Syphilis in animals. Characteristics of syphilis. Etiology. Conditions and routes of infection with syphilis. Experimental syphilis. General course of syphilis. How does bacteria enter the body?

The descriptions of syphilis by Spanish doctors from Barcelona Skilatus and Diaz de Isla, which date back to 1493, are historically reliable. Their first patients were sailors of Christopher Columbus who returned from a trip around the world. It was found that they received their disease from the natives of the island of Haiti, where it had long been known to the local population. Soon the disease spread among the inhabitants of Barcelona, ​​and then the epidemic spread to neighboring cities and states. The campaign of the French king Charles VIII of Valois in Italy in 1494 and the subsequent siege of Naples contributed significantly to the spread of syphilis. In the army of Charles VIII there was a detachment of 300 Spanish mercenaries, among whom were patients with syphilis. After the war, Charles VIII's multi-tribal mercenaries spread the disease throughout all European countries, causing a significant pandemic in Europe and then in Asia. At first, syphilis occurred in extremely severe, malignant forms among European residents, which was facilitated by the complete lack of methods for treating it.

There is, however, another point of view, according to which syphilis was found in Europe back in ancient times. When studying skeletons excavated by archaeologists from ancient burials, bone and dental changes characteristic of congenital syphilis were sometimes discovered. G. Forberg (1924) believed, for example, that the busts of Socrates in the Vatican and Louvre museums depicted typical external signs of congenital syphilis (such as a saddle-shaped nose). This statement, of course, cannot be considered indisputable.

12. What does the word "syphilis" mean?

A detailed description of syphilis was given in the work of the famous Renaissance scientist, physician and poet Girolamo Fracastoro. The work was called "On the French Disease." The same author, in a poetic poem, outlined the love story of a shepherd named Syphilis, who was punished by the gods for disobeying them with a previously unknown disease. Fracastoro described the manifestations and course of the “French disease” in Syphilis, doing it so clearly that subsequent authors already used the name Syphilis as a common noun.

At first, syphilis had many names in different countries. In total, up to 300 names of this disease are known. So, in France this disease was called Spanish, in Italy and Poland - French, in Russia it was called Polish and French, in Japan - Chinese disease.

13. What are the first signs of syphilis?

Immediately after infection, syphilis does not detect itself. The disease seems to be gaining strength before manifesting itself openly. In the body there is a rapid proliferation of pathogens - Treponema pallidum, but there is usually no temperature or any complaints. Only three weeks after infection (the so-called incubation period), a small painless ulcer appears at the site of the introduction of Treponema pallidum, dense to the touch - a chancre. It is usually located on the genitals (if the infection is sexually transmitted), but if the infection occurs through household contact or through other contacts (for example, a kiss, a bite, infected saliva or mucus getting on the skin abrasions of a healthy person), a hard chancre can be located on the lip, in mouth, hands and other parts of the body. The lymph nodes closest to the chancre are significantly enlarged, which helps the doctor distinguish an ulcer of another origin from a syphilitic one.

Sometimes from the moment of infection to the appearance of hard chancre, not three weeks pass, but more or less. The incubation period of syphilis is shortened if it affects a person weakened by other diseases (tuberculosis, chronic pneumonia, alcoholic cirrhosis of the liver, rheumatism, etc.), poorly nourished, and with weak resistance to infections. An extension of the incubation period can be observed in cases where the patient begins to take antibiotics during this period for another reason. Usually their dose is insufficient to stop the onset of syphilis, but it delays its manifestations, makes the symptoms “erased”, unclear, and complicates the diagnosis.

Three weeks after the appearance of chancroid, the correctness of the diagnosis can be confirmed by specific blood tests of the patient. It should be remembered that with some forms of syphilis infection, for example transfusion, that is, when blood is transfused from a donor with syphilis, chancroid does not occur and there are no described signs of infection. The disease immediately manifests itself with its next stage - secondary syphilis.

14. How does syphilis occur?

Syphilis is a common chronic infectious disease that affects all organs and tissues of the human body. If left untreated, the duration of syphilis is unlimited; it can last for decades. Syphilis is extremely diverse in its clinical manifestations, depending on the predominant damage to certain organs. However, several regular periods can be distinguished during its course. First of all, this is the already mentioned incubation period without any external manifestations of the disease, lasting 3 weeks. Then - primary syphilis, its duration is 6 - 7 weeks. It is characterized by the presence of hard chancre at the site of entry of the pathogen, enlarged lymph nodes and the appearance of positive serological reactions in the blood. Only a little over two months after infection does a pronounced clinical picture of a common general disease appear - secondary fresh syphilis. The most demonstrative skin lesions are in the form of a rash, and in some patients - pigmentation and baldness. Internal organs also suffer: syphilitic tonsillitis, hepatitis, meningitis, neuritis, etc. may occur. Even in the absence of treatment, after some time the symptoms of the disease smooth out, subside, and the disease seems to “go inside.” After some time, however, a relapse of secondary syphilis occurs. Such relapses can occur repeatedly, over 2 to 4 years or more, after which syphilis enters the third stage (tertiary syphilis). This stage is characterized by foci of specific inflammation of the skin and internal organs in the form of gummas and tubercles, while the affected body tissues disintegrate with the formation of extensive ulcers and then rough scars. Some patients develop malignant forms of damage to the spinal cord and brain - tabes dorsalis and progressive paralysis. These forms of the disease are fatal if left untreated.

