Syphilis

Syphilis is a chronic infectious disease transmitted predominantly 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 can be aimed at eliminating the symptoms and signs of a primary infection (ulcer or chancre at the site of infection), secondary (manifestations involving a rash, mucous and skin lesions, adenopathy) or tertiary infection (disorders of the heart, nervous system, eye, auditory disorders and gummous lesions). Infection can also be detected in the latent stage using serological tests. Patients with latent (latent) syphilis who know that they are infected during the previous year are treated as patients with early latent syphilis; in all other cases late latent syphilis or syphilis with unknown duration is diagnosed. Theoretically, treatment with late latent syphilis (as well as with tertiary syphilis) should be more prolonged, as microorganisms divide more slowly; However, the reliability and significance of such a concept are not defined.

Causes of syphilis

The causative agent of the disease is pale treponema, which belongs to the genus Treponema. The pale, treponemal form is a corkscrew spiral slightly tapering toward the ends. It has from 8 to 14 uniform curls. The length of each curl is about um, 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. On both its ends and sides there are thin spiral flagella, due to which pale treponema is very mobile. There are four types of movement: translational (periodic, with different speeds - from 3 to 20 mcm / h); Rotator (rotation around its axis); bending (pendular, pendulous); contractile; (wavy, convulsive). Often, all these movements are combined. The pale spirochete is very similar to Sp. Buccalis and Sp. Dentium, which are saprophigous or conditionally pathogenic flora of the mucous membranes. Movement and form of pale treponema distinguishes it from these microorganisms. The source of infection is a person with syphilis, infection from which can occur in any period of the disease, including latent. Pale spirochete enters the body mainly through damaged skin, mucous membranes, as well as during transfusion of contaminated blood. It can be found on the surface of syphilitic elements (erosion, ulcers), in lymph nodes, cerebrospinal fluid, nerve cells, tissues of internal organs, as well as in human milk and seminal fluid. A patient with active manifestations of syphilis is contagious to others. There is a household way of transmission of infection, for example, through common objects (spoons, mugs, glasses, toothbrushes, smoking pipes, cigarettes), with kisses, bites, breast-feeding.

In the literature, cases of syphilis infection of medical personnel (especially gynecologists and surgeons) are described with careless examination of patients, pathologists from corpses of people suffering from syphilis. Syphilitic infection is characterized by different duration (from several months to several years) and wave-like flow, caused by a change in active manifestations with periods of latent state. The periodicity of the flow is associated with the infectious immunity arising in this disease, the tension of which is different in different periods of syphilis.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

Symptoms of syphilis

There are congenital and acquired syphilis. The first occurs if the pale spirochete enters the fetus through the placenta. During the acquired syphilis there are 4 periods: incubation, primary, secondary, tertiary.

The incubation period of syphilis is considered from the moment of infection of the body with pale treponema until the appearance of the first clinical symptom - a solid chancre, and usually lasts 20-40 days. However, it may be shortened to 10-15 days (with massive infection, which is manifested by multiple or bipolar chancres, and also with superinfection in the form of "consecutive chancre" or "chancre-imprints") or lengthening up to 4 months. The lengthening of the incubation period is observed in severe co-morbidities, in elderly people, after treatment with small doses of antibiotics for intercurrent diseases, in particular with simultaneous infection of gonorrhea. During this period pale treponema multiplies in the body and spreads through the lymphatic system. The blood stream treponema are carried to different organs and systems, causing various pathological processes and changing the reactivity of the organism.

The primary period begins with the appearance on the site of the introduction of pale trospotem of a solid chancre before the appearance of the first generalized rash. This period lasts an average of 6-7 weeks.

The solid chancre that emerges at the site of the pathogen injection is the only syphilide of the primary period - accompanied by regional lymphangitis and regional lymphadenitis, which at the end of the period turns into a specific polyaddipit that persists without any changes for six months. Distinguish primary seronegative (from the time of the appearance of a solid chancre to the transition of serological reactions from negative to positive) and primary seropositive (from the moment of the emergence of serological reactions positive to the appearance of a generalized rash) periods of syphilis.

The secondary period (from the first generalized rash to the appearance of tertiary syphilis - tubercles and hum) lasts 2-4 years, characterized by a wave-like course, abundance and a variety of clinical symptoms. The main manifestations of this period are spotted, papular, pustular, pigment syphilis and alopecia.

