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

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

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

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

Transmission routes

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

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

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

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

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

Infection of medical personnel is possible when examining patients with syphilis, performing medical procedures and manipulations, coming into contact with the internal organs of patients (during surgery), and during autopsies of corpses, especially newborns with early congenital syphilis.

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

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

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

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

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

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

Electron microscopic studies have made it possible to establish that the skin of patients with early forms of syphilis is most damaged in its nervous system and vascular network, with adjacent areas of connective tissue.

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

Primary lesions in syphilis

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

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

Secondary lesions in syphilis

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

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

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

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

Tertiary stage of syphilis

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

Malignant syphilis

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

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

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

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

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

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

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

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

Primary seropositive syphilis is syphilis with positive serological reactions.

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

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

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

Erosive chancre is usually round or oval in shape. Its diameter is 0.7-1.5 cm, the bottom is bright red (the color of fresh meat) or the color of spoiled lard, the edges are not undermined, clearly defined, at the same level as the skin. There are no signs of acute inflammation in the periphery. The discharge from the surface of the erosion is serous, in small quantities. At the base of the chancre, a clearly demarcated leaf-shaped or lamellar compaction is palpable. To determine it, the base of the erosion is grabbed with two fingers, slightly lifted and squeezed; At the same time, a dense elastic consistency is felt. The bottom of the erosion is smooth, shiny, as if varnished. Primary syphiloma is characterized by painlessness. After epithelization, a pigment spot remains, which soon disappears without a trace. The infiltrate at the base of the erosion persists for a longer time (several weeks, and sometimes months), but then completely resolves.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3) bone sarcoma often affects the proximal part of the metaphysis, is solitary, painful, characterized by progressive growth, minor symptoms of reactive osteosclerosis, and splitting of the periosteum.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Considering the high percentage of false positivity in elderly and senile people, as a rule, their lack of history and clinical manifestations of syphilis on the skin and visible mucous membranes, changes in the nervous system, internal organs, based on positive serological blood reactions alone, such patients are given specific treatment not assigned.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Diagnosis of syphilis

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

Based on materials from the Medical Encyclopedia of Professor Ivan Ivanovich Mavrov. “Sexual diseases” 2002

The malignant form of syphilis develops during a syphilitic infection, characterized by the severity and severity of the clinical manifestations of the disease, especially in the skin and mucous membranes. The malignant form of syphilis is currently almost never found in the Russian Federation.

Primary syphiloma in cases of malignant syphilis in most cases does not differ from that in the normal course of syphilis. Only in some patients does it have a tendency towards peripheral growth and deeper decay. After the initial period, often shortened to 3-4 weeks, patients, accompanied by severe general symptoms and high temperature, develop skin lesions in the form of pustular syphilides. Much less often, the malignant form of syphilis occurs as a relapse at 5-6 months from the onset of the disease. There is damage to the mucous membranes, in the form of deep ulcerations, as well as damage to the bones, periosteum and testicles. Damages to internal organs and the nervous system are observed relatively rarely, but are extremely severe. A peculiar feature of malignant syphilis is its insignificant severity, and often the complete absence of changes in the lymph nodes, as well as the often negative result of serological reactions.

Having no tendency to pause and go into a latent state, the process can drag on in separate outbreaks, one after another, for many months. Only then does the disease begin to gradually subside and enter a latent state. Subsequent relapses are common.

Pathologically, malignant syphilis is characterized by the phenomena of exudative-purulent inflammation, with massive leukocyte infiltration of tissues and their subsequent purulent melting. Neutrophilia is observed in the blood.

The pathogenesis of malignant syphilis has not yet been fully established. The peculiar course of syphilis is determined in most cases by the weakening and exhaustion of the body under the influence of severe general diseases, intoxication, starvation, difficult living conditions and, in connection with this, a decrease in its reactivity.

See syphilis

Saenko I. A.

Sources:

1. Kozorez E. S. Skin and venereal diseases: textbook. manual for higher students honey. textbook establishments. M.: Publishing house VLADOS-PRESS, 2005.
2. Pavlov S. T. Textbook of skin and venereal diseases for students of the Military Medical Academy of the Order of Lenin. S. M. Kirov. Publication of the Military Medical Order of Lenin Academy named after. S. M. Kirov. Leningrad, 1960.
3. Skripkin Yu. N., Sharapova G. Ya., Selissky G. D. Diseases transmitted through sexual contact - Leningrad: Medicine, 1985.

What is syphilis? Chronic infectious pathology that develops when Treponema pallidum penetrates the body. The disease progresses rapidly, affects all systems and organs, and is accompanied by various complications.