15. Is a patient with syphilis always contagious?

A patient with syphilis is contagious during all periods of the disease. It is especially dangerous for others in stages I and II of syphilis, which is why the latter are called highly infectious forms. The surface of the chancre contains a large number of pale treponema. Numerous rashes on the skin and mucous membranes in the secondary fresh and recurrent periods of syphilis can, when moistened and rubbed (on the genitals, in the mouth, in the folds of the skin), grow, become wet and ulcerate, releasing a huge number of pale treponemas, and pose a great epidemiological danger to everyone, who comes into contact with the patient or the objects he used (dishes, cigarettes, toilet seats, clothes, etc.). Treponema pallidum is found in the saliva, milk of a nursing mother, semen and other physiological fluids of patients.

Let us give as an example two cases of indirect transmission of syphilis.

1st case. An 81-year-old woman with an ulcer on her back came to one of the dispensaries. Much to the doctor's surprise, the ulcer bore all the typical features of chancroid. Enlarged, dense, painless lymph nodes were felt in the right armpit (on the side of the chancre). Laboratory testing revealed the causative agent of syphilis - Treponema pallidum. As a result of an epidemiological survey, an unusual method of household infection with syphilis was identified. The patient lived alone, in a separate apartment with all amenities. She didn’t go anywhere, but 1.5 months ago her son stayed with her while passing through for one day and spent the night in her bed. She did not change her underwear after her son. A request was sent to the skin and venereal disease clinic at the son’s place of residence with instructions to carry out a medical examination of him. My son turned out to have secondary fresh syphilis. Consequently, when he was visiting his mother, he had a hard chancre, the discharge from which he stained his underwear, and his mother became infected through the underwear from her son.

2nd case. A young engineer, a good family man, went to the dispensary about a skin rash. Upon examination, a chancre was found on the gum, a profuse syphilitic rash and enlarged lymph nodes. The wife has been diagnosed with primary syphilis; she contracted it from her husband. All residents of the communal apartment in which the patient lived were examined. A neighbor, a single man, was diagnosed with secondary recurrent syphilis. As it turned out, the sick engineer mistakenly used a neighbor's toothbrush, which was very similar to his own, which turned out to be enough to transmit syphilis.

16. Is the patient contagious with latent (latent) syphilis?

Contagious. However, the degree of its epidemiological danger to others is somewhat less than with acute infectious forms of syphilis. Although such a patient does not have any external manifestations of syphilis, he can transmit his disease to others through sexual contact, since the semen of a patient with latent syphilis and the vaginal secretions of women may contain Treponema pallidum. Such a patient can always have manifestations of syphilis on the mucous membrane of the mouth that are invisible to him and can transmit syphilis through saliva when kissing or using shared utensils. In addition, a patient with latent syphilis may experience a relapse of the disease with active manifestations at any time.

17. Should I tell my loved ones about being infected with syphilis?

This is decided individually in each specific case, taking into account the interests of the patient and the health of the people around him. All persons who were in contact with the sick person are examined to determine possible infection. The examination is carried out correctly, and where there is no need, neither the patient’s name nor the real reason for the examination is mentioned. Of course, the wife or husband, as well as persons who had sexual contact with the patient, should be informed about the disease. If the patient follows all the doctor’s instructions, his secret is maintained.

18. Is it possible to cure syphilis without seeing a doctor?

Treatment of syphilis requires high professional training of the doctor, knowledge of the general pathology of syphilis, and the characteristics of the course of syphilis during various periods of the disease. Treatment regimens and methods are varied. A combination of a number of drugs is used in a certain sequence and timing. The biggest mistake a patient makes is self-medication. It is dangerous in all respects: incorrectly selected drugs and their doses, irregular administration, insufficient concentration of drugs in the body, etc. - all this will result in the transfer of the pathogen into the so-called “survival forms” - L-forms and cysts , which lose any external resemblance to treponema pallidum, are surrounded by a multi-layered membrane, are persistently preserved in the patient’s tissues and are no longer amenable to the further action of commonly used medications. The external symptoms of the disease disappear, but years will pass, and syphilis will manifest itself with more severe consequences or be found in the patient’s offspring.

19. Do animals get syphilis?

Syphilis is a human disease. Although some sexually transmitted infections have been described in some animals, they do not suffer from syphilis under natural conditions. Only in experiments can monkeys, rabbits, white mice and rats be infected with syphilis. However, clinical manifestations of syphilis in white mice and rats, despite reliable infection, are virtually absent. In laboratory conditions, they are used as biological reservoirs for the preservation of certain strains of Treponema pallidum. Only in great apes the disease with syphilis occurs like in humans. But the most accessible in laboratories is the modeling of syphilis in rabbits. If a number of conditions are met, they manage to develop chancroid and manifestations of secondary syphilis. Vaccination of syphilis in animals, especially rabbits, is effectively used in scientific laboratories to develop new treatment methods and study general issues of the pathology of syphilis.

20. Syphilophobia - what is it?

Fear of contracting syphilis can also become a disease. Sometimes people who have had casual sexual intercourse and have experienced the fear of becoming infected make a diagnosis for themselves, based on random, insignificant signs. Having decided that they are sick, such people visit doctors many times, insisting on repeated examinations and courses of treatment, do not believe assurances that they do not have a disease, believe that doctors are “hiding the bitter truth from them,” or treat them inattentively. Sometimes patients with syphilophobia insist on examining family members, most often their children, and also convince them that they have “syphilis.” In all these cases, we are essentially talking about mental disorders from mild, reversible “overvalued ideas” to delusional experiences indicating the presence of psychosis. Patients with syphilophobia need consultation and help from a psychiatrist.

