Syphilis is a venereal disease that has a long undulating course and affects all organs. The clinic of the disease begins with the occurrence of a solid chancre infection (primary syphiloma) at the site of infection, an increase in regional and then distant lymph nodes. It is characterized by the appearance of syphilitic rashes on the skin and mucous membranes, which are painless, do not itch, and proceed without fever. In the future, all internal organs and systems may be affected, which leads to irreversible changes and even death. Treatment is carried out by a venereologist, it is based on systemic and rational antibiotic therapy.
Syphilis (Lues) is an infectious disease that has a long, undulating course. According to the volume of damage to the body, disease refers to systemic diseases, and according to the main transmission pathway – to venereal. Disease affects the entire body: the skin and mucous membranes, cardiovascular, central nervous, digestive, musculoskeletal systems. Untreated or poorly treated syphilis can last for years, alternating periods of exacerbations and latent (latent) course. During the active period, syphilis manifests itself on the skin, mucous membranes and internal organs, during the latent period it practically does not manifest itself.
Disease ranks first among all infectious diseases (including STIs), in terms of morbidity, contagiousness, degree of harm to health, certain difficulties in diagnosis and treatment.
Features of the causative agent
The causative agent is a pale spirochete microorganism (Treponema – Treponema pallidum). The pale spirochete has the form of a curved spiral, is able to move in different ways (translationally, rotationally, flexibly and undularly), multiplies by transverse division, is colored with aniline dyes in pale pink.
Pale spirochete (treponema) finds optimal conditions in the human body in the lymphatic pathways and lymph nodes, where it actively multiplies, appears in high concentrations in the blood at the stage of secondary syphilis. The microbe persists for a long time in a warm and humid environment (optim. t = 37 ° C, in wet underwear for up to several days), resistant to low temperatures (in the tissues of corpses – viable for 1-2 days). Pale spirochete dies when drying, heating (55 ° C – after 15 minutes, 100 ° C – instantly), when treated with disinfectants, acid solutions, alkalis.
A patient with syphilis is contagious in any periods of the disease, especially during periods of primary and secondary syphilis, accompanied by manifestations on the skin and mucous membranes. Syphilis is transmitted when a healthy person comes into contact with a patient through secrets (semen during sexual intercourse, milk – from nursing women, saliva when kissing) and blood (with direct blood transfusion, during operations – from medical staff, using a common straight razor, a common syringe – from drug addicts). The main route of transmission of syphilis is sexual (95-98% of cases). Less often there is an indirect household path of infection – through wet household items and personal belongings (for example, from sick parents to children). There are cases of intrauterine transmission to a child from a sick mother. A necessary condition for infection is the presence in the patient’s secrets of a sufficient number of pathogenic forms of pale spirochetes and a violation of the integrity of the epithelium of the mucous membranes and skin of his partner (microtrauma: wounds, scratches, abrasions).
The course of this disease is a long wave–like, with alternating periods of active and latent manifestations of the disease. In the development of syphilis, there are periods that differ in a 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, lasts on average 3-4 weeks. Pale spirochetes spread through the lymphatic and circulatory pathways throughout the body, multiply, but clinical symptoms do not manifest. A patient with syphilis is unaware of his illness, although he is already contagious. The incubation period can be shortened (up to several days) and lengthened (up to several months). Elongation occurs when taking medications that somewhat inactivate the pathogens of syphilis.
Lasts 6-8 weeks, characterized by the appearance of pale spirochetes of primary syphiloma or solid chancre at the site of penetration and subsequent enlargement of nearby lymph nodes.
It can last from 2 to 5 years. There is a lesion of internal organs, tissues and body systems, the appearance of generalized rashes on the mucous membranes and skin, baldness. This stage of syphilis proceeds in waves, periods of active manifestations are replaced by periods of absence of symptoms. There are secondary fresh, secondary recurrent and latent syphilis.