Syphilis is transmitted when Treponema pallidum enters the body

Classification of syphilis

Syphilis (lues) is a sexually transmitted disease, the symptoms of which appear periodically, which often makes diagnosis difficult. To classify the disease, various criteria are used - the duration of infection, the degree of damage to internal organs.

How is syphilis classified:

1. By period of infection– incubation, primary, secondary, tertiary.
2. According to the duration of the disease. Early latent syphilis - infection occurred less than 2 years ago, the nervous system was not affected. Late latent syphilis - more than 2 years have passed since infection, pathogenic bacteria are present in the cerebrospinal fluid. Unspecified – the time of infection could not be determined.
3. Along the path of infection– early and late forms of congenital disease, sexual, domestic, transfusion, headless acquired syphilis.
4. Neurosyphilis– Treponema pallidum affects the vessels and membranes of the brain, then the tissues of the organ.
5. Visceral syphilis– divide the disease depending on which organs are destroyed.

The main feature of syphilis is its wavy course. In the active form, the clinical picture is clearly expressed. The latent type of the disease is the remission phase, there are no signs of infection, the pathogen can only be detected using laboratory tests.

Incubation syphilis

The incubation period lasts on average 3–4 weeks, with strong immunity it can extend to 3 months, in people with a weakened body it is reduced to 9–11 days.

After infection, there are no clinical manifestations; after the end of the initial period, characteristic ulcers and erosions appear at the site of penetration of pathogenic bacteria - chancre, most often in the genital area, what it looks like can be seen in the photo.

The appearance of hard chancres on the skin is the first sign of syphilis in the incubation period

Primary period

Duration – 6–7 weeks. The first signs are a red spot that gradually thickens. A distinctive feature is that the rashes have a regular shape in the form of a circle or oval, the color resembles raw meat, the surface is polished, since little serous fluid is secreted.

Hard chancre can occur anywhere, but most often they are found on the genitals, mouth, mammary glands, and in the rectal area. The size of the erosion can reach the size of a ten-kopeck coin; usually no more than 5 pieces appear. After 4–8 weeks they disappear on their own, even without drug therapy; a slight scar may remain - this does not mean that the disease has become latent; the bacteria continue to actively multiply.

Types of chancre:

1. Chancre felon- forms on the phalanx of the finger, is accompanied by swelling, redness, the ulcer has an uneven edge, a dirty gray coating accumulates in it, and in the advanced form, rejection of the nail is observed.
2. Chancroid-amygdalitis- forms on one of the tonsils, the affected tonsil swells, turns red, thickens, pain occurs when swallowing, and a headache in the back of the head.
3. Mixed chancre- the result of simultaneous infection with syphilis and chancroid, the disease can develop within 3-4 months.

At the secondary stage of the disease, pink syphilitic papules appear on the palms

After six months, the signs of the disease, spotted syphilide, disappear. In this form, the disease can persist until the end of life in 50–70% of patients; in other people it develops into tertiary syphilis. Secondary syphilis can be fresh and recurrent.

Tertiary syphilis

A slowly progressive inflammatory process that occurs after 5–10 years of illness. The pathology affects almost all internal organs, which causes death.

Signs:

• severe cardiovascular diseases, stroke, complete or partial paralysis;
• large single nodes (gummas) gradually turn into long-term non-healing ulcers, after which specific star-shaped scars remain;
• small group rashes on the lower legs, shoulder blades, and shoulders.

Specific scars that remain in place of large single nodes

In tertiary syphilis, the ulcers are deep, often destroy bone tissue, and form a hole between the nasal and oral cavities, which manifests itself in the form of a nasal voice.

Visceral syphilis

Syphilitic visceropathy– damage to internal organs by Treponema pallidum, develops in secondary and tertiary forms of syphilis, is diagnosed in every 5 patients.

A separate form of the disease is malignant syphilis, the disease develops quickly and is severe; it is diagnosed in people with weakened immune systems, HIV-infected people, diabetics, and in the presence of autoimmune pathologies.

Causes of the disease

The causative agent of syphilis is Treponema pallidum, a mobile spiral-shaped bacterium, anaerobic, absent nucleus, DNA without chromosomes. The pathogenic microorganism is poorly stained by dyes that are used in the diagnosis of sexually transmitted diseases.

Routes of infection:

1. Sexual– the main route of infection, the cause of the disease is sexual intercourse with a carrier of the infection, you can also become infected through a kiss, if there are wounds in the mouth, bacteria can also be present in saliva.
2. Intrauterine– congenital syphilis is considered the most dangerous form of the disease and causes the formation of various pathologies. The early type of the disease is diagnosed in a child under 2 years of age, the late type – in children over 3 years of age.
3. Vertical– transmitted through milk to the baby during lactation.
4. By everyday means- upon contact with a person on whose body there are open syphilitic rashes.
5. Transfusion– infection occurred due to accidental transfusion of contaminated blood.
6. Headless– bacteria enter the blood through cuts, syringe needles.

