Syphilis

Syphilis is a chronic infectious disease transmitted primarily through sexual intercourse. It is characterized by periodicity of the course and various clinical manifestations.

What is syphilis?

Syphilis is a systemic disease caused by Treponema pallidum. In patients with syphilis, treatment may be directed at eliminating the symptoms and signs of primary infection (ulcer or chancre at the site of infection), secondary infection (manifestations including rash, mucosal and skin lesions, adenopathy), or tertiary infection (cardiac, nervous, ocular, auditory, and gummatous disorders). Infection may also be detected in the latent stage by serologic tests. Patients with latent (hidden) syphilis who are known to have been infected within the previous year are considered to have early latent syphilis; all other cases are considered to have late latent syphilis or syphilis of unknown duration. Theoretically, treatment for late latent syphilis (as well as for tertiary syphilis) should be longer because the organisms divide more slowly; however, the validity and significance of this concept have not been determined.

Causes of Syphilis

The causative agent of the disease is pale treponema, which belongs to the genus Treponema. Pale treponema is a corkscrew-shaped spiral, slightly tapering towards the ends. It has 8 to 14 uniform curls. The length of each curl is about µm, and the length of the entire treponema depends on the number of curls. Like other cells, pale treponema consists of a cell wall, cytoplasm and nucleus. At both its ends and on the sides are thin spiral flagella, due to which pale treponema is very mobile. There are four types of movement: translational (periodic, at different speeds - from 3 to 20 µm / h); rotary (rotation around its axis); flexion (pendulum-shaped, whip-like); contractile; (wave-like, convulsive). Often all these movements are combined. Pale spirochete is very similar to Sp. buccalis and Sp. Dentium, which are saprophytes or opportunistic flora of mucous membranes. The movement and shape of pale treponema distinguish it from these microorganisms. The source of infection is a person with syphilis, infection from whom can occur at any stage of the disease, including latent. Pale spirochete enters the body mainly through damaged skin, mucous membranes, and also during transfusion of infected blood. It can be found on the surface of syphilitic elements (erosions, ulcers), in lymph nodes, cerebrospinal fluid, nerve cells, tissues of internal organs, as well as in breast milk and seminal fluid. A patient with active manifestations of syphilis is contagious to others. There is a household route of transmission of infection, for example, through common household items (spoons, mugs, glasses, toothbrushes, smoking pipes, cigarettes), through kissing, biting, breastfeeding.

The literature describes cases of syphilis infection of medical personnel (especially gynecologists and surgeons) during careless examination of patients, pathologists from corpses of people who had syphilis. Syphilitic infection is characterized by varying duration (from several months to several years) and a wave-like course, caused by the change of active manifestations with periods of a latent state. The periodicity of the course is associated with the infectious immunity that arises with this disease, the intensity of which varies in different periods of syphilis.

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Symptoms of Syphilis

A distinction is made between congenital and acquired syphilis. The first occurs if the pale spirochete enters the fetus's body through the placenta. During acquired syphilis, 4 periods are distinguished: incubation, primary, secondary, tertiary.

The incubation period of syphilis is considered to be from the moment of infection of the organism with pale treponema until the appearance of the first clinical symptom - hard chancre, and usually lasts 20-40 days. However, it can be shortened to 10-15 days (in case of massive infection, which is manifested by multiple or bipolar chancres, as well as in case of superinfection in the form of "sequential chancres" or "imprint chancres") or extended to 4 months. An extension of the incubation period is noted in case of severe concomitant diseases, in elderly people, after treatment with small doses of antibiotics for intercurrent diseases, in particular with simultaneous infection with gonorrhea. During this period, pale treponema multiplies in the organism and spreads through the lymphatic system. Treponemas are carried by the bloodstream to different organs and systems, causing various pathological processes and changing the reactivity of the organism.

The primary period begins with the appearance of a hard chancre at the site of the introduction of pale treponemas until the appearance of the first generalized rash. This period lasts on average 6-7 weeks.

The hard chancre that appears at the site of pathogen introduction is the only syphilid of the primary period and is accompanied by regional lymphangitis and regional lymphadenitis, which at the end of the period turn into a specific polyadspit, which persists without any particular changes for six months. A distinction is made between primary seronegative (from the moment the hard chancre appears until serological reactions change from negative to positive) and primary seropositive (from the moment serological reactions become positive until the appearance of a generalized rash) periods of syphilis.

The secondary period (from the first generalized rash to the appearance of tertiary syphilides - tubercles and gummas) lasts 2-4 years, is characterized by a wave-like course, abundance and diversity of clinical symptoms. The main manifestations of this period are spotted, papular, pustular, pigmented syphilides and baldness.

