Secondary syphilis is the period following the primary syphilis, which is characterized by a disseminated rash with a large polymorphism of elements (roseoli, papules, vesicles, pustules), damage to somatic organs, musculoskeletal system, nervous system and generalized lymphadenitis. Diagnosis is carried out by detecting pale treponema in the separated skin elements, punctate lymph nodes and spinal fluid; staging serological reactions. Treatment includes penicillin therapy and symptomatic therapy of internal organ lesions.
General information
The period of secondary syphilis begins 2-3 months after the penetration of pale treponemas into the body and is associated with their entry into the blood and lymph. Syphilis pathogens spread through the blood and lymphatic vessels to the internal organs, lymph nodes and the nervous system, causing their defeat. Under the influence of the immune response of the body, pale treponema can form spores and cysts, in which it persists in a non-virulent form, causing the development of a latent period. With a decrease in the activity of immune mechanisms, the pathogen is able to transform again into a pathogenic mobile form, causing a relapse of the disease.
Classification
Fresh secondary syphilis – develops after primary syphilis and is manifested by a profuse disseminated small polymorphic rash, the presence of a solid chancre in the resolution stage and polyadenitis. Duration 2-4 months.
Latent secondary syphilis is characterized by the disappearance of clinical symptoms and is detected only by positive results of serological studies. Lasts up to 3 months or more.
Recurrent secondary syphilis – there is an alternation of recurrent syphilis with hidden periods. During relapses, the rash appears again. However, unlike fresh secondary syphilis, it is less abundant, larger and arranged in groups, forming arcs, rings, garlands and half-rings.
Secondary syphilis symptoms
The development of the disease often begins with common symptoms similar to the manifestations of SARS or influenza. This is malaise, fever, chills, headache. A distinctive feature is arthralgia and myalgia, which increase at night. Only a week after the appearance of these prodromal symptoms, skin manifestations of secondary syphilis occur.
Secondary syphilis rashes – secondary syphilis – are characterized by significant polymorphism. At the same time, they have a number of similar characteristics: a benign course without peripheral growth and destruction of surrounding tissues, a rounded shape and a clear separation from the surrounding skin, the absence of subjective symptoms (occasionally there is a slight itching) and inflammatory signs, healing without scarring. Secondary syphilides contain a large concentration of pale treponemas and cause a high infectious danger of a patient with secondary syphilis.
The most common form of rash in secondary syphilis is syphilitic roseola or spotted syphilis, manifested by rounded pale pink spots up to 10 mm in diameter. They are usually localized on the skin of the limbs and trunk, but can be on the face, feet and hands. Roseoles appear gradually 10-12 pieces a day for a week. Typically, the disappearance of the roseola when pressing on it. The rarer forms of roseolous rash in secondary syphilis include peeling and rising roseoles. The first one has a slight depression in the center and is covered with lamellar scales, the second one rises above the general level of the skin, which makes it look like a blister.
Papular syphilis is the second most common in secondary syphilis. Its most typical form is lenticular, having the appearance of densely elastic papules with a diameter of 3-5 mm of pink or copper-red color. Over time, peeling begins in the center of the papule, which spreads to the periphery. The “Biette collar” is characteristic – peeling along the edge of the papule while in the center it has already ended. The resolution of papules ends with the formation of a long-existing hyperpigmentation. Rarer forms of papular syphilis include seborrheic, coin-shaped, psoriasis-like, weeping syphilis, papular syphilis of the palms and soles, as well as broad condylomas.
A rare form of rash is pustular syphilis. Its appearance is usually observed in weakened patients (tuberculosis patients, drug addicts, alcoholics) and indicates a more severe course. Pustular syphilis is characterized by the presence of purulent exudate, which dries with the formation of a yellowish crust. The clinical picture resembles the manifestations of pyoderma. Pustular syphilis can have the following forms: impetiginous, acne-like, ectimatous, smallpox-like, rupoidic.
With recurrent secondary syphilis, pigmented syphilis (syphilitic leukoderma) can be observed, appearing on the side and back of the neck in the form of rounded whitish spots, called the “Venus necklace”.