You can become infected with syphilis through an infected blood transfusion.

With transfusion and decapitated syphilis, pathogenic microorganisms penetrate directly into the blood, so chancroid does not occur, and signs of a secondary form of the disease immediately appear.

Which doctor should I contact?

If signs of syphilis appear, it is necessary to see a venereologist. After examination and identification of specific symptoms, it may be necessary. Some clinics have a syphilidologist - a specialist in syphilis.

It is possible to completely get rid of syphilis only in the early stages of the disease, when the pathological processes in the internal organs are still reversible; at the last stage, the disease cannot be treated and ends in death.

Diagnostics

Syphilis has a number of characteristic signs that allow a preliminary diagnosis to be made after an initial examination; the main criteria are the nature and location of the rash.

Types of skin manifestations and rashes with syphilis:

• roseola syphilide– round pink spots that appear on the legs, arms, in the area of ​​the ribs, on the mucous membranes, and when pressed they noticeably turn pale;
• papular syphilides– small nodules, dense, with a clear border;
• pigment syphilide– appears six months after infection, a dark rash;
• acne syphilide– conical small pustules, covered with crusts, do not disappear for a long time;
• impetiginous syphilide– dry out quickly;
• smallpox syphilide– spherical small dense rashes;
• syphilitic ecthyma– a sign of late syphilis, a deep and large pustule, covered with a thick crust, after which purplish-blue ulcers and a scar remain on the skin;
• syphilitic rupee– single rashes, prone to scarring;
• pustular syphilides– acne-like syphilitic rash with purulent contents;
• syphilitic alopecia– the appearance of small bald spots on the head;
• syphilitic leucoderma– white spots, located on the neck, chest, lower back.

Other external manifestations are enlarged lymph nodes, an increase in temperature, a decrease in blood pressure, muscle pain, headache, and heart rhythm disturbances.

Lab tests

After the examination, the doctor gives directions for tests that can confirm the diagnosis, show the extent of the disease, and the presence of damage to internal organs. For laboratory tests, samples are taken from rashes on the skin and mucous membranes of the genital organs, in the anus, in the mouth, puncture of the lymph nodes and cerebrospinal fluid is performed.

Diagnostics:

• clinical analysis of urine and blood;
• dark field microscopy– use a special microscope, against a dark background you can clearly see the treponemes;
• direct fluorescence reaction– after treating the biomaterial with a special serum, pathogenic bacteria begin to glow;
• PCR– allows you to detect the presence of Treponema DNA in the blood and cerebrospinal fluid;
• VDRL– shows the presence of antibodies, is highly reliable, only this reaction becomes negative after complete recovery, unlike other serological research methods;
• Wasserman reaction– can be positive, negative, doubtful, weakly positive, strongly positive;
• REEF– detects the presence of antibodies produced by the immune system after infection;
• RPGA– when plasma and specially prepared red blood cells are mixed, the blood becomes granular; even after complete recovery, the reaction remains positive for life.

Almost all methods for diagnosing syphilis are based on blood tests in various specific ways

ELISA is one of the main methods for identifying various infectious pathologies; it allows you to determine the number of bacteria and indicate the time period of infection. 14 days after infection, IgA antibodies are present in the blood; after 4 weeks, the body produces immunoglobulins such as IgA and IgM. If IgG joins the two previous groups of antibodies, the disease is at its peak of exacerbation.

Why do false positive test results occur?

In diagnosing syphilis, several types of tests are always used, since false positive results often occur.

Main reasons:

• exacerbation of chronic infectious diseases;
• serious injuries;
• heart attack;
• any vaccination a few days before testing;
• intoxication due to food poisoning;
• pathological processes in connective tissues;
• tuberculosis, HIV, hepatitis B, C;
• kidney diseases;
• autoimmune diseases.

False-positive reactions to syphilis often occur in pregnant women - this is due to changes in the body at the hormonal and immune levels.

Is there a cure for syphilis?

Syphilis can only be treated with antibacterial drugs; all other means and methods are useless. In therapy, medications are used mainly in the form of injections; the dosage and duration of the course depend on the severity of the disease.