The active stage of this period is characterized by the most vivid and abundant eruptions (secondary fresh syphilis), accompanied by the remains of a solid chancre, expressed polyadenitis. The rash lasts several weeks or less - months, then spontaneously disappears. Repeated episodes of rashes (secondary recurrent syphilis) alternate with periods of complete absence of manifestations (secondary latent syphilis). Eruptions in secondary recurrent syphilis are less abundant, but larger in size. In the first half of the year they are accompanied by polyadenitis. The mucous membranes, internal organs (viscerosyphilis), the nervous system (neurosyphilis) are often involved in the process. Syphilis secondary period is very contagious, because they have a huge number of spirochetes.

The tertiary period is observed in persons who have not received or received inferior treatment. It begins more often on 3- 4 year of illness at absence of treatment lasts up to the end of a life of the patient.

Symptoms of this period are the greatest severity, lead to indelible disfigurement of appearance, disability and | often to death. Tertiary syphilis is characterized by a wavy course with alternating active manifestations in various organs and tissues (primarily in the skin, mucous membranes and bones) and prolonged latent conditions. The tertiary period syphilis is represented by tubercles and nodes (gum). They contain a small amount of pale treponem. There are tertiary active, or manifest, and tertiary latent syphilis. Clinical manifestations of viscero- and neurosyphilis are often noted.

In some patients, deviations from the classical course of syphilis are observed. This refers to the so-called "decapitated" ("mute") syphilis or "syphilis without chancre", when the pathogen immediately penetrates deep into the tissue or enters the vessel (for example, with a deep cut, with blood transfusion). In this case there is no primary period, and the disease begins after the elongated incubation period, respectively, by rashes of the secondary period of syphilis.

Innate immunity to syphilis does not exist, that is, a person can become infected again after curing (reinfection). With syphilis, there is non-sterile or infectious immunity. Superinfection is a new infection with syphilis from a person already infected with syphilis. With an additional infection, the clinical manifestations correspond to that period of syphilis, which is currently observed in the patient.

Differential diagnosis of primary syphilis is carried out with a number of erosive-ulcerative dermatoses, in particular, with a furuncle in the stage of ulceration, erosive and ulcerative balapoposthitis and vulvitis, herpes simplex, and a squamous cell epithelioma. Syphilitic roseola is differentiated from manifestations of typhus and typhoid fever and other acute infectious diseases, from toxic roseola; at allergic medicinal toxicodermia, at localization of rashes of the secondary period in the area of a throat - from an ordinary sore throat. Papular syphilis differentiate from psoriasis, red flat lichen, parapsoriasis, etc .; wide condylomas in the anus of the anus - from genital warts, hemorrhoids; pustular syphilis - from pustular skin diseases; manifestations of the Tertiary period - from tuberculosis, leprosy, skin cancer, etc.

Diagnosis of syphilis

Exudate or affected tissue examination in a dark field of vision or with direct immunofluorescence (PIF) is an accurate method for diagnosing early syphilis. Preliminary diagnosis is carried out using 2 types of tests: a) non-treponemal - VDRL (Venereal Diseases Research Laboratories) and RPR; b) treponemal (absorption of treponemal fluorescent antibodies - RIF-abs, and passive microhematagglutination reaction - RPGA). The use of tests of only one type does not give accurate results because of the possibility of obtaining false-positive responses in non-treponemal tests. The titres of non-treponemal tests usually correlate with the activity of the disease. A 4-fold change in titer, equivalent to a change of 2 dilutions (eg, 1:16 to 1: 4, or 1: 8 to 1:32) is considered. It is believed that after treatment non-treponemal tests should become negative, but in some patients they remain positive in low titers for a certain period, and sometimes throughout life. In 15-25% of patients who receive treatment during the primary stage of syphilis, serological reactions can be reversed, giving negative results in 2-3 years. Antibody titers in treponemal tests are poorly correlated with the activity of the disease and should not be used to evaluate the response to treatment.

Follow-up serological testing should be performed using the same serological reactions (eg VDRL or RPR) and in the same laboratory. VDRL and RPR are equally significant, but the quantitative results of these tests can not be compared, since the RPR titles often slightly exceed the VDRL titles.

