a direct indication for surgical treatment of osteomyelitis with removal of the sequestrum itself. Removal of the sequester is necessary because it helps maintain the inflammatory process in the bone.
According to size and origin, sequesters are divided into the following types:
- cortical;
- central ( intracavitary);
- penetrating;
- total ( segmental, tubular).
Cortical sequestration develops from the outer layer of bone, often including a portion of the periosteum. The separation of such sequestration occurs outside the bone.
Central sequester develops from the inner layer of bone. Often necrosis is located circularly. The dimensions of such sequesters rarely reach 2 cm in longitudinal section. The separation of such sequesters occurs only towards the bone marrow canal.
Penetrating sequestration it is considered such when the zone of necrosis extends over the entire thickness of the bone, but only in one semicircle. In other words, at least a small isthmus of healthy tissue must be present. Such sequesters can be quite large. Their separation takes place both inside and outside the bone.
Total sequestration – complete damage to the entire thickness of the bone at a certain level. Such a lesion in osteomyelitis often leads to the formation of pathological fractures and false joints. The dimensions of such sequesters are the largest and depend on the thickness of the bone. Their separation occurs either by disintegrating into smaller sections or by completely moving away from the bone.
Clinical forms and stages of osteomyelitis
There are many classifications of osteomyelitis. This article will present only those that have direct clinical significance and affect the process of diagnosis and treatment of this disease.The following clinical forms of osteomyelitis are distinguished:
- acute hematogenous osteomyelitis;
- post-traumatic osteomyelitis;
- primary chronic osteomyelitis.
- Brody's abscess;
- albuminous osteomyelitis;
- antibiotic osteomyelitis;
- Garre's sclerosing osteomyelitis.
Acute hematogenous osteomyelitis
This type of osteomyelitis develops classically when pathogenic microorganisms enter intraosseous vessels with the formation of an inflammatory focus in them. The highest risk category is children from 3 to 14 years old, however, hematogenous osteomyelitis develops, including in newborns, adults and the elderly.According to statistics, the male gender is more often affected, which is associated with their more active lifestyle and, as a result, more frequent injuries. There is also a certain seasonality of this disease. An increase in the number of cases is observed in the spring-autumn period, when there is an annual increase in acute viral diseases.
The most common pathogen seeded from the bottom of the bone cavity in hematogenous osteomyelitis is Staphylococcus aureus. Less common are Proteus, hemolytic streptococcus, Pseudomonas aeruginosa and Escherichia coli. The most common sites for this clinical form of osteomyelitis are the femur, then the tibia and humerus. Thus, a certain pattern can be traced between bone length and the likelihood of developing osteomyelitis.
The following variants of the course of hematogenous osteomyelitis are distinguished:
- broken;
- protracted;
- fulminant;
- chronic.
This is the most favorable variant of the course of osteomyelitis, in which the body’s reaction is pronounced and the recovery processes are most intense. The disease ends with complete recovery within 2–3 months.
Prolonged option
This variant is characterized by a subacute long-term course of the disease. Despite the weakness of the recovery processes and the low immune status of the body, recovery still occurs after 6 to 8 months of treatment.
Lightning option
This is the most rapid and deplorable outcome of the disease, in which there is a massive release of bacteria into the blood. More often, this form is characteristic of hematogenous osteomyelitis of staphylococcal etiology. This microbe does not produce exotoxins, but is easily destroyed. As it breaks down, it releases an extremely aggressive endotoxin, causing blood pressure to drop to zero. At this pressure, without massive medical assistance, brain death occurs within 6 minutes.
Chronic variant
With this option, the course of the disease is long - more than 6 - 8 months with periods of remission and relapses. Characteristic is the formation of sequesters ( areas of dead tissue), maintaining inflammation for a long time. Fistulas open and close according to the phases of exacerbation and chronicity. In addition, often being tortuous, fistulas themselves provoke a resumption of the inflammatory process. With prolonged inflammation, connective tissue is formed around the fistulas, which can lead to cicatricial degeneration of muscles and their gradual atrophy. Chronic inflammation is a risk for amyloidosis ( protein metabolism disorder) with damage to the corresponding target organs in this disease.
Post-traumatic osteomyelitis
The mechanism of development of post-traumatic osteomyelitis is associated with the entry of pathogenic microorganisms into the bone through the open route through contact with contaminated objects and environments.According to the reasons, the following types of post-traumatic osteomyelitis are distinguished:
- firearm;
- postoperative;
- after an open fracture, etc.
Primary chronic osteomyelitis
In recent decades, there has been a steady increase in osteomyelitis with a primary chronic course. The reason for this is air and food pollution, decreased immunity in the population, irrational use of antibiotics and much more. These forms of osteomyelitis are characterized by an extremely sluggish course, which makes it difficult to make a correct diagnosis.Brody's abscess
This is an intraosseous abscess with a sluggish course and scant symptoms, which develops when a weak pathogen interacts with a strong immune system. Such an abscess is soon encapsulated and remains in this form for many years. Some pain may occur when applying slight pressure to the bone and gently tapping it over the location of the abscess. X-ray reveals a cavity in the bone, in which sequestration is never found. Periosteal reaction ( reaction of the periosteum to irritation) is weakly expressed.
Albuminous osteomyelitis
This type of osteomyelitis develops when an initially weak microorganism is unable to transform aseptic transudate into pus. A distinctive feature of this form is pronounced infiltration of the periosteal tissues. Despite the pronounced swelling, the pain is low. X-rays show a mild periosteal reaction with superficial fibrous overlays.
Antibiotic osteomyelitis
Antibiotic osteomyelitis develops due to the unjustified use of antibiotics. In the presence of a certain constant concentration of antibiotic in the blood, the pathogenic microorganism that has entered the bone will not be destroyed, since the concentration of antibiotic in the bone is low. Instead, the microbe slowly multiplies and becomes encapsulated. Clinical and paraclinical data are extremely scarce.
Sclerosing osteomyelitis
This rare type of osteomyelitis is characterized by a subacute onset, dull night pain in the area of the affected bone, and a body temperature of no more than 38 degrees. Periods of clinical subsidence alternate with relapses. The formation of small sequesters is typical. Radiologically, the periosteal reaction appears only at the beginning of the disease, then it disappears. During surgical intervention for this disease, pronounced sclerosis of the bone marrow canal is revealed.