How to treat:

• Bicillin-1 - injections are given every 24 hours;
• Bicillin-3 – administered intramuscularly in the morning and evening;
• Bicillin-5 - injections are indicated 2-3 times a week;
• Tetracycline – twice a day;
• Ceftriaxone – once a day;
• Doxycycline - morning and evening;
• drugs in tablets - Rovamycin, Sumamed, Cefotaxime, Amoxicillin, you need to take them every 8 hours.

When treating syphilis, Ceftriaxone injections are given daily.

If a woman has a history of even completely cured syphilis, she is recommended to undergo preventive treatment during pregnancy to avoid infecting the child.

Consequences and complications of syphilis

In representatives of both sexes, the disease progresses and is treated the same, but complications are sometimes different. Men sometimes develop phimosis, which develops against the background of the formation of a hard chancre in the area of ​​the foreskin. In women, chancroid can be in the vagina and cervix.

How dangerous the disease is - the consequences of the disease depending on the stage of the syphilitic process:

1. Primary syphilis- an atypical hard chancre located in a hard-to-reach, unusual place in the mouth, on the tonsils. Hard chancre can cause the development of balanitis, balanoposthitis, and ulcerative-necrotic processes.
2. Secondary syphilis– initial damage to the nervous system and internal organs, various types of rashes.
3. Tertiary syphilis. In advanced forms of the disease, many gummas form on the outside and on the internal organs - lumps that can destroy bone and muscle tissue.

Treponema pallidum is able to bypass the human immune system; when the body begins to fight pathogens on its own, the bacteria transform into an armored form, in which they can remain for several months.

Prevention

To avoid contracting syphilis, it is necessary to use condoms when engaging in any type of sex; people who are sexually active and often change partners must be tested for STIs every six months.

The constant presence of an infected person nearby increases the risk of household transmission of the disease, to prevent this, it is necessary to exclude any bodily contact, allocate individual dishes to the sick person, bedding, bathtub and toilet must be regularly treated with antiseptics and disinfectants.

After unprotected sexual intercourse with a possible carrier of the infection, you must visit a venereologist within 48 hours, the doctor will select antibiotics for preventive treatment.

A condom reduces the likelihood of contracting syphilis, but infection cannot be completely excluded - if there are erosions and ulcers on the body, they contain a lot of treponemes.

Syphilis is a dangerous disease from which you can die, mainly transmitted through sexual contact. Treatment is effective only in the early stages of the disease, then irreversible processes begin to occur in tissues and internal organs.

In the classic course of syphilis there are: three clinical periods: primary, secondary and tertiary, which successively replace each other. First clinical sign diseases - chancre, or primary sclerosis - appears after 3-4 weeks. after infection at the site through which treponemes entered the human body. Chancre is most often localized on the genitals, although other localizations are often noted, including oral and anal.

Incubation period

The time from the moment of infection until the appearance of Treponema pallidum of primary sclerosis at the site of introduction is called incubation period. It is sometimes shortened to 8-15 days or extended to 108-190 days. Its shortening is noted with a bipolar location of the chancre. The body is saturated with treponemes more quickly than the two foci, which accelerates the generalization of the infection and the development of immunological changes in the body. An extension of the incubation period occurs if the patient receives antibiotics for intercurrent diseases during the incubation period. The generally accepted duration is 3-4 weeks. Shortening the incubation period to 10-11 days and lengthening it to 60-92 days occurs in no more than 2% of patients. According to V. A. Rakhmanov (1967), the incubation period was less than 3 weeks in 14% of patients, in 86% it was more than 3 weeks, and in 15% it was 41-50 days. Therefore, in accordance with Instructions for the treatment and prevention of syphilis, approved by the Ministry of Health of the Republic of Belarus (1995), patients with acute gonorrhea with unidentified sources of infection, who have a permanent place of residence and work, are subject to a thorough clinical and serological examination and observation (after treatment of gonorrhea) for 6 months, and if it is impossible to establish for them long-term follow-up are subject to preventive antisyphilitic treatment in the amount of one course of treatment with penicillin in a hospital setting.

Primary syphilis

From the moment hard chancre appears, primary period of syphilis(Syphilis primaria, Syphilis I, Lues I), which continues until multiple syphilitic rashes appear on the skin and mucous membranes. This period lasts 6-8 weeks 5-8 days after the onset of chancre, regional lymph nodes begin to enlarge ( specific bubo, or regional scleradenitis), and after 3-4 weeks an increase in all lymph nodes is observed - specific polyadenitis. Recently, the absence of regional scleradenitis has been noted in 4.4-21% of patients. (Fournier did not find it in 0.06% of patients. Ricor wrote: “There is no chancre without a bubo.”) Third symptom primary syphilis - syphilitic lymphangitis(occurs less frequently, currently registered in 20% of men).