Skin manifestations are accompanied by a generalized enlargement of the lymph nodes (lymphadenitis). Enlarged cervical, axillary, femoral, inguinal lymph nodes remain painless and are not soldered to the surrounding tissues. A violation of the nutrition of the hair roots leads to hair loss with the development of diffuse or focal alopecia. Lesions of the mucous membranes of the oral cavity (oral syphilis) and larynx are often noted. The latter cause the characteristic hoarseness of the voice in patients.
On the part of somatic organs, mainly functional changes are observed, which quickly pass during treatment and are absent during periods of latent secondary syphilis. Liver damage is manifested by its soreness and enlargement, violation of liver tests. Gastritis and gastrointestinal dyskinesia are often observed. On the part of the kidneys, proteinuria and the occurrence of lipoid nephrosis are possible. The defeat of the nervous system is manifested by irritability and sleep disturbance. Some patients have syphilitic meningitis, which is easily amenable to therapy. It is possible to damage the bone system with the development of osteoperiostitis and periostitis, manifested by nocturnal pain mainly in the bones of the extremities and proceeding without bone deformities. In some cases, otitis media, dry pleurisy, retinitis, neurosyphilis may be observed.
Diagnosis
The diverse clinical picture dictates the need to conduct research on syphilis in every patient with a diffuse rash combined with polyadenopathy. First of all, this is a study of the separated skin elements for the presence of pale treponema and the formulation of an RPR test. It is also possible to identify pale treponema in the material taken during a puncture biopsy of the lymph node. Examination of cerebrospinal fluid obtained by lumbar puncture during the period of fresh secondary syphilis or relapse also often reveals the presence of the pathogen.
In secondary syphilis, most patients have positive serological reactions (IFR). The exception is only 1-2% of cases of false negative reactions caused by too high an antibody titer, which can be lowered by diluting the serum.
Clinical manifestations from the internal organs may require additional consultation of a gastroenterologist, urologist, oculist, neurologist, otolaryngologist; abdominal ultrasound, gastroscopy, pharyngoscopy, kidney ultrasound, lung radiography, etc.
Differential diagnosis
The pronounced polymorphism of the bulk elements causes a large list of diseases with which it is necessary to carry out its differential diagnosis. These are infectious diseases accompanied by a rash (rubella, measles, typhoid fever, typhoid fever, chickenpox, etc.), dermatological diseases (toxicoderma, psoriasis, lichen planus, tuberculosis of the skin, acne), fungal diseases (pityriasis, pink lichen, candidiasis), infectious skin lesions (vulgar ectima, streptococcal impetigo). Broad condylomas of secondary syphilis need to be differentiated from genital warts caused by HPV. Mucosal lesions are differentiated with aphthous stomatitis, leukoplakia, glossitis, SLE, sore throat, laryngitis, thrush.
Secondary syphilis treatment
In the treatment of secondary syphilis, the same drugs are used as in the treatment of primary syphilis. In case of damage to somatic organs, symptomatic agents are additionally used. The most effective treatment is considered to be water-soluble penicillins, during which the necessary concentration of penicillin in the blood is constantly maintained. But such therapy can be carried out only in stationary conditions, since intramuscular administration of the drug is required every 3 hours.
Failure to comply with an adequate treatment regimen or sufficient duration of therapy leads to further development of the disease and its transition to the next stage — tertiary syphilis.
Literature
- Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015; MMWR Recomm Rep 2015; 64 (No. RR-3): 1 – 138. link
- Janier M., Hegyi V., Dupin N. et al. 2014 European guideline on the management of syphilis. J Eur Acad Dermatol Venereol, 2014; 28 (12): 1581 – 1593. link
- Ballard R., Hook E.W. III. Syphilis. In: Unemo M., Ballard R., Ison C., Lewis D., Ndowa F., Peeling R., eds. Laboratory diagnosis of sexually transmitted infections, including human immunodeficiency virus. World Health Organization (WHO), Geneva, Switzerland, 2013: 107 – 129.