21. How does syphilis of parents affect the offspring?

A pregnant woman with syphilis may become infected with the developing fetus and develop congenital syphilis in the child. Infection usually occurs as a result of syphilitic damage to the placenta (baby place), often in the 4th to 5th months of pregnancy. The causative agent of syphilis, Treponema pallidum, finds favorable conditions in the tissues of the fetus for its rapid reproduction. There is significant damage to fetal tissue: lungs, liver, nervous system, spleen, bones, etc. In many cases, these damage to internal organs are so severe that they become incompatible with life, and the fetus dies in utero, followed by miscarriage or stillbirth. Many children with congenital syphilis die soon after birth. A newborn suffering from congenital syphilis often has a characteristic appearance: wrinkled, grayish skin, low weight, large belly, where a significantly enlarged liver and spleen are visible. It is typical that the more “recent” the mother’s disease is, the more often cases of intrauterine fetal death are observed, and the more severe the disorders in newborns are.

22. Can congenital syphilis be cured?

We will certainly heal. Modern treatment methods provide a complete guarantee of this. It is important to recognize the disease in time and carry out proper treatment.

23. If a child becomes infected during childbirth, passing through the mother’s birth canal, can this syphilis be considered congenital?

There are cases when a woman becomes infected with syphilis in the last trimester of pregnancy, and Treponema pallidum does not have time to infect the fetus before the infection begins to generalize. In these cases, the child enters labor healthy, but during the passage of the birth canal becomes infected from contact with the affected mucous membranes of the mother. Following this, he develops primary syphiloma after the usual incubation period, and syphilis proceeds in the same way as in persons with acquired infection. The approach to treatment and prognosis for such cases is different, more favorable than for congenital syphilis.

24. Is congenital syphilis common today in our country, what measures are being taken to prevent it?

Exceptionally rare. The USSR has organized a well-thought-out system for the prevention of congenital syphilis as one of the sections of comprehensive measures to combat sexually transmitted diseases. According to the Instructions of the USSR Ministry of Health for 1976, a double examination for syphilis is carried out: at the first visit of a pregnant woman to an obstetrician-gynecologist (usually in the first half of pregnancy) and at 5, 6, 7 months before maternity leave.

The blood must be tested according to the generally accepted set of classical serological reactions to syphilis. If necessary, to clarify the diagnosis, more labor-intensive and more informative specific reactions to syphilis are performed - the Treponema pallidum immobilization reaction (TRE) and the immunofluorescence reaction (RIF).

Pregnant women who have had syphilis in the past, who have completed treatment, but have not been removed from the register during the observation period, receive additional specific treatment during pregnancy. An additional course of anti-syphilitic treatment is also carried out during the first pregnancy of those women who previously had syphilis, but have already been removed from the register.

Congenital syphilis is registered mainly in the children of women who did not know about their illness, who went to the doctor late, and mainly in the children of women with antisocial behavior, suffering from alcoholism, indifferent to their health, to the health and fate of their unborn child, who did not apply during pregnancy to a medical institution.

25. Can a father pass syphilis to his offspring, while the mother remains healthy?

No. There cannot be hereditary syphilis, that is, syphilis transmitted through germ cells, in particular through sperm. The latter die when Treponema pallidum is introduced into them. A sick father is guilty of infecting the expectant mother, and a sick mother is guilty of infecting the child in utero. Therefore, we need to say “congenital” syphilis, and not “hereditary”.

26. Is it possible, if you have syphilis, not to know about it?

Such cases are quite possible. Syphilis can occur hidden if the initial symptoms went unnoticed by the patient, and subsequently syphilis did not show itself for some time. More often women do not know about their disease, less often - men, since in women primary syphiloma (hard chancre) can be located in the cervix. In addition, chancre may remain unrecognized both by the patient himself and by doctors of other specialties who are not sufficiently familiar with the clinical picture of syphilis. A chancre on the tonsils is mistaken for a sore throat, in the area of ​​the nail phalanx - for a panaritium, in the area of ​​the anus - for a fissure, etc.

Syphilis often becomes latent when the dose of antibiotics taken during the incubation period (usually for another reason) turns out to be insufficient to prevent it, but makes the classic symptoms of the initial stages of syphilis “erased” and less noticeable.

Unknown syphilis is usually discovered during an active examination of contacts of other patients, during a blood test for the Wasserman reaction as a general clinical examination, or during a relapse of syphilis based on manifestations on the skin, bones, and internal organs.

Manifestations of secondary syphilis, as a rule, do not give subjective sensations; the rash is usually faded, without itching or pain, and may temporarily disappear on its own, without any treatment. All this is the reason that the patient does not consult a doctor in a timely manner, is unaware of his illness and can infect others.

Let us give the following illustrative example.