The active stage of this period is characterized by the most vivid and abundant rashes (secondary fresh syphilis), which are accompanied by the remains of hard chancre, pronounced polyadenitis. The rash lasts for several weeks or, less often, months, then spontaneously disappears. Repeated episodes of rashes (secondary recurrent syphilis) alternate with periods of complete absence of manifestations (secondary latent syphilis). Rashes in secondary recurrent syphilis are less abundant, but larger in size. In the first half of the year, they are accompanied by polyadenitis. The process often involves mucous membranes, internal organs (viscerosyphilis), and the nervous system (neurosyphilis). Secondary syphilides are very contagious, since they contain a huge number of spirochetes.

The tertiary period is observed in individuals who have not received or have received inadequate treatment. It usually begins in the 3rd or 4th year of the disease and, in the absence of treatment, lasts until the end of the patient's life.

The symptoms of this period are the most severe, leading to permanent disfigurement of appearance, disability and often death. Tertiary syphilis is characterized by a wave-like course with alternating active manifestations in various organs and tissues (primarily in the skin, mucous membranes and bones) and long-term latent states. Tertiary syphilides are represented by tubercles and nodes (gummas). They contain a small number of pale treponemas. A distinction is made between tertiary active, or manifest, and tertiary latent syphilis. Clinical manifestations of viscero- and neurosyphilis are often noted.

Some patients exhibit deviations from the classic course of syphilis. This is the so-called "headless" ("silent") syphilis or "syphilis without hard chancre", when the pathogen immediately penetrates deep into the tissue or enters a vessel (for example, with a deep cut, during a blood transfusion). In this case, there is no primary period, and the disease begins after a correspondingly extended incubation period with rashes of the secondary period of syphilis.

There is no innate immunity to syphilis, i.e. a person can become infected again after recovery (reinfection). In syphilis, there is non-sterile or infectious immunity. Superinfection is a new infection with syphilis of a person already sick with syphilis. With additional infection, clinical manifestations correspond to the period of syphilis that is currently observed in the patient.

Differential diagnosis of primary syphilis is carried out with a number of erosive and ulcerative dermatoses, in particular with a furuncle in the ulceration stage, erosive and ulcerative balaposthitis and vulvitis, herpes simplex, sninocellular epithelioma. Syphilitic roseola is differentiated from manifestations of typhus and typhoid fever and other acute infectious diseases, from toxic roseola; in allergic drug toxicoderma, when localizing secondary period rashes in the pharynx area - from common tonsillitis. Papular syphilides are differentiated from psoriasis, lichen planus, parapsoriasis, etc.; broad condylomas in the anal area - from pointed condylomas, hemorrhoids; pustular syphilides - from pustular skin diseases; manifestations of the tertiary period - from tuberculosis, leprosy, skin cancer, etc.

Diagnosis of syphilis

Examination of exudate or affected tissues in a dark field of vision or using direct immunofluorescence (DIF) are accurate methods for diagnosing early syphilis. Preliminary diagnostics are performed using two types of tests: a) non-treponemal - VDRL (Venereal Diseases Research Laboratories) and RPR; b) treponemal (absorption of treponemal fluorescent antibodies - RIF-abs, and passive microhemagglutination reaction - RPHA). Using only one type of test does not give accurate results due to the possibility of obtaining false-positive responses in non-treponemal tests. Titers of non-treponemal tests usually correlate with disease activity. A 4-fold change in titer is considered, equivalent to a change of 2 dilutions (e.g., from 1:16 to 1:4, or from 1:8 to 1:32). Nontreponemal tests are expected to become negative after treatment, but in some patients they remain positive at low titers for some time, and sometimes for life. In 15-25% of patients treated during the primary stage of syphilis, serologic reactions may revert, giving negative test results after 2-3 years. Antibody titers in treponemal tests correlate poorly with disease activity and should not be used to assess response to treatment.

Subsequent serologic testing should be performed using the same serologic assays (e.g. VDRL or RPR) and in the same laboratory. VDRL and RPR are equally valid, but quantitative results from these tests cannot be compared because RPR titers are often slightly higher than VDRL titers.

Unusual serologic test results (unusually high, unusually low, and fluctuating titers) are common in HIV-infected patients. In such patients, other tests (eg, biopsy and direct microscopy) should be used. However, serologic tests have been shown to be accurate and reliable in diagnosing syphilis and assessing treatment response in most HIV-infected patients.