Symptoms of osteomyelitis
According to the clinical course, the following forms of osteomyelitis are distinguished:
- local form;
- generalized form.
Local osteomyelitis
Clinically, local osteomyelitis is manifested by severe bursting pain throughout the affected bone. With very gentle superficial percussion ( tapping) it is possible to determine the place of greatest pain directly above the inflammatory focus. Any stress on the bone, as well as movement in nearby joints, is limited so as not to cause pain. The skin over the source of inflammation is hot and red. Severe swelling, especially pronounced with intermuscular phlegmon, causes tension in the skin and creates a feeling of shine. Fluctuation may be felt by palpation above the phlegmon ( undulation). Body temperature is within 37.5 – 38.5 degrees. The breakthrough of pus through the periosteum into the intermuscular space leads to a decrease in pain. The formation of a full-fledged fistula is accompanied by the disappearance of both pain and other signs of inflammation.Based on location, the following types of local osteomyelitis are distinguished:
- osteomyelitis of long bones ( femur, tibia, humerus, etc.);
- osteomyelitis of flat bones ( pelvic bones, cranial vault and scapula);
- osteomyelitis of mixed bones ( patella, vertebrae, jaw, etc.)
Osteomyelitis of tubular bones, in turn, is divided into:
- epiphyseal;
- metaphyseal;
- diaphyseal;
- total.
Generalized osteomyelitis ( toxic, septicopyemic)
It is important to remember that osteomyelitis is not an exclusively local process, as was previously believed. This disease must be considered as a preseptic process, since it can behave extremely unpredictably and lead to generalization of infection at any time, regardless of what phase the disease is in.The onset of the disease is identical to the local form, but at a certain point in time symptoms of intoxication appear. Body temperature rises to 39 - 40 degrees and is accompanied by chills and profuse cold, sticky sweat. Multiple metastatic foci of infection in various organs manifest themselves accordingly. Purulent damage to the lungs presents a picture of pneumonia with severe shortness of breath, pale complexion, cough with purulent-bloody sputum. Kidney damage is manifested by severe pain on the corresponding side with irradiation to the groin, pain when urinating, frequent trips to the toilet in small portions, etc. When purulent metastases enter the coronary vessels, purulent pericarditis, myocarditis or endocarditis develops with symptoms of acute heart failure.
In addition, a small petechial rash is often observed, which tends to merge. Damage to the brain is predominantly toxic in nature, but inflammation of the membranes of the brain, manifested by stiff neck and severe headaches, cannot be ruled out. Neurological damage occurs in two stages. Initially, productive mental symptoms appear, such as convulsions, delirium. As brain damage progresses, symptoms of depression of consciousness occur, such as stupor, stupor, precoma and coma.
The general condition of such patients is extremely serious. Symptoms of local osteomyelitis recede into the background. In the vast majority of cases, the patient dies either from collapse at the beginning of generalization of the infection, or from multiple organ failure in the next few hours, less often a day.
Diagnosis of osteomyelitis
Laboratory and paraclinical instrumental studies can provide significant assistance in diagnosing osteomyelitis. The most accessible and frequently used methods are listed below. General blood analysis
In a general blood test, first of all, there is a shift in the leukocyte formula to the left. In the local form, leukocytes are in the range of 11 – 12 * 10 9 \l ( leukocytosis). In the generalized form, they increase to 18 - 20 * 10 9 \l in the first few hours of the disease, then they decrease to 2 - 3 * 10 9 \l ( leukopenia).Total blood protein in the local form is within 70 g/l, in the generalized form – less than 50 g/l. Albumin less than 35 g/l. Increase in C-reactive protein to 6 – 8 mg/l.
The content of the article
Syphilis(syphilis, synonym: lues, morbus gallicus) is a chronic disease that occurs as a result of infection with a contagious infection (occasionally infection occurs through transfusion). The causative agent of syphilis is the Chaudin-Hoffman spirochete pallidum. It penetrates through minor defects in the skin or mucous membranes and causes a complex of local and general reactions.Primary syphilitic affect - chancroid (ulcus durum) - is localized mainly on the external genitalia, but can be localized on the cheeks, lips, chin, tongue, soft palate, tonsils and gluteal folds, in the armpit and anus, on the breast nipples glands, as well as on the fingers.
Bones and joints are affected mainly by secondary syphilis or in the late period of the disease (quaternary syphilis).
Bone and joint syphilis clinic
In the second stage of syphilis, painful bone deposits can form - luetic (syphilitic) periostitis. Most often, periostitis develops on the bones of the skull, tibia and ribs, causing night pain. Similar changes are observed with congenital syphilis. Especially often, luetic changes occur on the tibia, which is deformed and takes on a saber shape.In the fourth stage of syphilis, gummas (gummae) form in the bones. The process affects not only the periosteum, but also the bone itself, causing osteitis, and the bone marrow, causing osteomyelitis. In parallel with the formation of gumma, the destruction of bone tissue and its formation occur. Most often, gummas are found in the ribs, sternum, bones of the forearm and lower leg. Small bones (nose, soft palate) are completely destroyed. In their place, ulcers form, surrounded by a dense ridge. After the ulcers heal, large star-shaped scars remain, tightly fused to the bone. Luetic mono- and polyarthritis develops in the knee, ankle and elbow joints.
Diagnosis and differential diagnosis of syphilis of bones and joints
Sometimes the diagnosis of syphilis is very difficult to make. Syphilis of bones and joints must be differentiated from bone tuberculosis, chronic osteomyelitis and malignant tumor (sarcoma). An important role in making the correct diagnosis is played by sero- and liquorological diagnostics (classical Wassermann and Kahn reactions, as well as their modifications).Treatment of syphilis of bones and joints
The treatment is specific. Surgical intervention should be performed only if a secondary purulent infection is associated with syphilis.Syphilis is a chronic disease that occurs as a result of contact infection. It is also possible to transmit the infection through transfusion.
Primary Syphilis (chancroid) appears 3 weeks after infection. At the site of infection, a rounded plate-shaped thickening of the skin is formed, which is slightly raised and sharply limited from the surrounding tissues. When the epithelial cover is damaged, a moist surface appears, in which the pathogen can be seen when taking a smear. 1-2 weeks after the appearance of the primary lesion, regional lymph nodes become hard and enlarged, however, they retain good mobility and remain painless.