Unusual results of serological tests (unusually high, unusually low and fluctuating titers) are usually observed in HIV-infected patients. In such patients, other tests should be used (for example, biopsy and direct microscopy). However, it has been shown that serological tests are accurate and give reliable results in diagnosing syphilis and evaluating the response to treatment in most HIV-infected patients.

You can not use only one test to diagnose all cases of neurosy-phyllis. Diagnosis of neurosyphilis in the presence or absence of clinical manifestations should be based on the results of various serological tests in combination with data on the content of cells and protein in the cerebrospinal fluid (CSF) and the results of VDRL with CSF, (RPR for CSF is not used). In the presence of active syphilis, the number of leukocytes in the CSF is usually increased (> 5 / mm ³ ); This test is also a sensitive method of assessing the effectiveness of treatment. The VDRL test is the standard serological test for CSF testing; if the reaction is detected in the absence of significant contamination of CSF with blood, it can be considered as a diagnostic test for neurosyphilis. However, VDRL with CSF can also give negative results in the presence of neurosyphilis. Some experts recommend conducting a test of RIF-abs with CSF. RIF-abs with CSF is less specific for diagnosis of neurosyphilis (that is, it gives more false-positive results) than VDRL. However, this test is highly sensitive and some reputable experts believe that a negative result of RIF-abs with CSF allows the exclusion of neurosyphilis.

[11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25]

Treatment of syphilis

Penicillin G, administered parenterally, is the drug of choice for the treatment of all stages of syphilis. Type of preparation (s) (eg, 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 the treatment of syphilis was proven with its clinical application even before the results of clinical randomized trials were obtained. Consequently, almost all recommendations for the treatment of syphilis are based on the opinion of experts and are confirmed by a series of open clinical trials and 50 years of clinical use.

Parenteral penicillin G is the only drug whose effectiveness is proven in the treatment of neurosyphilis or syphilis during pregnancy. Patients who are allergic to penicillin, including patients with neurosyphilis and pregnant women with any stage of syphilis, should be treated with penicillin, after preliminary desensitization. In some cases, skin tests for allergy to penicillin may be used (see Management of patients with a history of penicillin allergy). However, such testing is difficult due to the lack of commercial allergens.

The Yarisch-Hexheimer reaction-an acute temperature reaction accompanied by headache, muscle aches and other symptoms-can be observed during the first 24 hours of syphilis therapy; patient should be warned about the possibility of such a reaction. The Yaris-Hexheimer reaction is most often observed in patients with early syphilis. You can recommend the use of antipyretic agents; there are currently no ways to prevent this reaction. In pregnant women, the Jarish-Hexheimer reaction can provoke premature birth or cause pathological conditions in the fetus. This circumstance should not be the reason for refusing or delaying treatment.

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

Preventive treatment is provided to persons who have not had more than 2 months from the moment of contact with a sick syphilis.

For preventive treatment, one ha of the following methods is used: benzathine benzylpenicillin or bicillin 2.4 million units IM once, or bicillip-3 at 1.8 million units, or bicillin-5 at 1.5 million units per square meter p. No. 2, or benzylpenicillin for 600 thousand units per minute / day. Daily for 7 days, or benzylpenicillin procaine for 1.2 million units in / m r / day. Daily number 7.

For the treatment of patients with primary syphilis one of the following methods is used: benzathine benzylpepicillin 2.4 million units IM once a day in 7 days No. 2, or bicillin 2,4 million units IM once / 5 times number 3, or bicillin-3 for 1.8 million units or bicillin-5 for 1.5 million units per m 2 p / ped. No. 5, or benzylpenicillin procaine for 1.2 million units IM in / m 1 p / day. Daily number 10, or benzylpenicillin 600 thousand units per day / m 2 p / day. Daily for 10 days, or benzylpenicillin for million units of ED IM every 6 hours (4 r / day) daily for 10 days.

For the treatment of patients with secondary and early latent syphilis, one of the following methods is used: benzathine benzylpenicillin 2.4 million units IM once / 7 times number 3 or bicillin 2,4 million units IM once / 5 times number 6, or bicillin-3 for 1.8 million units or bicillin-5 for 1.4 million units per m 2 p / week. No. 10, or benzylpenicillin procaine, but 1.2 million units in / m day. Daily number 20, or benzylpenicillin 600 thousand units per minute / day. Daily for 20 days, or benzylpepicillin for million units of ED IM every 6 hours (4 r / day) daily for 20 days.