No single test can be used to diagnose all cases of neurosyphilis. The diagnosis of neurosyphilis, with or without clinical manifestations, should be based on the results of various serologic tests in combination with cerebrospinal fluid (CSF) cell and protein counts and the results of CSF VDRL (RPR is not used for CSF). In the presence of active syphilis, the CSF white blood cell count is usually elevated (>5/mm ³ ); this test is also a sensitive method for assessing the response to treatment. The VDRL test is the standard CSF serologic test; if it is reactive in the absence of significant CSF contamination with blood, it can be considered a diagnostic test for neurosyphilis. However, CSF VDRL may be negative in the presence of neurosyphilis. Some experts recommend the CSF RIF-ABS test. RIF-ABS with CSF is less specific for the diagnosis of neurosyphilis (i.e., it gives more false-positive results) than VDRL. However, this test has high sensitivity and some authorities believe that a negative RIF-ABS with CSF allows to exclude neurosyphilis.

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Treatment of syphilis

Penicillin G, administered parenterally, is the drug of choice for the treatment of all stages of syphilis. The type of drug(s) (e.g., benzathine, aqueous procaine, or aqueous crystalline), dosage, and duration of treatment depend on the stage and clinical manifestations of the disease.

The efficacy of penicillin in treating syphilis was established in clinical use before the results of randomized clinical trials were available. Consequently, almost all recommendations for the treatment of syphilis are based on expert opinion and supported by a series of open clinical trials and 50 years of clinical use.

Parenteral penicillin G is the only drug proven effective in the treatment of neurosyphilis or syphilis during pregnancy. Patients allergic to penicillin, including those with neurosyphilis and pregnant women with any stage of syphilis, should be treated with penicillin after desensitization. In some cases, penicillin skin testing may be used (see Management of Patients with a History of Penicillin Allergy). However, such testing is difficult because commercial allergens are unavailable.

The Jarisch-Hexheimer reaction, an acute febrile reaction with headache, muscle pain, and other symptoms, may occur during the first 24 hours of syphilis therapy; the patient should be warned of the possibility of this reaction. The Jarisch-Hexheimer reaction is most often seen in patients with early syphilis. Antipyretic drugs may be recommended; there are currently no ways to prevent this reaction. In pregnant women, the Jarisch-Hexheimer reaction may trigger premature labor or cause pathological conditions in the fetus. This circumstance should not be a reason for refusing or delaying treatment.

Treatment of syphilis depends on clinical forms and is described in more detail in the Instructions for the diagnosis, treatment and prevention of syphilis, approved by the Ministry of Health. This publication provides general information and some treatment regimens used.

Preventive treatment is given to people who have had contact with a patient with syphilis for no more than 2 months.

For preventive treatment, one of the following methods is used: benzathine benzylpenicillin or bicillin 2.4 million units intramuscularly once, or bicillin-3 1.8 million units, or bicillin-5 1.5 million units intramuscularly 2 times a week No. 2, or benzylpenicillin 600 thousand units intramuscularly 2 times a day daily for 7 days, or benzylpenicillin procaine 1.2 million units intramuscularly 2 times a day daily No. 7.

For treatment of patients with primary syphilis one of the following methods is used: benzathine benzylpenicillin 2.4 million IU intramuscularly once every 7 days No. 2, or bicillin 2.4 million IU intramuscularly once every 5 days No. 3, or bicillin-3 1.8 million IU or bicillin-5 1.5 million IU intramuscularly 2 times a day No. 5, or benzylpenicillin procaine 1.2 million IU intramuscularly 1 time per day daily No. 10, or benzylpenicillin 600 thousand IU intramuscularly 2 times per day daily for 10 days, or benzylpenicillin million IU intramuscularly every 6 hours (4 times per day) daily for 10 days.

For treatment of patients with secondary and early latent syphilis use one of the following methods: benzathine benzylpenicillin 2.4 million IU intramuscularly once every 7 days No. 3 or bicillin 2.4 million IU intramuscularly once every 5 days No. 6, or bicillin-3 1.8 million IU or bicillin-5 1.4 million IU intramuscularly 2 times a week No. 10, or benzylpenicillin procaine but 1.2 million IU intramuscularly once a day daily No. 20, or benzylpenicillin 600 thousand IU intramuscularly 2 times a day daily for 20 days, or benzylpenicillin 1 million IU intramuscularly every 6 hours (4 times a day) daily for 20 days.