The primary localization of the primary lesion is the external genitalia. It can be on the cheeks, lips, chin, on the border of the forehead with hair, on the front third of the tongue, on the soft palate and tonsils, in the buttock folds, armpits, anus, rectum, on the nipples of the mammary glands, as well as on the fingers. . The reason for such atypical localization is the possibility of transmission of the pathogen through hands, infected shaving, drinking and eating utensils; sometimes infection occurs through kissing and some types of sexual intercourse.
Secondary stage. It begins 6-12 weeks after infection and lasts 2-4 years. At this stage, the generalization of the process occurs. The skin and mucous membranes are especially affected, where there are moist papules, ulcerations and infiltrates.
Tertiary syphilis (late) follows secondary syphilis many years, sometimes decades. Mainly internal organs are affected. The greatest surgical significance is for bone damage. A typical manifestation of late syphilis is gumma (syphiloma), which is a granule-like tumor up to the size of a man’s fist. Despite the fact that the gumma is sufficiently supplied with vessels, its center is easily necrotic. The proliferation of connective tissue around gummous nodes causes cicatricial encapsulation of the lesion.
This late stage of syphilis is of significant surgical interest, since it affects virtually all organs. In addition, late syphilis can distort the clinical picture of any disease.
All parts of the bone can be affected. Depending on the localization of the process, there are periostitis, osteitis, osteomyelitis. As a rule, the process develops in the periosteum, spreads to the bone and can be in the nature of an infiltrative-exudative or gummous-destructive process.
The exudative-infiltrative form of syphilis manifests itself in the form of ossifying osteoperiostitis. The process ends with a sharp thickening of the bone - osteosclerosis, leading in some cases to significant bone deformation. Gummy osteoperiostitis is most often localized in the diaphyses of the tibia, in the bones of the upper extremities, clavicle, ribs, as well as in the bones of the cranial vault and face. When the gummous process is localized in the facial bones, destruction of the nose and orbit may occur. In syphilitic gummas of bones, complicated by secondary infection, extensive necrosis with bone sequestration is observed. X-rays reveal osteoperiostitis with signs of bone destruction. When the gummous infiltrate suppurates, the skin is involved in the process, on which round ulcers are formed, bordered by dense, sclerotic edges. Bone syphilis is characterized by excruciating night pain in the bones.
Syphilis of the joints– affects large joints and manifests itself in the form of pain, aggravated by movement, and may be accompanied by effusion in the joint. Manifests itself in the form of gummous synovitis or osteoarthritis. Synovitis occurs either as a result of a reaction to a gummous process localized in the metaphysis near the joint, or as a result of syphilitic damage to the epiphyses. With gummous osteoarthritis, all elements of the joint are affected.
Treatment– specific (mercury, bismuth, iodine, antibiotics). For loose joints, deformities, and ankylosis, orthopedic treatment is used. For arthritis complicated by secondary infection - arthrotomy.
51.Actinomycosis. Pathogenesis. Main localizations. Clinical manifestations, diagnosis, treatment.
Chronic human disease. It affects all tissues and organs, is characterized by the formation of a dense infiltrate and occurs almost without pain. The causative agent is a radiant fungus (actinomycete), first discovered by Langenbeck in 1845. Among various pathogenic actinomycetes, anaerobes and aerobes are distinguished. Of these, the following are of particular importance: Wolf-Israel anaerobes and Boström aerobes. The first type of actinomycete is the most pathogenic for humans, while the second is pathogenic or weakly pathogenic.
Infection occurs endogenously. The oral cavity, gastrointestinal tract and respiratory tract are the main place from which the radiant fungus enters the human body. The temperature-sensitive anaerobic form of actinomycetes is a permanent resident of the upper respiratory tract and gastrointestinal tract.
It has been established that actinomycetes are constantly present in the human oral cavity. Drusen are found in carious teeth, tonsils and gums. An anaerobically growing actinomycete manifests its pathogenic properties in humans only when it enters ischemic tissue due to inflammation or damage. The entry points for infection are ulcers of the oral mucosa, diseased tonsils, wound surfaces in the gastrointestinal tract or respiratory tract, as well as bronchial walls affected by inflammation after influenza infection or hypothermia.
As a result of the introduction of actinomycetes into tissues, chronic inflammation develops. A dense woody infiltrate appears, consisting of inflammatory granulomas, in the center of which there are characteristic colonies of radiant fungus. The construction of fungal colonies (so-called drusen) occurs as follows. In the center there is a widely branched filamentous network. A single fungal drusen reaches the size of a pinhead and is visible as a pale yellow nodule. The infiltrate tends to constantly and persistently spread to neighboring tissues, capturing and destroying muscles, bones, joints along the way, breaking into serous cavities and even blood vessels. In the latter case, metastases can be transferred through the bloodstream to various organs. The incubation period ranges from several weeks to several years. The disease is observed mainly among middle-aged men. Children get sick relatively rarely.
A characteristic sign of actinomycosis is the appearance of a dense, woody, progressive infiltrate. Another sign is the lack of response from the regional lymph nodes, since this infection does not spread through the lymphatic tract. If there is an increase in lymph nodes, then this indicates a secondary infection, which plays a large role in the development of the pathological process.
Localization:
· internal organs (gastrointestinal tract, lungs, bladder)
· When actinomycosis spreads to the portal vein, liver metastases develop.
Cervicofacial and temporofacial actinomycosis.
Treatment of actinomycosis. Regardless of the localization of the process, it is combined: immunotherapy, iodine therapy, x-ray therapy, the use of antibiotics and surgery. Iodine preparations have proven themselves therapeutically well (up to 3 grams of potassium iodide per day). Positive results are explained by the softening and resorption of infiltrates. Iodine therapy is usually combined with radiotherapy. The use of antibiotics in high doses with sulfonamide drugs is based on eliminating the mixed infection and changing the environment.
Immunotherapy is carried out by administering actinolysates in a dose of 0.5 to 2 grams 2 times a week intramuscularly. There are 20-25 injections per course of treatment. Along with conservative treatment, surgical treatment is also indicated, which consists of opening the fistula tracts and curettage of granulations. In some cases, it is possible to excise the infiltrate.