Latent syphilis has no skin manifestations of the disease, signs of specific damage to internal organs and the nervous system, is determined only by laboratory tests (positive serological reactions).
It is rare now, occurs in the absence of treatment years after the defeat. It is characterized by irreversible disorders of internal organs and systems, especially the central nervous system. It is the most severe period of syphilis, leading to disability and death. It is detected by the appearance of tubercles and nodes (gum) on the skin and mucous membrane, which, disintegrating, disfigure the patient. They are divided into syphilis of the nervous system – neurosyphilis and visceral syphilis, in which internal organs (brain and spinal cord, heart, lungs, stomach, liver, kidneys) are damaged.
Symptoms of syphilis
Primary syphilis begins from the moment when a primary syphiloma appears at the site of the introduction of pale spirochetes – a solid chancre. A solid chancre is a single, rounded erosion or ulcer, having 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, a crust, a dense painless infiltrate is felt at its base. Solid chancre does not respond to local antiseptic therapy.
The chancre can be located on any part of the skin and mucous membranes (anal area, oral cavity – lips, corners of the mouth, tonsils; mammary gland, lower abdomen, fingers), but most often located on the genitals. Usually in men – on the head, foreskin and trunk of the penis, inside the urethra; in women – on the labia, perineum, vagina, cervix. The size of the chancre is about 1 cm, but it can be dwarfed – with a poppy seed and giant (d = 4-5 cm). Chancres can be multiple, in the case of numerous minor injuries to the skin and mucous membranes at the time of infection, sometimes bipolar (on the penis and lips). When a chancre appears on the tonsils, a condition resembling a sore throat occurs, in which the temperature does not rise, and the throat almost does not hurt. The painlessness of the chancre allows patients not to notice it, and not to attach any importance. Soreness is characterized by a slit–like chancre in the crease of the anal opening, and a chancre – panaritium on the nail phalanx of the fingers. During the period of primary syphilis, complications (balanitis, gangrenization, phimosis) may occur as a result of the addition of a secondary infection. Uncomplicated chancre, depending on the size, heals after 1.5 – 2 months, sometimes before the appearance of signs of secondary syphilis.
5-7 days after the appearance of a solid chancre, an uneven enlargement and compaction of the lymph nodes closest to it (more often inguinal) develops. It can be unilateral and bilateral, the nodes are not inflamed, painless, have an ovoid shape and can reach the size of a chicken egg. Towards the end of the period of primary syphilis, a specific polyadenitis develops – an increase in most subcutaneous lymph nodes. Patients may experience malaise, headache, insomnia, fever, arthralgia, muscle pain, neurotic and depressive disorders. This is associated with syphilitic septicemia – the spread of the causative agent of syphilis through the circulatory and lymphatic system from the lesion throughout the body. In some cases, this process proceeds without fever and malaise, and the patient does not notice the transition from the primary stage of syphilis to the secondary stage.
Secondary syphilis begins 2-4 months after infection and can last from 2 to 5 years. It is characterized by generalization of infection. At this stage, all systems and organs of the patient are affected: joints, bones, nervous system, organs of hematopoiesis, digestion, vision, hearing. The clinical symptom of secondary syphilis is rashes on the skin and mucous membranes, which are ubiquitous (secondary syphilis). Rashes can be accompanied by body aches, headache, fever and resemble a cold.
Rashes appear paroxysmally: after lasting 1.5 – 2 months, they disappear without treatment (secondary latent syphilis), then reappear. The first rash is characterized by profusion and brightness of color (secondary fresh syphilis), subsequent repeated rashes are paler colored, less abundant, but larger in size and prone to fusion (secondary recurrent syphilis). The frequency of relapses and the duration of latent periods of secondary syphilis are different and depend on the immunological reactions of the body in response to the reproduction of pale spirochetes.
Disease of the secondary period disappear without scars and have a variety of forms – roseoles, papules, pustules.