An excited young woman came to an evening appointment with a doctor at a skin and venereal disease clinic with a request to examine her. The patient, getting ready for the theater, took a shower and put on a sleeveless dress. A friend who was present drew attention to some kind of rash on the patient’s skin, which the latter had not noticed before. During a medical examination, in addition to a skin rash, a hard chancre was discovered in the cervical area. The diagnosis of syphilis was confirmed by laboratory tests. As it turned out, 2.5 months before the events described, the patient was in a rest home and had a casual relationship with an unfamiliar man. Thus, before the appearance of symptoms of secondary fresh syphilis, the patient did not suspect anything about the disease she had. After taking a shower, the rash became brighter and more noticeable.

27. Is it possible to get infected with syphilis and gonorrhea at the same time?

Simultaneous infection with these two sexually transmitted diseases is not uncommon. Due to the fact that each of them has its own clinical course, they appear at different times after infection. Gonorrhea reveals itself after 3 - 5 days, and the incubation period for syphilis is 21 - 28 days. Every patient with gonorrhea, in cases where the source of infection has not been identified, must be under the supervision of a doctor for six months. This is done because the antibiotics used in the treatment of gonorrhea also act on Treponema pallidum, the causative agent of syphilis, with the only difference that their total dose in the treatment of gonorrhea is insufficient to prevent syphilis, just as the method of their administration is unsatisfactory for this purpose (for syphilis, the concentration of the drug in the blood must be constantly high, and therefore injections are made every three hours, and for gonorrhea - 1-2 times a day). However, even in insufficient doses, antibiotics can delay the manifestations of syphilis and lengthen the incubation period to 4 months or more, which determines the need for physician supervision of this category of patients. During this period, repeated examinations of patients and serological blood tests for syphilis are carried out.

28. What does the “subscription” that is taken from venereal patients oblige you to?

The subscription is a legal document that sets out the existing legislation regarding criminal liability for contracting a sexually transmitted disease under Art. 115 of the Criminal Code of the RSFSR with amendments and additions made to the article by the Decree of the Presidium of the Supreme Soviet of the USSR of October 1, 1971 “On strengthening responsibility for the spread of sexually transmitted diseases.” The subscription states that the patient is informed of the presence of a contagious venereal disease, of the need for treatment and observation by a doctor until removal from the dispensary register, compliance with the prescribed regimen and the need to abstain from sexual activity until complete recovery. The patient gives his signature, and the subscription is subsequently stored in the medical history.

29. How is syphilis treated?

Currently, doctors have a whole arsenal of highly effective medications at their disposal to treat syphilis, ensuring a complete cure of syphilis. Taking into account the full responsibility of treating such a serious disease, the consequences of poorly treated syphilis, the ability of pallid treponema (according to the latest scientific data) with insufficient doses of drugs to turn into “survival forms” - L-forms and cysts, “protected” from adverse effects by multilayer membranes with a special structure , treatment of syphilis in our country is carried out only in strict accordance with the “Instructions for the treatment and prevention of syphilis”. In this regard, syphilis is the only infection where the choice of drugs, their doses, sequence of administration and timing of treatment must be carried out without any deviations from the instructions. That is why in the USSR the treatment of syphilis by private practitioners is strictly prohibited and prosecuted by law.

The “Instructions” are periodically updated taking into account the latest scientific data and the results of clinical testing of treatment regimens and new drugs, summarizing the accumulated experience and analyzing the results of the work of all scientific and practical institutions in the country. The latest “Instructions” of 1976 were compiled by a team of authors from the Central Research Dermatovenerological Institute of the USSR Ministry of Health. 7 research institutes, departments of skin and venereal diseases of the country's largest medical universities and some large skin and venereal disease dispensaries took part in its development.

Penicillin and bismuth preparations are mainly used to treat syphilis. Iodine preparations, vitamins, drugs that have a stimulating effect (pyrogenal, prodigiosan, aloe), autohemotherapy, sulfur preparations and others are used as auxiliary agents.

All patients newly diagnosed with syphilis and suffering from contagious forms of syphilis are subject to mandatory inpatient treatment. This is done in the interests of society (isolation of an infectious patient) and in the interests of the patient himself, since it is important to administer medications at a certain time (for example, penicillin is administered every 3 hours around the clock).

Treatment of syphilis begins and is carried out only if an accurately established diagnosis is confirmed by clinical and laboratory data (detection of treponema pallidum, positive serological reactions).

30. What is the duration of treatment for syphilis?

The duration of treatment for syphilis depends on a number of circumstances: the clinical form of syphilis, the age of the patient, his general condition, the presence of concomitant diseases, drug tolerance, the dynamics of the disease and the rate of negativity of serological reactions during treatment. On average, treatment with penicillin antibiotics for primary syphilis with a negative Wasserman reaction lasts from 40 to 68 days, with a positive reaction - from 76 to 125 days, for secondary fresh syphilis - from 100 to 157 days. In all other cases - with secondary recurrent syphilis, with tertiary and congenital - only a course of treatment with various drugs is carried out. The course duration for combined treatment is on average from 40 to 60 days, with a break of 1 month. The number of courses depends on the form of syphilis, ranging from 2 to 8 courses.

31. What is preventive treatment and who is it prescribed for?

This is a preventative treatment. It is prescribed to persons who had contact (sexual or domestic) with a patient with syphilis when there was a possibility of infection. Drugs, timing and doses of treatment are prescribed depending on the duration of contact. If no more than two weeks have passed since possible infection, one course of treatment with penicillin or ecmonovocillin is prescribed. For a longer period (from 2 to 4 months), treatment is carried out as for primary syphilis with a negative Wasserman reaction (primary seronegative syphilis).