52.Leprosy. Pathogens. Clinical manifestations, surgical manual.
(specific osteomyelitis)
Syphilis is a sexually transmitted disease caused by the spirochete pallidum. There are acquired and congenital syphilis. During acquired syphilis, there are 3 periods: 1. Primary. 2. Secondary. 3. Tertiary. Congenital syphilis is divided into early - before 1 year and late - after 4-5 years and up to 16 years. The skeletal system can be affected in all periods of acquired syphilis.
In primary syphlis, bones are rarely affected; There are only isolated reports of periostitis with chancre.
Bone lesions in the secondary period of acquired syphilis are also rare and account for 0.5-3%. In this case, periostitis is observed, without the formation of typical gummas.
In the tertiary period, according to the literature of previous years, bone damage is one of the private symptoms, observed in 20-30% of patients and is in second place in frequency after damage to the skin and mucous membranes. Due to the sharp decrease in advanced forms of syphilis, bone lesions are now not common (periostitis, specific osteomyelitis).
The number of lesions of the skeletal system in early congenital syphilis is especially high (up to 85%). It can be recognized that bone lesions are the most common symptom of early congenital syphilis. Damage to the skeletal system in early congenital syphilis (osteochondritis) is predominantly systemic, often symmetrical in nature, affecting many bones at the same time.
With late congenital syphilis, bone changes occur much more often than with secondary and tertiary acquired syphilis, but less often than with early congenital syphilis and are observed in approximately 40% of patients. The tibia, bones of the nose and palate, and skull bones are affected.
With late congenital syphilis, multiplicity and symmetry of the process are less common.
Specific bone changes in syphilis are observed in two types: 1. Infiltrative-exudative process (without phenomena of destruction). 2. Destructive-proliferative (gummy) process.
With the infiltrative-exudative process, ossifying periostitis and osteitis develop. Specific vascular damage develops, with the formation of a pervascular infiltrate of lymphoid and plasma cells. Vascular sclerosis occurs, inflammatory infiltration is organized, which radiographically manifests itself in the form of osteosclerosis, ending in the development of hyperostosis and closure of the bone marrow canal. The bone appears thickened and its compactness is enhanced.
Rarely, during a rapid course, in the presence of an entrance gate for a secondary pyogenic infection, the exudative-inflammatory infiltrate can turn into purulent with the formation of sequesters.
Destructive-proliferative (gummy) processes can be located subperiosteally, intracortically, and less commonly in the bone marrow. Syphilitic gumma in the initial stages of development is an inflammatory node with decay in the center. Intense formation of osteosclerosis occurs around the gummous lesion.
X-ray picture: the focus of destruction is elongated or round in shape with reactive osteosclerosis. Multiple syphilitic gummas can be milliary, subbiliary or significant in size. When they merge, continuous syphilitic granulation tissue is formed - multiple foci of destruction located in a limited area, having clear contours with a rim of sclerosis. Syphilitic osteomyelitis develops in the presence of a secondary pyogenic infection. Syphilitic gummas are very rarely complicated by suppuration with the formation of sequestration and fistulous tracts. Only mixed infection leads to significant bone sequestration.
Gummous changes occur mainly in tertiary acquired syphilis. With early congenital syphilis, both forms of bone tissue damage can occur.
Bone changes in early congenital syphilis are presented in the form of specific osteochondritis, periostitis and isolated gummas.
With specific osteochondritis, changes occur both in the cartilage of the epiphysis and in the bone tissue of the metaphysis. These changes occur during the period from 5 months of intrauterine life to 12 months after birth. After 1 year, osteochondritis occurs as a rare phenomenon, and after 16 months, it is not observed at all.
Osteochondritis goes through 3 stages in its development. In stage 1, increased deposition of lime occurs in the pre-calcification zone (it increases to 1.5-2.5 mm). In stage 2, along with a wide calcified zone, a narrow strip of granulation tissue is formed, located between the metaphysis and the calcification zone. In the calcification zone, multiple small notches appear, facing the epiphysis. This jagged line towards the epiphysis and the emerging band of clearing are the most typical signs of osteochondritis. At stage 3, the strip of granulation tissue expands. The granulations also destroy the cortical substance, grow towards the diaphysis, and also dissolve the zone of preliminary calcification so that its calcified marginal part, undermined on all sides by the granulations, freely sticks out to the side.
When the connection between the epiphysis and metaphysis is completely disrupted, an intrametaphyseal bone fracture is formed. Clinically, these fractures are designated as pseudoparalysis or Parrot's palsy - the limb near the joint is swollen, painful, and the muscles are flabby. The lower limbs are usually contracted, and the upper limbs are flaccid and lie motionless.
Periostitis in early congenital syphilis is very common and can be combined with osteochondritis. On radiographs, periostitis appears as a more or less wide ossified strip located parallel to the length of the bone. Very fresh periostitis, when there are only proliferative changes, remain invisible on radiographs. The first radiological symptoms of inflammation of the periosteum appear only with calcification of the periosteal layers. The superficial one ossifies first.
layer of periosteum.
When ossification of the entire periosteal layer occurs, its shadow completely merges with the shadow of the cortex.
Based on localization, there are 2 types of periostitis in early congenital syphilis - diaphyseal and epimetaphyseal.
Diaphyseal periostitis in the form of a sleeve or case covers the entire diaphysis. The outer contours of the calcified periosteum in congenital syphilis are smooth and clear. Sometimes periostitis is a manifestation of a reactive process during diaphyseal gummous destructive changes in the bones.
Epimetaphyseal periostitis always accompanies severe syphilitic osteochondritis. In this section, the periosteal reaction is less pronounced. The calcified shell surrounding the peripheral third of the bone has the shape of a half-spindle, the narrow part merges with the diaphysis.
Gummous (focal destructive process) with early congenital syphilis is not often observed. It is localized mainly in the ulna and tibia, as well as in flat bones. Changes can be observed in the metaphysis, in the diaphysis, located subperiosteally and in the bone marrow. Changes can be single or multiple. Their diameter is 0.2 to 0.8 cm. On radiographs, isolated foci of destruction have an oval or round shape, surrounded by a zone of osteosclerosis.