In the primary period of syphilis, especially towards its end (before the appearance of rashes of secondary fresh syphilis), patients often experience malaise, insomnia, headaches, loss of appetite, increased irritability, bone pain (especially at night), sometimes an increase in temperature to 38-39 °C.

Primary period of syphilis divided by primary seronegative when standard seroreactions are still negative, and primary seropositive, when standard seroreactions become positive, which occurs approximately 3-4 weeks after the onset of primary syphiloma. It is believed that if even one of the reactions (for example, Wasserman, Kahn, Sachs-Vitebsky) is positive 3, 2 or even 1 time, then in this case the patient is diagnosed with primary seropositive syphilis.

Secondary syphilis

Secondary period of syphilis(Syphilis secundaria. Syphilis II, Lues II) occurs 6-8 weeks after the appearance of chancre, or 9-10 weeks after infection, and is characterized clinically mainly by lesions on the skin and mucous membranes in the form roseolous, papular, pustular rashes. In this case, internal organs (liver, kidneys), nervous and skeletal systems are affected. The rashes of the secondary period, having existed for several weeks, disappear spontaneously, leaving no scars, and a latent period of the disease begins. In the absence of treatment, after some time it is observed relapse of the disease(return) - rashes characteristic of the secondary period appear again on the skin and mucous membranes. This stage of syphilis is called secondary relapse(Syphilis II recidiva). After this, a latent period of the disease may begin again. With secondary recurrent syphilis, the rashes become smaller with each subsequent return of the disease, and the rashes themselves are more faded, large, monomorphic, asymmetrical and tend to be grouped (in the form of circles, arcs, ovals, garlands). The secondary period of syphilis lasts on average 3-4 years without treatment.

Tertiary syphilis

If the patient is not treated or is not treated sufficiently, then after 3-4 years (usually later) it may occur. tertiary period of syphilis(Syphilis tertiaria, Syphilis III, Lues III). In this case, the formation of tuberculate and nodular syphilides is characteristic. Morphological elements are formed on the skin, mucous membranes, subcutaneous fat, bones, internal organs and nervous system. When disintegrating, tubercles and gummas can cause destructive changes in the affected organs and tissues. The course of syphilis in this period is characterized undulation, when the phases of active manifestations are replaced by phases of hidden, or latent, manifestations of infection. Tertiary syphilis can last for many years. In the occurrence of tertiary syphilides, trauma (physical, psychological), chronic infection, intoxication (alcoholism), and severe somatic diseases (malaria, tuberculosis, etc.) play an important role.

Relapses of tertiary syphilis are rare and occur after a long latent period. It is believed that over the years the number of Treponema pallidum in organs and tissues gradually decreases. This explains the rarity of relapses and their limited nature, as well as the low infectiousness of patients with tertiary syphilis.

At the same time, experimental studies have established that Treponema pallidum, located in the tertiary elements, completely retains its pathogenicity. Seroreactions in 25-35% of patients are negative.

In some patients (untreated or insufficiently treated), the disease, bypassing the tertiary period or combined with it, leads to damage to internal organs, musculoskeletal system and to severe inflammatory and degenerative changes in the central nervous system (tabes dorsalis, progressive paralysis). They usually develop after a long latent period. Their pathogenesis has not yet been fully studied. Lesions of the nervous system are quite often combined with syphilitic lesions of internal organs (heart, aorta, liver). Much less frequently, progressive paralysis and tabes dorsalis are combined with tertiary syphilides of the skin and mucous membranes.

Atypical forms of syphilis

In addition to the described classical course of syphilis, it is much less common atypical manifestations.

Syphilis without chancre. The development of syphilitic infection without the formation of primary syphiloma occurs when Treponema pallidum penetrates the human body, bypassing the skin and mucous membranes. This can happen with deep cuts, injections, or when the pathogen is introduced directly into the bloodstream (transfusion syphilis). 2-2.5 months after infection, the disease manifests itself with symptoms of the secondary period. They are often preceded by prodromal phenomena (fever, headaches, pain in bones and joints). The further course of the disease is normal.

Malignant syphilis. The peculiarity of the development and course of syphilitic infection in this form is associated in most cases with weakening and exhaustion of the body, with a decrease in its reactivity. Clinically, malignant syphilis is distinguished by its severity and severity. Primary syphiloma in some patients has a tendency to grow peripherally. The primary period is often shortened. During the secondary period, against the background of general severe symptoms and high body temperature, pustular syphilides, mainly ecthyma and rupees, form on the skin. The precipitation of new elements occurs continuously, without latent intervals. In addition to the skin, the process may involve mucous membranes (deep ulcerations), bones, testicles (orchitis) and other organs and tissues. Internal organs and the nervous system are rarely affected, but the pathological process that develops in them is difficult. Changes in the lymph nodes are often absent, and standard seroreactions are negative. Outbreaks of the disease can drag on for many months.