Syphilitic roseoles are small rounded spots of pink (pale pink) color that do not rise above the surface of the skin and the epithelium of the mucous membranes, which do not peel off and do not cause itching, when pressed on them they pale and disappear for a short time. Roseolous rash with secondary syphilis is observed in 75-80% of patients. The formation of roseoles is caused by disorders in the blood vessels, they are located throughout the body, mainly on the trunk and limbs, in the face area – most often on the forehead.
Papular rash is a rounded nodular formation protruding above the surface of the skin, bright pink in color with a bluish tinge. Papules are located on the trunk, do not cause any subjective sensations. However, when pressing on them with a button probe, acute pain appears. With syphilis, the rash of papules with greasy scales on the edge of the forehead forms the so-called “crown of Venus”.
Syphilitic papules can grow, merge with each other and form plaques, get wet. Wet erosive papules are especially contagious, and syphilis at this stage can easily be transmitted not only during sexual intercourse, but also during handshakes, kisses, and the use of common household items. Pustular (pustular) rashes with syphilis are similar to acne or chickenpox, covered with a crust or scales. They usually occur in patients with reduced immunity.
The malignant course of syphilis can develop in weakened patients, as well as in drug addicts, alcoholics, HIV-infected. Malignant syphilis is characterized by ulceration of papular-pustular syphilis, continuous relapses, violation of the general condition, fever, intoxication, weight loss.
Patients with secondary syphilis may have syphilitic (erythematous) sore throat (pronounced redness of the tonsils, with whitish spots, not accompanied by malaise and fever), syphilitic congestion in the corners of the lips, syphilis of the oral cavity. There is a general slight malaise, which may resemble the symptoms of a common cold. Characteristic of secondary syphilis is generalized lymphadenitis without signs of inflammation and soreness.
During the period of secondary syphilis, skin pigmentation disorders (leukoderma) and hair loss (alopecia) occur. Syphilitic leukoderma manifests itself in the loss of pigmentation of various skin areas on the neck, chest, abdomen, back, lower back, and armpits. On the neck, more often in women, a “Venus necklace” may appear, consisting of small (3-10 mm) discolored spots surrounded by darker areas of skin. It can exist without change for a long time (several months or even years), despite the ongoing anti-syphilitic treatment. The development of leukoderma is associated with a syphilitic lesion of the nervous system, pathological changes in the cerebrospinal fluid are observed during examination.
Hair loss is not accompanied by itching, peeling, by its nature it happens:
- diffuse – hair loss is typical for ordinary baldness, occurs on the scalp, in the temporal and parietal regions;
- small focal is a vivid symptom of syphilis, hair loss or thinning by small foci located randomly on the head, eyelashes, eyebrows, mustache and beard;
- mixed – there is both diffuse and small-focal.
With timely treatment of syphilis, the hairline is completely restored.
When syphilis affects the vocal cords, hoarseness of the voice appears.
Cutaneous manifestations of secondary syphilis accompany lesions of the central nervous system, bones and joints, and internal organs.
If a patient with syphilis was not treated or the treatment was incomplete, then a few years after infection, he develops symptoms of tertiary syphilis. Serious violations of organs and systems occur, the patient’s appearance is disfigured, he becomes disabled, in severe cases, a fatal outcome is likely. Recently, the incidence of tertiary syphilis has decreased due to its treatment with penicillin, severe forms of disability have become rare.
There are tertiary active (in the presence of manifestations) and tertiary latent syphilis. Manifestations of tertiary syphilis are few infiltrates (tubercles and gummas), prone to decay, and destructive changes in organs and tissues. Infiltrates on the skin and mucous membranes develop without changing the general condition of patients, they contain very few pale spirochetes and are practically not contagious.
Tubercles and gummas on the mucous membranes of the soft and hard palate, larynx, nose ulcerate, lead to a disorder of swallowing, speech, breathing, (perforation of the hard palate, “failure” of the nose). Gum syphilis, spreading to bones and joints, blood vessels, internal organs cause bleeding, perforations, scar deformities, disrupt their functions, which can lead to death.