With early congenital syphilis, damage to the phalanges is noted. Syphilitic phalangitis most often affects the upper extremities, less often the lower, mainly the main phalanges. The lesion is bilateral, but not symmetrical. Characteristically, there is a pronounced periosteal reaction in the form of a bone coupling around the phalanges, which are thickened in the form of a barrel. Their structure is compacted; against the background of sclerosis, there may be foci of destruction due to
Additional symptoms of early congenital syphilis: “Olympic forehead”, “Buttock-shaped skull”, “Saddle nose”.
“Olympic forehead” - due to enlargement of the frontal and parietal tubercles.
“Buttock-shaped skull” is a sharp protrusion of the frontal and parietal tubercles with a depression located between them, which gives the skull the appearance of a buttock. (Before the age of 10-12 months and even in intrauterine life, diffuse syphilitic osteoperiostitis develops in the frontal and parietal bones).
The “saddle nose” in congenital syphilis is not explained by the formation of gummas that destroy the nasal bones, but by the resorption of the nasal septum as a result of a long-term specific process in the mucous membrane, leading to atrophy of the nasal cartilage.
Differential diagnosis has to be carried out with rickets, tuberculosis and childhood scurvy.
Rickets is characterized by diffuse osteoporosis of long tubular bones, a periosteal reaction of the fringe type is possible, and pathological fractures of the “greenstick” type are observed. Cup-shaped deformation of the metaphyses of tubular bones is characteristic. There are no foci of destruction.
In tuberculosis, the foci of destruction are located mostly in the epiphyses, without sclerotic phenomena, with a tendency to sequestration. The focus of destruction without clear contours gradually passes into the surrounding bone, which is osteoporotic. When located in the epiphysis or metaphysis, the articular cartilage is destroyed and the process moves to the joint.
Infantile scurvy most often appears between the ages of 7 and 15 months. The disease is manifested by increased fragility of blood vessels and subperiosteal hemorrhages. Hematomas peel off the periosteum, and during the repair stage they are impregnated with lime salts.
X-ray - tender club-shaped layers in the epimetaphyses of long tubular bones can be combined with intrametaphyseal fractures. It is necessary to take into account the clinic, anamnestic and serological data.
Damage to the skeletal system in late congenital syphilis. The process can be limited (gummous in nature) and diffuse - diffuse.
A diffuse and gummous process can be located in any part of the bone - in the periosteum, in the cortex, spongy substance or in the bone marrow. There are osteoperiostitis and osteomyelitis.
Syphilitic osteoperiostitis is of two types - gummous and diffuse.
Gummy periostitis is observed in its favorite place, in the diaphysis (usually the tibia) - in the ossified periosteum one or more gummas of an oval or round shape are determined. Radiographs usually show limited bone thickening in the shape of a half-spindle at the level of the diaphysis due to thickening of the periosteum with a smooth outer contour. Gumma - one or several in the form of a focus of destruction (no more than 1.5-2 cm in size) is located in the very central place of the osteophyte, directly under the periosteum, with clear sclerotic contours.
Differential diagnosis should be made with osteoid osteoma.
Diffuse syphilitic osteoperiostitis with late congenital syphilis takes 1st place in the frequency of lesions. The tibia is predominantly affected. On radiographs, the thickened, ossified periosteum merges with the cortex. In all layers of the bone there is massive sclerosis, the bone loses its structure over a large area. The outer contour is clear, but may be somewhat wavy. Among the sclerosis, pockets of destruction due to milliary gummas can be observed - this is a combination of multiple gummous and diffuse syphilitic periostitis.
When the process is localized in the tibia, a characteristic “saber-shaped tibia” pattern is observed (the bone is elongated, thickened, and bends anteriorly). Rarely there are “comb-shaped” periostitis with the presence of transverse stripes resembling comb teeth, and “lace” periostitis - a combination of layered and ridge periostitis that resembles lace. The outer contours are usually jagged.
Syphilitic osteomyelitis. Multiple gummy osteitis, when gummas are located at different depths, has the character of gummy osteomyelitis, most often localized in the diaphysis. Processes localized in the diaphysis, metaphysis or epiphysis have their own characteristics. The syphilitic process in the diaphysis is accompanied by a violent endosteal reaction, and massive reactive sclerosis is observed around the gummas. The gummous process in the metaphysis has some features of the diaphyseal, but the endosteal and periosteal reaction is less pronounced. The process does not pass into the epiphysis through the germinal cartilage. Syphilitic epiphysitis occurs in the form of single gummas. In late congenital syphilis they are rare. A focus of destruction with mild sclerosis and slight periostitis is determined.
With late congenital syphilis, dental dystrophy is observed, most often the two upper middle incisors. Atrophy of the chewing surface is pronounced, as a result of which the neck is wider than the cutting edge. There may be a semilunar notch on the cutting edge. This symptom is pathognomonic for late congenital syphilis (Hutchinson, 1856).
Differential diagnosis must be made with nonspecific osteomyelitis and bone tuberculosis.
In bone tuberculosis, the epiphysis is a typical location. Children under the age of five are most often affected. The focus of destruction is not accompanied by a sclerotic reaction and spreads without clear boundaries to the adjacent osteoporotic area of the bone. There is almost always sequestration in the form of “melting sugar”. There is no periostitis.
Nonspecific osteomyelitis is localized in the metaphysis. If with syphilis the processes of bone creation prevail, and with tuberculosis - destruction, then with osteomyelitis these processes are combined. Sequestration almost always occurs. Clinical manifestations and laboratory data should be taken into account.
Garre's osteomyelitis affects the diaphysis. There are no foci of destruction. The bone is thickened in the form of a regular spindle with smooth outer contours. With syphilis there may be foci of destruction; osteoperiostitis does not have such a regular spindle shape, its outer contours are slightly wavy.
CHAPTER III
BONE TUMORS
According to their clinical course, primary bone tumors are divided into benign and malignant. These properties are inseparable from the biological properties of the tumor and are determined mainly by the degree of its maturity.
Diagnosis of bone tumors is based on clinical and radiological data and sometimes presents certain difficulties. The radiologist’s task is to determine the morphological characteristics of the tumor in each case of bone tumor. However, it is not always possible to verify the conclusion only on the basis of clinical and radiological data. In such cases, it is necessary to resort to a puncture biopsy of the tumor and subsequent morphological examination.