Syphilis latent, unspecified. Syphilis is often diagnosed only on the basis of positive serological reactions in the absence of clinical manifestations and anamnestic data. The sexual partners (spouses) of such patients, despite constant and long-term sexual contacts, most often remain healthy and uninfected. This condition is called latent syphilis, unspecified.

In practice, there are cases when patients with syphilis first detected only in the tertiary period in the absence of indications of it in the past. There are observations when people with a “pure” venereological history, who, due to the nature of their work, undergo constant and long-term medical examinations with serological testing of blood for syphilis, are unexpectedly diagnosed with late forms of the disease during the next examination, including tabes dorsalis and vascular syphilis. Similar observations confirm possibility of an initially asymptomatic course of the disease.

According to M.V. Milich (1972, 1980), after the pathogen enters the body, a period of long asymptomatic syphilis may occur. In this case, after infection, the patient seems to bypass the early active forms of the disease. It is assumed that in these cases, treponemes that entered the body of a sexual partner from a patient with an active form of syphilis, due to some unfavorable conditions, are immediately transformed into L-forms, which determines the absence of a clinic and the negativity of serotests. Under favorable conditions, L-forms are reversed to their original state and cause the development of late forms of syphilis. Such patients are identified by chance during a serosurvey and are diagnosed as sick latent unspecified syphilis. 70-90% of them deny active syphilis in the past. In 71% of patients with late congenital syphilis, previous manifestations of early congenital syphilis were not identified, which indicates the possibility of a long asymptomatic course of infection with congenital syphilis.

M.V. Milich (1972) believes that it is possible three variants of the course of acquired syphilis:

1. usual stage course;
2. long-term asymptomatic;
3. cases of self-healing.

It is necessary to note the ability of Treponema pallidum transmitted during pregnancy from mother to fetus through the placenta.

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Syphilis is a classic venereal disease. Syphilis in men, women and children at different stages is characterized by such signs as damage to the skin, mucous membranes, internal organs (cardiovascular system, stomach, liver), osteoarticular and nervous systems.

Symptoms of the disease, among other manifestations, may include:

• fever (temperature);

The causative agent - treponema pallidum, or pale spirochete - was discovered in 1905. "Pale" - because it is almost not stained with the usual aniline dyes used for this purpose in microbiology. Treponema pallidum has a spiral shape, resembling a long, thin corkscrew.

Stages of syphilis

Syphilis is a very long-term disease. A rash on the skin and mucous membranes gives way to periods when there are no external signs and the diagnosis can be made only after a blood test for specific serological reactions. Such latent periods can drag on for a long time, especially in the later stages, when, in the process of long-term coexistence, the human body and Treponema pallidum adapt to each other, achieving a certain “equilibrium.” Manifestations of the disease do not appear immediately, but after 3-5 weeks. The time preceding them is called incubation: bacteria spread through the flow of lymph and blood throughout the body and multiply quickly. When there are enough of them, and the first signs of the disease appear, the stage of primary syphilis begins. Its external symptoms are erosion or ulcer (hard chancre) at the site of infection entering the body and enlargement of nearby lymph nodes, which disappear without treatment after a few weeks. 6-7 weeks after this, a rash appears that spreads throughout the body. This means that the disease has entered the secondary stage. During this period, rashes of various types appear and, after existing for some time, disappear. The tertiary period of syphilis occurs after 5-10 years: nodules and tubercles appear on the skin.

Symptoms of primary syphilis

Hard chancre (ulcers), one or more, are most often located on the genitals, in places where microtraumas usually occur during sexual intercourse. In men, this is the head, foreskin, and less commonly, the shaft of the penis; sometimes the rash may be located inside the urethra. In homosexuals, they are found in the circumference of the anus, in the depths of the folds of skin that form it, or on the mucous membrane of the rectum. In women, they usually appear on the labia minora and majora, at the entrance to the vagina, on the perineum, and less often on the cervix. In the latter case, the ulcer can only be seen during a gynecological examination on a chair using mirrors. Chancres can practically appear anywhere: on the lips, in the corner of the mouth, on the chest, lower abdomen, on the pubis, in the groin, on the tonsils, in the latter case resembling a sore throat, in which the throat hardly hurts and the temperature does not rise. Some patients develop thickening and swelling with severe redness, even bluing of the skin, in women - in the labia majora, in men - in the foreskin. With the addition of a “secondary”, i.e. additional infection, complications develop. In men, this is most often inflammation and swelling of the foreskin (phimosis), where pus usually accumulates and you can sometimes feel a lump at the site of an existing chancre. If, during the period of increasing swelling of the foreskin, it is moved back and the head of the penis is opened, then the reverse movement is not always successful and the head ends up pinched by the sealed ring. It swells and if not released, it may become dead. Occasionally, such necrosis (gangrene) is complicated by ulcers of the foreskin or located on the head of the penis. About a week after the appearance of chancre, nearby lymph nodes (most often in the groin) painlessly enlarge, reaching the size of a pea, plum, or even a chicken egg. At the end of the primary period, other groups of lymph nodes also increase.