Of particular importance is the so-called preventive treatment of pregnant women who previously had syphilis and completed treatment before pregnancy. Treatment is prescribed to them in order to maximum guarantee the birth of a healthy child. Preventive treatment is also carried out for children born to mothers who previously had syphilis, even if these children are practically healthy, with negative serological reactions to syphilis.

32. Is syphilis completely curable?

Modern treatment methods make it possible to guarantee a complete cure of syphilis, which is proven by extensive experience in clinical observations, experimental studies, and the birth of healthy children from mothers who previously had syphilis and completed treatment by the beginning of pregnancy. Convincing evidence of the curability of syphilis is re-infection with it, accompanied by manifestations of primary syphilis. Decisive and determining the outcome and prognosis of syphilis is the timely initiation of treatment and its implementation in full accordance with current instructions and taking into account the individual characteristics of the patient.

33. Is it possible to get re-infected with syphilis?

Syphilis after treatment does not leave immunity, that is, immunity to re-infection. A person who has had syphilis and was successfully treated can become ill with syphilis again. There are known cases of not only double, but also triple and even quadruple syphilis. Repeated infection is called reinfection. Each time during reinfection, the disease begins and proceeds in the same way as during the first infection: with a chancre, in the absence of treatment - with subsequent generalization of the infection, enlarged lymph nodes, baldness and other common manifestations of syphilis. Immunological changes are also consistently increasing, which are revealed by changing periods of syphilis, the appearance of a positive Wasserman reaction and other serological reactions. Reinfection indicates complete cure of syphilis from a previous infection.

34. Are there any features of the course of syphilis during re-infection?

Upon careful study and analysis of cases of re-infection with syphilis, it was found that most often people with antisocial behavior, abusing alcohol, and leading a promiscuous sex life are re-infected. In such people, even with primary infection, a more unfavorable course of the disease is observed. However, when comparing equal populations of people with primary and repeated infection, it was found that with repeated infection, syphilis is more severe: ulcerative and multiple chancre, purulent (pustular, with tissue decay) rashes are more often observed, the positive Wasserman reaction is more persistent, and a longer period is often required treatments, additional courses of therapy, restoratives and stimulants. Simultaneous anti-alcohol treatment in persons suffering from chronic alcoholism is of great importance.

35. If a person is sick with latent syphilis and has had contact with a patient with a contagious form of syphilis, will he become infected again?

In such a situation, there will not be a re-infection, but a layering of infection or a so-called superinfection. At the same time, as experimental and clinical studies show, no reaction develops at the site of penetration of treponemes or an element of rash appears that corresponds to the clinical picture of the stage of syphilis that the patient has: for example, with secondary syphilis - a papule (nodule), with tertiary syphilis - a tubercle with ending in the rumen. Hard chancre, which develops as a response to Treponema pallidum in a previously healthy person, usually does not occur during superinfection.

36. Is it possible to become infected with syphilis through a blood transfusion?

This possibility cannot be excluded if the donor had syphilis in the incubation period at the time of donating blood, but he did not know about it. When examining such a donor, there were no clinical manifestations of syphilis, serological reactions to syphilis were negative and there was no reason to suspect infection. In order to prevent such cases, appropriate sanitary and educational work is carried out with donors. Before donating blood, all donors are examined by a doctor, and the blood taken from them is examined using a complex of classical serological reactions for syphilis. In turn, each patient is necessarily asked whether he has donated blood, and a corresponding entry is made in the medical history.

37. Can a person who has had syphilis be a donor?

38. What measures are taken if a person receives a blood transfusion from a person with syphilis?

First of all, if it is established that a donor donated blood and later turns out to have syphilis, the blood taken is destroyed. If the patient’s blood has already been used, it is immediately established when and to whom it was transfused. All persons who have received infected blood are given preventive treatment.

39. Is disinfection carried out in the house of a patient with syphilis?

The causative agent of syphilis - treponema pallidum (spirochete) - quickly dies outside the human body, especially when dried out, exposed to disinfectants and even hot water and soap. Therefore, special disinfection is not required in the patient’s home. It is recommended to boil underwear and bed linen, washcloths and towels with the addition of washing powders. Of course, you need to treat the bathtub, toilet, sink used by the patient with a disinfectant solution (for example, chloramine), and then wash them with hot water.

40. How does syphilis occur in patients who abuse alcohol?

Systematic alcohol abuse significantly reduces the body's resistance to many infections, including syphilis. In chronic alcoholics, syphilis, as a rule, is more severe, often malignant. The so-called galloping course of syphilis is often noted. The incubation period may be shortened, generalization of the syphilitic infection occurs unusually early (after 4 weeks), and specific signs of the disease such as swollen lymph nodes and a positive Wasserman reaction are often absent, which makes diagnosis difficult. Manifestations of secondary syphilis are more polymorphic; pustular (purulent) rashes are often found, which are similar to pustular skin diseases - acne, boils, purulent ulcers.

In chronic alcoholics suffering from syphilis, syphilitic alopecia and pigmentary syphilide in the neck area are more common, tertiary gummous manifestations and severe damage to the nervous system occur early - meningitis, tabes dorsalis, progressive paralysis, liver damage develops, resulting in cirrhosis.