Knowledge of their classifications is of no small importance for the correct diagnosis of bone tumors. Well-known classifications of bone tumors (Ewing, 1939; Lichtenstein, 1951-1965; I. G. Lagunova, 1957; Coley, 1960; M. V. Volkov, 1968; T. P. Vinogradova, 1973) are not free from shortcomings.
It seems to us appropriate to have a classification that reflects all the main forms of tumors, the nomenclature of which is based on histogenetic and histological characteristics. In this regard, the classification of primary bone tumors proposed by T. P. Vinogradova facilitates the differential diagnosis of neoplasms.
When presenting the lecture course and in our practical work, we mainly use this classification, slightly changing the order of the groups of tumors and do not include osteochondral exostoses, chondromatosis of bones and processes bordering on tumors in the classification of benign bone tumors.
Malignant Ewing tumor is classified as a non-osteogenic tumor of reticuloendothelial tissue.
The existence of parallel classifications, including the main forms of tumors most often encountered in practice, is fully justified.
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The skeletal system can be affected in all periods acquired syphilis and with congenital syphilis e.
It has been written about the structure of bone tissue. Bone damage in congenital syphilis has been described.
Bone disease with acquired syphilis is observed much less frequently than with congenital syphilis.
Syphilitic lesions of the musculoskeletal system can be either an independent isolated manifestation of a syphilitic infection or combined with lesions of other organs.
Depending on the location (in the periosteum, cortical layer, spongy substance, bone marrow) of the pathological syphilitic process, periostitis, osteitis or osteomyelitis develops. With acquired syphilis, a combination of periostitis and osteitis is mainly observed - osteoperiostitis .
In long tubular bones, the diaphyses are predominantly affected.
The inflammatory process in bone syphilis in the secondary period of the disease is exudative-proliferative without pronounced foci of destruction, and in later periods it is gummous, destructive with more or less significant bone destruction.
The infiltrative-exudative inflammatory process leads to the formation of ossifying syphilitic periostitis and osteitis, in which specific vascular damage occurs and the formation of a perivascular and diffuse infiltrate consisting of lymphocytes and plasma cells. There is no necrosis. With syphilis, sclerosis of the vascular walls occurs with a persistent narrowing of the lumen of blood vessels. In the initial stage of syphilis, infiltrate and exudate occur in the cambial (inner) layer of the periosteum, so nerve endings are involved in the process. This causes severe pain in the bones affected by syphilis, especially with pressure.
Ultimately, the infiltrate either resolves or, more often, scleroses, that is, it organizes and turns into bone tissue. In the periosteum, at the site of the inflammatory infiltrate, new layers of ossified tissue are formed.
Similar changes in syphilis occur in the spongy spaces and in the Haversian canals of the bone. The formation of new bone substance also occurs, which leads to bone sclerosis.
Diffuse and perivascular infiltrative-exudative process caused by syphilitic infection can also be localized in the bone marrow. In these cases, ossification occurs throughout the entire bone mass.
When bones are affected in the tertiary period of syphilis, destructive-proliferative (gummy) processes occur. Gummous infiltration may be diffuse or limited. Limited gummas of tertiary syphilis are solitary (subperiosteal, central, bone marrow) and multiple. Gummous infiltrate causes two parallel processes in the bone: osteoporosis (destruction and atrophy of bone tissue in the area of infiltrate) and osteosclerosis (formation of new bone tissue around the infiltrate).
With gummous syphilitic periostitis, the infiltrate appears on the inner layer of the periosteum. Usually this infiltrate quickly spreads to the bone tissue, so osteoperiostitis occurs.
Syphilitic gumma in the periosteum in the initial stage is an inflammatory node containing in the center a small amount of a light, thick gelatinous mass. Over time, the central part of syphilitic gummas undergoes caseous decay and necrosis, and tissue destruction occurs. In the peripheral part, a powerful infiltrate develops, consisting of lymphoid plasma and scattered epithelioid and giant cells. The infiltrate is located mainly along the existing and newly formed vessels. Infiltrate and granulation tissue destroy the normal bone structure, forming foci of destruction. Osteosclerosis develops around the syphilitic gummous lesion due to abundant vascularization as a result of a reactive productive (condensing) process.
In the cortical and spongy substance of the bone during syphilis, mainly single gummas appear, growing both inward and outward. The gummous process can spread to these parts of the bone also from the periosteum. The gummous infiltrate from the periosteum penetrates through the vascular canals into the cortical and cancellous layer of the bone. As a result of this, the bone tissue in the spongy substance around the vascular canals is destroyed, and the surrounding spongy tissue is thinned out. On the contrary, sclerosis occurs along the periphery of syphilitic lesions.
With gummous tertiary syphilis, extensive necrosis with bone sequestration and fistula formation usually does not occur. During the process of reverse development, the foci of destruction are filled with bone masses of endosteal origin.
It should be noted that when the gummous process of tertiary syphilis is localized in the spongy bone, destructive changes are extensive, while reactive changes are insignificant. With gumma in the compact substance of the bone, tissue destruction is insignificant, and reactive changes are quite pronounced.
With diffuse gummous osteoperiostitis, the changes are similar to those with limited syphilitic gummas, but more widespread, diffuse.
Gummas in bone marrow syphilis, like gummas of spongy bone, are characterized by a weak tendency to cheesy necrosis.
The bone canal in tertiary syphilis can be completely filled with newly formed bone substance (bone eburnation).
Clinically, it should be noted that already at the end of the primary period of syphilis, patients may complain of pain in various bones. The pain can be constant and strictly localized (usually in the bones of the skull, sternum, long bones of the limbs) or unstable, changing localization, “wandering”, “flying” pain. These pains especially bother patients at night. The examination does not reveal any objective changes.
Syphilitic periostitis of the secondary period is characterized by the appearance on the surface of the bone of a small, dense, painful fusiform or hemispherical tumor, the skin over which is not changed. A characteristic feature of syphilitic periostitis is a nocturnal exacerbation of pain. Usually, syphilitic periostitis of the secondary period of syphilis disappears without a trace, less often lime salts are deposited at the site of the lesion, which leads to the development of persistent hyperostoses and exostoses.