For the treatment of patients with tertiary latent late and latent unspecified syphilis, one of the following methods is used: benzylpenicillin, one million units ED every 6 hours (4 r / day) daily for 28 days, after 2 weeks - the second course of benzylpenicillin in similar doses or one of the medications of medium durant (benzylpenicillin or benzylpenicillin procaine) for 14 days, or benzylpenicillin procaine for 1.2 million units IM m / day. Daily number 20, after 2 weeks - the second course of benzylpenicillin procaine in a similar dose number 10, or benzylpenicillin 600 thousand units per day / m 2 p / day. Daily for 28 days, after 2 weeks - the second course of benzylpenicillin in a similar dose for 14 days.

In the presence of allergic reactions to penicillin, reserve preparations are used: doxycycline 0.1 g per os 2 r / day. Daily for 10 days - for preventive treatment, 15 days - for treatment of primary and 30 days - for treatment of secondary and early latent syphilis, or tetracycline for 0.5 g per os 4 r / day. Daily for 10 days - for preventive treatment, 15 days - for primary and 30 days - for treatment of secondary and early latent syphilis, or erythromycin for 0.5 g per os 4 r / day. Daily for 10 days - for preventive treatment, 15 days - for primary treatment and 30 days - for treatment of secondary and early latent syphilis, or oxacilin or ampicillin for 1 unit ED v / m 4 r / day. (every 6 hours) daily for 10 days - for preventive treatment, 14 days - for primary treatment and 28 days - for the treatment of secondary and early latent syphilis.

When treating doxycycline and tetracycline in the summer, patients should avoid prolonged exposure to direct sunlight because of their photosensitizing side effect.

Management of sexual partners with syphilis

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

• Persons who have had contact with a patient with a primary, secondary or latent syphilis (less than 1 year old) for 90 days preceding the detection of syphilis can be infected even if they are seronegative, so they should be given preventive treatment.
• Persons who have had sex with a patient with primary, secondary or latent syphilis (less than 1 year old) more than 90 days before syphilis is identified, should be treated proactively if the serological test results can not be obtained immediately, and the possibility The subsequent monitoring is not exactly established.
• To identify partners and carry out preventive treatment, patients with syphilis of unknown duration who show high titres in non-treponemal tests (<1:32) should be treated as patients with early syphilis. However, on the basis of the value of titers of serological reactions, early latent syphilis should not be differentiated from the late latent syphilis in order to determine the tactics of treatment (see Treating hidden syphilis).
• Constant partners of patients with late syphilis are subject to a clinical and serological examination for syphilis and, depending on its results, they are prescribed treatment.

The pre-treatment time periods during which the sexual partners exposed to risk 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

Prevention of syphilis is divided into social and individual. The methods of public prevention include free treatment of qualified specialists of dermatological-venereological dispensaries, active detection and involvement of syphilis patients with infection and contacts, the provision of clinical and serological control over patients prior to removal from the register, preventive screening for syphilis in donors, pregnant women, all inpatients, food workers and children's institutions. According to the epidemiological evidence, so-called risk groups in the region (prostitutes, homeless people, taxi drivers, etc.) can be involved in the survey. An important role is played by health education, especially in youth groups. At the dermatovenerologic dispensaries, a network of 24-hour points for individual prevention of syphilis and other sexually transmitted diseases has been deployed. Personal (individual) prophylaxis of syphilis is based on the exclusion of casual sexual intercourse and especially promiscuous sexual life, the use of condoms as necessary, and after conducting a suspicious contact of a set of hygiene measures both at home and at the point of individual prevention. The traditional preventive complex, conducted in dispensaries, consists in immediate urination. Washing of the genitals and perigenital areas with warm water and household soap, wiping these places with one of the disinfecting solutions (1: 1000, 0.05% chlorhexidine bigluconate, cidipol), instillation of a 2-3% protargol solution into the urethra or 0.05% solution of chlorhexidium bigluconate (gibitan). This treatment is effective within the first 2 hours after a possible infection, when the causative agents of venereal diseases are still on the surface of the mucocutaneous cover. After 6 hours after contact, it becomes useless. Currently, in any situation, immediate autoprophylaxis of venereal diseases is possible with the use of ready-made "pocket" prophylactic drugs sold in pharmacies (cidipol, miramistin, gibitane, etc.).