Symptoms of secondary syphilis

Secondary syphilis begins with the appearance of a profuse rash throughout the body, which is often preceded by a deterioration in health, and the temperature may rise slightly. The chancre or its remains, as well as enlarged lymph nodes, are still preserved by this time. The rash usually appears as small pink spots that evenly cover the skin, do not rise above the surface of the skin, do not itch or peel. This kind of spotty rash is called syphilitic roseola. Since they do not itch, people who are inattentive to themselves can easily overlook it. Even doctors can make a mistake if they have no reason to suspect a patient has syphilis, and diagnose measles, rubella, scarlet fever, which are now often found in adults. In addition to roseola, there is a papular rash, consisting of nodules the size of a match head to a pea, bright pink, with a bluish, brownish tint. Much less common are pustular, or pustular, similar to common acne, or a rash with chicken pox. Like other syphilitic rashes, pustules do not hurt. The same patient may have spots, nodules, and pustules. The rashes last from several days to several weeks, and then disappear without treatment, only to be replaced by new ones after a more or less long time, opening a period of secondary recurrent syphilis. New rashes, as a rule, do not cover the entire skin, but are located in separate areas; they are larger, paler (sometimes barely noticeable) and tend to cluster together to form rings, arcs and other shapes. The rash can still be macular, nodular or pustular, but with each new appearance the number of rashes becomes smaller and the size of each of them larger. For the secondary relapse period, nodules on the external genitalia, in the perineal area, near the anus, and under the armpits are typical. They enlarge, their surface becomes wet, forming abrasions, the weeping growths merge with each other, resembling cauliflower in appearance. Such growths, accompanied by a fetid odor, are little painful, but can interfere with walking. Patients with secondary syphilis have so-called “syphilitic tonsillitis,” which differs from the usual one in that when the tonsils become red or whitish spots appear on them, the throat does not hurt and the body temperature does not rise. Whitish flat formations of oval or bizarre shapes appear on the mucous membrane of the neck and lips. On the tongue there are bright red areas of oval or scalloped outlines, in which there are no papillae of the tongue. There may be cracks in the corners of the mouth - so-called syphilitic jams. Brownish-red nodules sometimes appear on the forehead - the “crown of Venus”. Purulent crusts may appear around the mouth, simulating ordinary pyoderma. A rash on the palms and soles is very common. If any rashes appear in these areas, you should definitely check with a venereologist, although skin changes here may also be of a different origin (for example, fungal). Sometimes small (the size of a little fingernail) rounded light spots, surrounded by darker areas of skin, form on the back and sides of the neck. "Necklace of Venus" does not peel and does not hurt. There is syphilitic baldness (alopecia) in the form of either uniform hair thinning (up to pronounced) or small numerous patches. It resembles moth-eaten fur. Eyebrows and eyelashes often also fall out. All these unpleasant phenomena occur 6 or more months after infection. An experienced venereologist only needs a quick glance at the patient to diagnose him with syphilis based on these signs. Treatment quickly leads to restoration of hair growth. In weakened patients, as well as in patients who abuse alcohol, there are often multiple ulcers scattered throughout the skin, covered with layered crusts (the so-called “malignant” syphilis. If the patient is not treated, then several years after infection he may enter the tertiary period.