For treatment of patients with tertiary latent late and latent unspecified syphilis use one of the following methods: benzylpenicillin million units intramuscularly every 6 hours (4 times a day) daily for 28 days, after 2 weeks - a second course of benzylpenicillin in similar doses or one of the drugs of medium durability (benzylpenicillin or benzylpenicillin procaine) for 14 days, or benzylpenicillin procaine 1.2 million units intramuscularly once a day. daily No. 20, after 2 weeks - a second course of benzylpenicillin procaine in a similar dose No. 10, or benzylpenicillin 600 thousand units intramuscularly 2 times a day. daily for 28 days, after 2 weeks - a second course of benzylpenicillin in a similar dose for 14 days.

In the presence of allergic reactions to penicillin, reserve drugs are used: doxycycline, 0.1 g per os 2 times a day daily for 10 days - for preventive treatment, 15 days - for the treatment of primary and 30 days - for the treatment of secondary and early latent syphilis, or tetracycline, 0.5 g per os 4 times a day daily for 10 days - for preventive treatment, 15 days - for the treatment of primary and 30 days - for the treatment of secondary and early latent syphilis, or erythromycin, 0.5 g per os 4 times a day daily for 10 days - for preventive treatment, 15 days - for the treatment of primary and 30 days - for the treatment of secondary and early latent syphilis, or oxacillin or ampicillin at million IU intramuscularly 4 times a day. (every 6 hours) daily for 10 days for preventive treatment, 14 days for primary treatment and 28 days for secondary and early latent syphilis.

When treated with doxycycline and tetracycline in the summer, patients should avoid prolonged exposure to direct sunlight due to their photosensitizing side effects.

Management of sexual partners with syphilis

Sexual transmission of T. pallidum is observed only in the presence of syphilitic lesions of the mucous membranes and skin; these manifestations are rarely seen 1 year after infection. However, persons who have had sexual contact with patients with any stage of syphilis are subject to clinical and serological examination in accordance with the following recommendations:

• Persons who have had contact with a patient with primary, secondary, or latent (less than 1 year) syphilis within 90 days before the diagnosis of syphilis may be infected even if they are seronegative and should be given preventive treatment.
• Persons who have had sexual contact with a patient with primary, secondary, or latent (less than 1 year duration) syphilis more than 90 days before the diagnosis of syphilis should be treated preventively if serologic test results are not immediately available and the possibility of follow-up is not clearly established.
• For partner identification and preventive treatment, patients with syphilis of unknown duration who have high titers in nontreponemal tests (< 1:32) should be considered as having early syphilis. However, the titers of serological reactions should not be used to differentiate early latent syphilis from late latent syphilis for the purpose of determining treatment (see Treatment of latent syphilis).
• Permanent partners of patients with late syphilis are subject to clinical and serological examination for syphilis and, depending on the results, they are prescribed treatment.

The time periods before initiation of treatment during which at-risk sexual partners are identified are 3 months plus the duration of symptoms for primary syphilis, 6 months plus the duration of symptoms for secondary syphilis, and 1 year for early latent syphilis.

Prevention of syphilis

Syphilis prevention is divided into public and individual. Public prevention methods include free treatment by qualified specialists at dermatovenerologic dispensaries, active identification and involvement of sources of infection and contacts of syphilis patients in treatment, ensuring clinical and serological monitoring of patients until they are removed from the register, preventive examinations for syphilis in donors, pregnant women, all hospital patients, workers in food enterprises and children's institutions. According to epidemiological indications, so-called risk groups in a given region (prostitutes, homeless people, taxi drivers, etc.) can also be involved in the examination. Health education work plays a major role, especially in youth groups. A network of 24-hour individual prevention points for syphilis and other sexually transmitted diseases has been deployed at dermatovenerologic dispensaries. Personal (individual) prevention of syphilis is based on the exclusion of casual sexual relations and especially promiscuous sexual life, the use of condoms when necessary, and also on the implementation of a set of hygienic measures after suspicious contact both at home and at the individual prevention center. The traditional preventive complex, carried out in dispensaries, consists of immediate urination, washing the genitals and perigenital areas with warm water and laundry soap, wiping these areas with one of the disinfectant solutions (mercuric chloride 1: 1000, 0.05% solution of chlorhexidine bigluconate, cidipole), instillation of a 2-3% solution of protargol or 0.05% solution of chlorhexidine bigluconate (gibitan) into the urethra. This treatment is effective during the first 2 hours after possible infection, when the pathogens of venereal diseases are still on the surface of the skin and mucous membranes. After 6 hours of contact, it becomes useless. Currently, immediate autoprophylaxis of venereal diseases is possible in any situation using ready-made "pocket" prophylactic agents sold in pharmacies (cidipol, miramistin, gibitan, etc.).