In rare cases, the inflammatory process in syphilis occurs rapidly, which is apparently associated with the addition of a secondary purulent infection. An abscess develops, which opens to form a deep ulcer. At the bottom, the probe clearly identifies bone tissue. The ulcer gradually granulates and heals with a retracted scar fused to the bone.
Osteitis of secondary syphilis is less common than specific periostitis. Osteitis begins with severe pain that is localized deep in the bone. The pain is caused by the fact that initially a specific cellular infiltrate is deposited in a limited area of the endosteum. It then penetrates the canals of the spongy substance, stretching them and causing severe pain. During this period of syphilis, no objective symptoms are detected. Later, when the pathological process reaches the outer surface of the bone, its outer plate protrudes and a very painful, hard swelling appears on the bone, especially with pressure. Subsequently, after the outer bone plate thins, the consistency of the swelling becomes elastic. At this stage of syphilis, the inflammatory process moves to the periosteum, and osteoperiostitis occurs.
Ultimately, the syphilitic infiltrate during osteitis in some cases resolves, in others osteosclerosis occurs, i.e. the infiltrate is impregnated with lime salts, turning into bone mass. For the patient, the second outcome is preferable, since in the first case, osteoporosis remains at the site of the infiltrate, caused by the death of part of the bone plates; the bone becomes fragile, and spontaneous fractures are possible with syphilis.
The third path of development of syphilitic secondary osteitis - the transition of inflammation to suppuration with the corresponding evolution - is rarely observed. In these cases, the pus separates the periosteum from the bone, melts the periosteum, muscles and skin and comes out. In the cortical layer, as a result of necrosis, a sequester can form with the release of pieces of bone.
In the tertiary period of syphilis, bone damage is promoted by trauma. Most often, bones that are poorly covered with muscles are affected: the bones of the legs, skull, sternum, collarbone, ulnas and nasal bones. Gummas or gummous diffuse infiltrates can occur in both the periosteum and bone. Usually these lesions in syphilis exist simultaneously.
With gummous syphilitic periostitis, a painful, elastic-elastic swelling of a flattened or spindle-shaped shape is determined. The swelling is limited by the dense bone ridge surrounding it.
In some cases, as a result of evolution, the gummous syphilitic infiltrate resolves and the swelling gradually disappears, the skin above it remains apparently unchanged.
As a result of osteoporosis due to syphilis, a defect remains on the bone in the form of a depression with a rough surface. Around this depression, as a result of peripheral osteosclerosis, a dense bone ridge can be felt.
In other cases, the syphilitic infiltrate disintegrates purulently. The skin turns red, a typical gummous ulcer forms, healing with a retracted scar tightly fused to the bone. A depression is felt in the bone, surrounded by a bone ridge.
The only symptom of the onset of gummous osteitis with syphilis is deep bone pain, worsening at night. Light percussion of the affected bone causes sharp pain. After the gummous infiltrate, spreading from the depths outward, reaches the outer plate of the bone, a very painful diffuse swelling of the bone appears, of a hard consistency, with vague boundaries. Over time, the outer bone plate becomes thinner, the consistency of the swelling becomes elastic, the pathological process spreads to the periosteum - osteoperiostitis develops. One of the outcomes of gummous osteoperiostitis in syphilis is purulent melting with the formation of a more or less large sequester. After separation along the demarcation line of the sequester, the ulcer cavity is granulated and scarred. With a significant size of the lesion or localization on the bones of the face, gummous osteoperiostitis, which has passed into sequestration, causes deformities.
With gummous syphilitic osteomyelitis, limited gummas are formed in the spongy bone and bone marrow, which either ossify, or a sequestration is formed in their central part, and reactive osteosclerosis occurs in the peripheral part. In the latter case, gummas, destroying the cortical substance of the bone and periosteum, are opened through the skin. The sequestration that does not separate for a long time and the associated purulent (pyococcal) infection support the purulent process.
With bone syphilis in the secondary period, changes are rarely observed on radiographs. In these cases, muff-like osteoperiosteal layers surrounding the affected bone are visible; Bone destruction is usually not observed.
The following x-ray picture is characteristic of syphilitic bone gumma: in the center there is a light focus of destruction, and around it there is an intense shadow of osteosclerosis. In the diffuse-hyperosteotic form of bone syphilis, when, as a result of ossification of continuous gummous infiltration, the central canal disappears (enostosis), the bone is significantly thickened, the medullary canal is narrowed or absent, the cortex is thinned, the entire bone acquires a pattern of spongy bone tissue, against which one or more sharp shadows of osteosclerosis and cleared areas of osteoporosis of a different intensity.
Sequestra in syphilis give an intense shadow in the form of plates of irregularly round or oval shape, located in saucer-shaped depressions and surrounded by a strip of clearing due to areas of sparse bone.
Differential diagnosis must be made between gummous syphilis of bones and osteomyelitis, bone tuberculosis, bone sarcoma, Paget's disease (deforming osteitis), lepromatous bone granuloma.
Positive serological blood reactions to syphilis, characteristic radiographs of bone lesions, extraosseous manifestations of syphilis (rashes on the skin and mucous membranes) facilitate the correct diagnosis. However, it must be taken into account that serological reactions often do not help in differential diagnosis: they can be negative for syphilis and false positive for tuberculosis, leprosy, sarcoma, and chronic purulent diseases. The results of RIBT and RIF (treponema pallidum immobilization reaction and immunofluorescence) are of greater, but not absolute, diagnostic significance.
At chronic osteomyelitis The radiological picture can simulate gummous osteoperiostitis in tertiary syphilis.
Osteomyelitis - purulent bone disease, occurs with the formation of bone sequesters, which do not tend to resolve. In acute osteomyelitis, unlike syphilis, sclerotic phenomena are weakly expressed. Differential diagnosis in chronic osteomyelitis and syphilis is difficult, since the sequestral cavities of osteomyelitis are very similar to the syphilitic gummous focus of destruction, and the pronounced sclerotic reaction in syphilis and osteomyelitis is very often exactly the same. A characteristic sign of chronic osteomyelitis, detected radiographically, is a fistulous tract extending from the sequestral cavity outward through the thickness of the bone and soft tissue.
Brody's abscess - a type of purulent osteomyelitis, located in the metaphysis (for syphilitic gumma this is a rarer localization), recognized by its regular spherical shape. X-rays reveal smooth, even edges of the lesion.