The famous French syphilidologist Fournier pointed out that syphilis preferentially affects organs that have a pathological past. Such an organ in patients suffering from chronic alcoholism is the liver. Double harm - alcoholic and syphilitic poisons - has a detrimental effect on the vascular wall and nervous tissue, determining an unfavorable prognosis of the disease. To illustrate, one clinical observation can be cited.

A young man who fell ill with syphilis in the North received one course of treatment and told the doctor that he had decided to return to his parents, informing the city and address where he was leaving. The patient was given a referral for further treatment and a notice was sent to the dermatovenerological dispensary of the city indicated by the patient. But the patient, having received a large sum of money during the settlement, decided to “take a walk” first before going to his parents. For six months he did not work, drank a lot, which he was prone to before. After being beaten in a drunken brawl, a thick knot appeared on his neck, which turned into an ulcer. Over time, the ulcer not only did not heal, but continued to spread, covering almost half of the neck, although the pain was of little concern. 2 months after the appearance of the ulcer, the patient was hospitalized and upon examination he was diagnosed with gummous syphilis. By this time, only 10 months had passed since the infection. Under the influence of specific treatment, the ulcer quickly healed, but an extensive scar remained, causing torticollis, which is why plastic surgery was performed at the end of treatment for syphilis.

Long before the discovery of Treponema pallidum, scientists made attempts to infect animals with syphilis. Now it is difficult to establish who was the first to do this, since the animal clinic was not supported by the discovery of the pathogen.

I.I. Mechnikov and Roux successfully inoculated two chimpanzees with syphilis in 1903. The first experiments on infecting a rabbit in the eye are attributed to Jense (1881); Bertarelli (1906) infected a rabbit with syphilis by rubbing it into a scratch on the cornea of ​​the eye. In 1907, Parodi first infected a rabbit by injecting material from a syphilitic papule under the tunica vaginalis.
Currently, the rabbit is the main animal for experiments to obtain experimental syphilis. Animals are infected with a suspension of pale treponema, extracted from syphilitic manifestations, by introducing intratesticularly (early orchitis), intradermally on the scrotum (receiving chancre), on the side into the shaved surface of the skin, by rubbing into the scarified surface of the skin or intradermally, into the anterior chamber of the eye, suboccipitally, into the brain.

After an incubation period (2-3 weeks), a small compaction appears at the site of administration of Treponema pallidum, gradually increasing in size and acquiring a cartilaginous consistency. Necrosis and chancre, covered with a small bloody crust, form in its center. A huge amount of treponema is found in the chancre contents. There are no inflammatory phenomena along the periphery of the chancre. After about 3-4 weeks, the chancre softens and the number of treponemas decreases. Serological reactions become positive, their titer gradually increases.

Simultaneously with the chancre, regional lymph nodes up to the size of a pea are palpated in the rabbit. 2.5-3 months after the formation of a chancre, the animal may experience secondary manifestations (papular, papulocortal, rupee-shaped rashes), in the contents of which pale treponema is found. Roseolas do not appear. The percentage of occurrence of secondary manifestations in rabbits varies. Most often, secondary manifestations are localized in the skin of the scrotum, limbs, roots of the ears, and superciliary arches. The secondary period of syphilis in rabbits is characterized by baldness. The development of parenchymal keratitis is also observed, the number of which varies depending on the time of year.

The manifestation of the tertiary period of syphilis is very rare. There is no convincing evidence of damage to the nervous system yet. Involvement of the internal organs of rabbits in the pathological process is observed: aortitis, liver changes, etc. (L. S. Zenin, 1929; S. L. Gogaishis, 1935). There are isolated reports in the literature (P.S. Grigoriev, K.G. Yarysheva, 1928) about successful experiences of obtaining congenital syphilis from them. Sometimes, when infected with treponema pallidum, rabbits do not develop any signs of illness or there are no clinical manifestations if the pathogen is present in the lymph nodes or internal organs (such rabbits are called nullers - they have infectious immunity to syphilis).
The therapeutic effectiveness of drugs is being studied using an experimental model of syphilis.

In recent years, reports have appeared that after immunizing rabbits with treponemal vaccines, it was possible to obtain protection from subsequent infection of these animals with a suspension of pathogenic treponema pallidum. However, these results were not confirmed by N. M. Ovchinnikov et al.

Treponema pallidum enters the human body through damaged skin or mucous membranes. Entrance gates can be so small that they go unnoticed. A person with syphilis is contagious to others, especially with active manifestations of the infection. Treponema pallidums can come to the surface with serous fluid from the depths of the tissues due to friction (during walking), friction (during sexual intercourse), irritation (mechanical or chemical), as well as from the oral cavity if syphilitic papules are found there.

Currently, sexual contact should be recognized as the main route of infection with syphilis. Cases of household infection (through dishes, cigarettes, pipes, etc.) are rare. Extrasexual infection is possible if there are eroded syphilitic elements in the patient’s mouth. Much less often, the discharge of syphilitic elements ends up on household items, which become intermediaries

nothing in the transmission of infection (in a humid environment, treponemes remain viable for a long time outside the human body). Health care workers can become infected when examining a patient with syphilis or during medical procedures. Such cases were observed among midwives, surgeons, obstetricians-gynecologists, dentists, venereologists, and laboratory workers who conducted research on Treponema pallidum. To avoid such infection, you need to work with gloves, monitor the integrity of the skin of your hands, and after examining the patient (especially with the contagious stage of syphilis), remove your gloves, wipe your hands with a disinfectant solution and wash them with soap.