All stages of syphilis cause numerous progressive lesions of the internal organs and nervous system, their most severe form develops in tertiary (late) syphilis:
- neurosyphilis (meningitis, meningovasculitis, syphilitic neuritis, neuralgia, paresis, epileptic seizures, spinal dryness and progressive paralysis);
- syphilitic osteoperiostitis, osteoarthritis, synovitis;
- syphilitic myocarditis, aortitis;
- syphilitic hepatitis;
- syphilitic gastritis;
- syphilitic nephritis, nephronecrosis;
- syphilitic eye damage, blindness, etc.
Syphilis is formidable with its complications. In the stage of tertiary syphilis, the disease is difficult to treat, and the defeat of all body systems leads a person to disability and even death. Intrauterine infection of a child with syphilis from a sick mother leads to the emergence of a severe condition – congenital syphilis, which is manifested by a triad of symptoms: congenital deafness, parenchymal keratitis, Getchinson’s teeth.
Diagnostic measures for syphilis include a thorough examination of the patient, collecting anamnesis and conducting clinical trials:
- Detection and identification of the causative agent of syphilis by microscopy of serous discharge of 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.
- Serological reactions (nonspecific, specific) are performed with serum, blood plasma and cerebrospinal fluid – the most reliable method of diagnosing syphilis.
Nonspecific serological reactions are: RPR – reaction of fast plasma reagins and RW – Wasserman reaction (compliment binding reaction). They allow to determine antibodies to pale spirochete – reagins. They are used for mass examinations (in polyclinics, hospitals). Sometimes they give a false positive result (positive in the absence of syphilis), so this result is confirmed by carrying out specific reactions.
Specific serological reactions include: RIF – immunofluorescence reaction, RPGA – passive hemagglutination reaction, RIBT – pale treponema immobilization reaction, RW with treponema antigen. They are used to determine species-specific antibodies. RIF and RPGA are highly sensitive assays, become positive already at the end of the incubation period. They are used in the diagnosis of latent syphilis and for the recognition of false positive reactions.
Positive indicators of serological reactions become only at the end of the second week of the primary period, therefore, the primary period of syphilis is divided into two stages: seronegative and seropositive.
Nonspecific serological reactions are used to evaluate the effectiveness of the treatment. Specific serological reactions in a patient who has had syphilis remain positive for life, they are not used to test the effectiveness of treatment.
Treatment of syphilis
Syphilis treatment begins after a reliable diagnosis is made, which is confirmed by laboratory tests. Treatment of syphilis is selected individually, carried out comprehensively, recovery should be determined in the laboratory. Modern methods of treatment, which venereology owns nowadays, allow us to talk about a favorable prognosis of treatment, provided correct and timely therapy that corresponds to the stage and clinical manifestations of the disease. But only a venereologist can choose a rational and sufficient therapy in terms of volume and time. Self-treatment of syphilis is unacceptable! Untreated syphilis turns into a latent, chronic form, and the patient remains epidemiologically dangerous.
The treatment is based on the use of penicillin antibiotics, to which the pale spirochete shows high sensitivity. In case of allergic reactions of the patient to penicillin derivatives, erythromycin, tetracyclines, cephalosporins are recommended as an alternative. In cases of late syphilis, iodine, bismuth, immunotherapy, biogenic stimulants, physiotherapy are prescribed in addition.
It is important to establish sexual contacts with a patient with syphilis, it is necessary to carry out preventive treatment of possibly infected sexual partners. At the end of treatment, all previously syphilis patients remain under dispensary observation by a doctor until a complete negative result of a complex of serological reactions.
In order to prevent syphilis, examinations of donors, pregnant women, employees of children’s, food and medical institutions, patients in hospitals; representatives of risk groups (drug addicts, prostitutes, homeless people) are conducted. Donated blood is necessarily tested for syphilis and subjected to canning.