Tertiary bone syphilis, complicated by purulent osteomyelitis, is very difficult to recognize.
Tuberculosis of bones most often observed in children. The course of the disease is long; malaise and low-grade fever are noted. Damage to the bones is accompanied by severe pain, which limits the movement of the affected limb, and therefore moderate atrophy of inactive muscles develops. There are no night pains characteristic of syphilis. Characteristic is the formation of long-term non-healing fistulas, through which sequestration leaves.
With bone tuberculosis, the epiphyses are predominantly affected. An x-ray of a tuberculosis lesion in the bone shows a characteristic picture: the focus of destruction, as a rule, does not cause a sclerotic reaction around it and passes without sharp boundaries to the adjacent part of the bone with porosity. There is almost always a sequestration and, as a rule, there is no periostitis.
The tuberculous process, located in the epiphysis or metaphysis, unlike syphilis, almost always destroys the line of articular cartilage and spreads into the joint.
Bone sarcoma occurs in young people. The favorite localization of sarcoma is the proximal part of the metaphysis and epiphysis of the tibia. This tumor is single, characterized by progressive growth, involvement of all layers of bone in the pathological process, and is accompanied by excruciating pain. On the radiograph there are no clear boundaries of the tumor, the signs of osteosclerosis are insignificant; in the destructive form of the disease, destruction of all layers of bone is visible; At the border with healthy bone, a typical splitting of the periosteum is noted, which hangs over the tumor in the form of a visor. The epiphyseal articular cartilage remains unaffected by the pathological process.
Lepromatous granulomas They are small in size (3-4 mm), their boundaries are unclear, and there is no compacted ridge. With them, neither hyperostosis nor sclerosis occurs; these phenomena are observed in syphilis. There are no night pains.
Paget's disease - a systemic disease that affects either the entire skeletal system or several bones. Often the bones of the skull are involved in the process. The essence of the disease is the resorption of bone tissue and the formation of osteoid tissue instead. In parallel with the destruction of the affected bone, the formation of new bone occurs. The bone marrow is replaced by fibrous connective tissue. X-rays determine a combination of osteoporosis and osteosclerosis; the bone has a mesh structure, which is not observed in syphilis. The bones of the legs can be arched forward, resembling saber-shaped legs in congenital syphilis. However, with syphilis, only the anterior surface is curved due to massive bone layers, and with Paget's disease, the curvature is arched and occurs due to both the anterior and posterior surfaces. The curvature of the bones of the lower leg can also be in the form of the letter “O”, as with rickets.
With syphilis, joint damage is observed much less frequently than bone damage. In the secondary period, there can be two forms of joint damage: arthralgia and hydrarthrosis. Syphilitic arthralgia occurs without visible changes in the joints.
At syphilitic hydrarthrosis The knee, shoulder and wrist joints are predominantly affected. Hydrarthrosis is accompanied by high fever, acute painful swelling of one or more joints, redness of the skin and the appearance of serous effusion in the joint capsule. In some cases, the disease is not so acute, with less severe symptoms.
What is common to the numerous proposed classifications of tertiary syphilitic arthritis is the identification of two main forms of the disease:
Primary synovial arthritis without preliminary damage to the cartilage and bones of the joints
Primary bone arthritis, which occurs as a result of specific damage to the articular ends of the bone.
Synovitis with syphilis occurs acutely or chronically and is characterized by inflammation of the synovial membrane and joint capsule, which is often accompanied by serous effusion (hydrarthrosis).
The group of syphilitic synovitis includes the following main clinical forms of arthritis.
Synovitis with syphilis, arising as a reaction to the gummous process in the bone, located in close proximity to the joint (most often in the metaphysis). They are acute. Clinically, this synovitis with syphilis is characterized by painful swelling and dysfunction of the joint, the development of hydrarthrosis. Radiological changes in the joint are not detected. Under the influence of specific antisyphilitic treatment, reactive synovitis quickly disappears.
Chronic synovitis of Cleton are considered as allergic arthritis to syphilis. These synovitis occur without an acute inflammatory reaction, without high fever, without severe pain and without significant dysfunction of the joint. They are usually bilateral. Radiological changes in the joint are not detected.
Cleton's synovitis is very resistant to antisyphilitic therapy.
Syphilitic acute polyarthritis the tertiary period, as well as that of the secondary period, is considered by some authors as arthritis of an allergic nature. The clinical picture is similar to rheumatic arthritis.
Primary gummous synovitis with syphilis they are very rare. They begin with moderate pain that worsens at a precise time. Mobility in the joint is almost painless, slightly limited. Symptoms of subacute hydrocele of the joint are noted. The skin over the joint is not changed. Later, subjective sensations and swelling of the joint intensify; Due to the growth of the synovial membrane and villi during movement in the joint, a friction noise is determined - crepitus. No fistulas are formed. Without treatment, ankylosis develops.
Secondary gummous syphilitic arthritis is a consequence of the spread of gummous infiltrate of the epiphysis of the bone into the joint. In rare cases, gumma in syphilis can (primarily be located in the articular ligaments, in the tissue surrounding the joint capsules) in the patella, etc.
Secondary gummous arthritis in syphilis, which is essentially primary bone arthritis, begins painlessly with the development of hydrocele of the joint
As the gummous infiltrate of the affected joint with syphilis spreads, the clinical picture becomes more and more similar to primary gummous arthritis.
Diagnosis of gummous arthritis in syphilis is difficult. They are in many ways similar to tuberculous arthritis. When recognizing syphilitic arthritis, it should be taken into account that with tuberculosis, pain and functional disorders are more intense than with syphilis. Syphilis is characterized by nighttime bone pain. In cases of tuberculosis, palpation of the affected joint reveals limited, very painful points.
Tuberculous arthritis causes an increase in temperature; this does not happen with syphilis. Tertiary syphilis of the joints differs from tuberculosis of the joints by the characteristic x-ray picture of the widening of the joint space and the presence of areas of steosclerosis. Antisyphilitic treatment in cases of syphilitic arthritis gives a good, rapid therapeutic effect.
It should be borne in mind that hybrid forms of osteoarthritis with syphilis are possible: syphilis and tuberculosis, syphilis and purulent infection.