Symptoms of tertiary syphilis

Single large nodes up to the size of a walnut or even a chicken egg (gumma) and smaller ones (tubercles), located, as a rule, in groups, appear on the skin. The gumma gradually grows, the skin becomes bluish-red, then a viscous liquid begins to be released from its center and a long-term non-healing ulcer with a characteristic yellowish bottom of a “greasy” appearance is formed. Gummous ulcers are characterized by a long existence, lasting for many months and even years. Scars, after they have healed, remain for life, and from their typical star-shaped appearance one can understand after a long time that this person had syphilis. Tubercles and gummas are most often located on the skin of the anterior surface of the legs, in the area of ​​the shoulder blades, forearms, etc. One of the common sites of tertiary lesions is the mucous membrane of the soft and hard palate. Ulcerations here can reach the bone and destroy bone tissue, the soft palate, wrinkle with scars, or form holes leading from the oral cavity to the nasal cavity, causing the voice to acquire a typical nasal tone. If gummas are located on the face, they can destroy the bones of the nose, and it “falls through.” At all stages of syphilis, internal organs and the nervous system can be affected. In the first years of the disease, some patients develop syphilitic hepatitis (liver damage) and manifestations of “latent” meningitis. With treatment they go away quickly. Much less often, after 5 or more years, compactions or gumma, similar to those that appear on the skin, sometimes form in these organs. The aorta and heart are most often affected. A syphilitic aortic aneurysm is formed; in some part of this vital vessel, its diameter sharply expands, and a sac with very thin walls (aneurysm) is formed. A rupture of an aneurysm leads to instant death. The pathological process can also “slide” from the aorta to the mouths of the coronary vessels that supply the heart muscle, and then attacks of angina occur, which are not relieved by the means usually used for this. In some cases, syphilis causes myocardial infarction. Already in the early stages of the disease, syphilitic meningitis, meningoencephalitis, a sharp increase in intracranial pressure, strokes with complete or partial paralysis, etc. can develop. These severe phenomena are very rare and, fortunately, respond quite well to treatment. Late lesions (tabes dorsalis, progressive paralysis). They occur if a person has not been treated or was treated poorly. With tabes dorsalis, treponema pallidum affects the spinal cord. Patients suffer from attacks of acute excruciating pain. Their skin loses sensitivity so much that they may not feel the burn and pay attention only to the damage to the skin. The gait changes, becomes “duck-like”, first there is difficulty urinating, and then urinary and fecal incontinence. Damage to the optic nerves is especially severe, leading to blindness in a short time. Severe deformities of large joints, especially the knees, may develop. Changes in the size and shape of the pupils and their reaction to light are detected, as well as a decrease or complete disappearance of tendon reflexes, which are caused by hitting the tendon below the knee (patellar reflex) and above the heel (Achilles reflex) with a hammer. Progressive paralysis usually develops after 15-20 years. This is irreversible brain damage. A person’s behavior changes sharply: ability to work decreases, mood fluctuates, the ability to self-criticize decreases, either irritability, explosiveness, or, conversely, unreasonable cheerfulness and carelessness appear. The patient sleeps poorly, often has a headache, his hands tremble, and his facial muscles twitch. After some time, he becomes tactless, rude, lustful, and displays a tendency to cynical abuse and gluttony. His mental abilities are fading, he loses his memory, especially for recent events, the ability to count correctly with simple arithmetic operations “in his head”, when writing he misses or repeats letters, syllables, his handwriting becomes uneven, sloppy, his speech is slow, monotonous, as if " stumbling." If treatment is not carried out, he completely loses interest in the world around him, soon refuses to leave his bed, and with symptoms of general paralysis, death occurs. Sometimes, with progressive paralysis, delusions of grandeur occur, sudden attacks of excitement, aggression, dangerous for others.

Diagnosis of syphilis

Diagnosis of syphilis is based on the evaluation of blood tests for syphilis.
There are many types of blood tests for syphilis. They are divided into two groups:
non-treponemal (RPR, RW with cardiolipin antigen);
treponemal (RIF, RIBT, RW with treponemal antigen).
For mass examinations (in hospitals, clinics), non-treponemal blood tests are used. In some cases, they can be false positive, that is, they can be positive in the absence of syphilis. Therefore, a positive result of non-treponemal blood tests must be confirmed by treponemal blood tests.
To assess the effectiveness of treatment, quantitative non-treponemal blood tests are used (for example, RW with cardiolipin antigen).
Treponemal blood tests remain positive after syphilis for life. Therefore, treponemal blood tests (such as RIF, RIBT, RPGA) are NOT used to assess the effectiveness of treatment.

Treatment of syphilis

Treatment of syphilis is carried out only after the diagnosis has been established and confirmed by laboratory research methods. Treatment of syphilis should be comprehensive and individual. Antibiotics are the mainstay of treatment for syphilis. In some cases, treatment is prescribed that complements antibiotics (immunotherapy, restorative drugs, physiotherapy, etc.).

Remember! It is dangerous to self-medicate syphilis. Recovery is determined only by laboratory methods.

Complications of syphilis

An insane number of problems arise in a person who has survived to tertiary syphilis, which is already difficult to treat and can lead to death. A sick pregnant woman will transmit the infection to her child in utero. Congenital syphilis is a severe condition.