Cases of infection with syphilis through direct blood transfusion from a donor with syphilis are very rare. It is believed that the patient’s saliva is contagious only if the patient has syphilitic elements in the oral cavity. It has been suggested that human milk is contagious, even if there are no visible syphilitic changes in the nipple area. The question of the infectiousness of sperm is also interpreted in the absence of manifestations of the disease on the genitals of a patient with active syphilis. At the same time, it is believed that the urine and sweat of patients with syphilis are not contagious. Transmission of infection from a sick mother to the fetus through the placenta is possible. As a result, congenital syphilis may develop.

For the development of syphilis, the amount of the pathogen introduced into the body of the experimental animal is also important. Apparently, this happens in a similar way in humans. For persons who have repeatedly had sexual contact with a patient with an active form of syphilis, the possibility of infection is much greater than for those who have had single and short-term sexual contact. In the blood serum of healthy people there are factors that immobilize Treponema pallidum. Along with other factors, they help explain why infection does not always occur upon contact with a sick person. Domestic syphilidologist M.V. Milich, based on his own data and analysis of the literature, believed that infection may not occur in 49-57% of cases.

Pathogenesis. The main routes of spread of Treponema pallidum in the body are the lymphatic and circulatory systems. Pathohistological studies have shown that in the first days after infection, Treponema pallidum fills the lymphatic gaps and perivascular lymphatic spaces. Only after this they are found in the lumens of small blood vessels and their walls. Explanation

This tropism of treponema pallidum, which is a facultative anaerobe, is seen in the significantly lower oxygen content in the lymph compared to arterial and venous blood. Treponema pallidums that have entered the body intensively multiply and spread in the lymph, where the oxygen content does not exceed 0.1%, while in venous blood it is 100 times higher, and in arterial blood it is 200 times higher (8-12 and 20%, respectively) .

Along with moving through the lymphatic system, treponemes are carried through the bloodstream to all organs and tissues. This is confirmed by known cases of infection of recipients with the blood of donors in the incubation period of the disease.

During primary and in the first months of secondary syphilis, the spiral form of treponema pallidum predominates, and later it transforms into L-forms and cysts, which serves as a pathogenetic justification for the change from manifest periods of syphilis to latent ones. The phenomenon of seroresistance - the preservation of positive serological reactions after full treatment - is associated with the long-term presence of altered forms of treponema pallidum in the patient's body. Cysts that are not affected by penicillin have antigenic activity, so serological reactions remain positive as long as altered forms of treponema pallidum remain in the body.

The ability of cysts and L-forms to transform back into a virulent spiral form plays an important role in the pathogenesis of clinical and serological relapses of the disease after full treatment. In some patients, after the disappearance of clinical signs of syphilis and negativism of serological reactions, after a few months they suddenly become positive, and in some cases clinical signs of infection reappear. Additional specific (antibiotics) and nonspecific (pyrogenal, vitamins) therapy does not always give the desired results. Only after several months can the titer of serological reactions decrease spontaneously and without additional treatment. Positive serological tests in any case require specific treatment.

The immune system is activated by the interaction of Treponema pallidum with antigen-presenting cells: monocytic cells and Langerhans cells. Having captured the antigen, Langerhans cells enter the mature stage, lose their processes and migrate to the lymph nodes and spleen, where they influence subpopulations

T- and B-lymphocytes enhance the presentation of CD4 antigens, keratinocytes and inflammatory infiltrate cells. In this case, suppression of the cellular component of immunity is observed.

Immunity. Superinfection. Reinfection. With a syphilitic infection, non-sterile (infectious) immunity is formed, which persists until the treponemas disappear. Infection occurs in people with insufficiency of humoral and cellular immunity factors, low levels of treponemostatic and treponemocidal substances in the blood serum. According to the WHO classification, syphilis is a disease with immune deficiency. Cellular immunosuppression was established in the early stages of infection, a decrease in the number of T-lymphocytes in the peripheral blood and T-dependent zones of lymphoid organs.

During the incubation period of syphilis, Treponema pallidum quickly spreads through the lymphogenous route. The body's response in the form of primary syphiloma and regional scleradenitis is delayed. At the end of the primary and beginning of the secondary period of syphilis, a massive proliferation of treponemes occurs and their spread throughout the body (treponemal sepsis). This causes the development of general symptoms of the disease (fever, weakness, malaise, pain in bones and joints, polyadenitis). As a result of the mobilization of immunobiological protective mechanisms, most of the treponemes die and the latent period of secondary syphilis begins.

As the protective processes of the macroorganism weaken, treponemes multiply and cause relapse (secondary recurrent syphilis). After this, the defenses are mobilized again, and in the absence of treatment, treponema pallidum (possibly cyst forms) contribute to the persistence of the syphilitic infection. The undulating course of infection in the secondary period reflects the complex relationship between the micro- and macroorganism.

In the secondary period, factors that suppress the proliferative function of lymphocytes are activated, the phagocytic activity of neutrophils decreases, and their ability to form phagosomes increases. The synthesis of antibodies is activated, the concentration of serum immunoglobulins G, A and M increases. It is believed that at the beginning of syphilis the level of serum IgG and IgM is higher, and in later forms only IgG remains. The antigen-antibody reaction, specific for syphilis, supports the wave-like, staged course of the disease, especially pronounced in the primary and secondary periods.

In the tertiary period of syphilis, when only a small amount of pale treponema remains in the tissues, high sensitization to treponemes and their toxins is manifested by a peculiar anaphylactic reaction with necrosis and subsequent scarring. Since after treatment not only the manifestations of syphilis regress, but also the humoral-cellular factors of immune defense, a new infection is possible with repeated contact.

Repeated infection is called reinfection. To diagnose reinfection, a different location of the chancre than during the first infection, the presence of pale treponema and the appearance of regional scleradenitis are necessary. The reliability of reinfection is confirmed by sufficient treatment of the first infection and negative serological reactions after treatment. The existence of a syphilitic infection through sexual contact is taken into account. Reinfection is distinguished from superinfection - re-infection of an uncured patient. In this case, it is as if a new portion of Treponema pallidum is added to the existing ones, therefore, at different periods of the disease, superinfection manifests itself in different ways. Thus, during the incubation period and in the first 10-14 days of the primary period of syphilis, when infectious immunity has not yet formed, additional infection is manifested by the development of a new chancre. This chancre is smaller in size and occurs after a shortened incubation period (up to 10-15 days). Such chancres are called sequential (ulcera indurata seccentu-aria). In other stages of superinfection, the body responds to a new infection with rashes corresponding to the stage in which it was at the time of the arrival of the new “portion” of treponemes. So, in the secondary period, a papule or pustule appears at the site of infection, in the tertiary period - a tubercle or gumma.

Classification of syphilis

The body's reaction to the introduction and reproduction of Treponema pallidum is manifested by a change in active, clinically pronounced periods of the disease and periods without manifestations on the skin and visible mucous membranes (the so-called hidden, latent periods). The French syphilidologist Ricor drew attention to the natural change of periods during the “classical” course of syphilis. During syphilis, incubation, primary, secondary and tertiary periods are distinguished.

In our country there is a unified classification of syphilis. It is based on the stage of the disease at which the patient first sought medical help.

Below is the division of syphilis according to the International Classification of Diseases, 10th revision. The ICD is based on the etiology, anatomical localization, circumstances of the onset of the disease with a diagnostic description of local manifestations, complications, and main disease processes. To obtain reliable statistical data, their centralized processing, especially with the help of computers, analysis of the epidemiological situation, and adequate assessment of the effectiveness of treatment methods, it seems advisable to use a single terminology.

Since 1999, the ICD has replaced all other classifications of diseases in Russia.

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 during 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 that are dangerous to 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.

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Etiology

The causative agent of syphilis, Treponema pallidum, was discovered by Schaudinn and Hoffman in 1905. They found it in morphological elements of the skin rash and lymph nodes in patients with syphilis. In 1912, Noguchi and Moore identified it in the cerebral cortex of patients with progressive paralysis.

T. pallidum is a prokaryotic microorganism: it lacks a nuclear membrane, its DNA is not divided into chromosomes, it reproduces by transverse fission, and its cell wall contains murein macromolecules.

T. pallidum belongs to the order Spirochaetalis, family Spirochaetaecae, as well as Borrelia and Leptospira, genus Treponema, species Treponema pallidum. The name “pale” treponema received due to its weak ability to perceive color. Microorganisms of the genus Treponema are found in humans and animals and can be pathogenic or saprophytic. Pathogenic for humans include T. pallidum (the causative agent of venereal and non-venereal syphilis); T. carateum, T. bojel, T. pertenue (pathogen of pint, yaws and bejel); pathogenic for animals are T. cuniculi, which causes syphilis in rabbits under natural conditions, and T. Friborg-Blanc, the causative agent of syphilis in monkeys.

Saprophytic for humans or animals include T. microdentium and T. macrodentium (in the oral cavity near the edges of the gums and in feces in the human anus); T. denticola (in the oral cavity of humans and chimpanzees); T. refringens (normal microflora of female and male genital organs); T. orale (in the folds of human gums); T. Scoliodentium and T. Vincentii (in the human oral cavity). Saprophytic strains of Treponema grow on artificial nutrient media and have antigenic differences from pathogenic microorganisms.

In the human body, Treponema pallidum exists in various forms. The contagious stages of the disease are characterized by a spiral shape; in the late and latent stages of syphilis, encysted and L-forms of Treponema pallidum appear, resistant to the effects of unfavorable environmental factors (antibodies, drugs, temperature effects, radiation, etc.).

These forms of treponema pallidum are the main way of maintaining and propagating the infection under unfavorable conditions and are important for understanding the pathogenesis of latent forms of syphilis, the occurrence of relapses and treatment failures.

Hoffman, in his monograph “Die Aetiologie der Syphilis” (1906), gives the following classic description of Treponema pallidum: “In the living state, it appears as a delicate, weakly refracting spiral-shaped formation. Its thickness barely reaches 1 micron, while its length varies within fairly wide limits - from 6 to 20 or more microns. It consists of numerous, on average 8-12 curls, characterized by uniformity, narrowness and steepness. The height of the curls towards the ends of the treponema decreases somewhat, and the distance between them increases.” There are very short specimens of the microorganism (one turn) and very long ones (especially in cultures), having up to 20 turns or more.

Hoffman notes another important feature of Treponema pallidum - its elasticity, the ability to stubbornly maintain its shape of a regular spiral. Even treponema pallidum, caught between the red blood cells and the cover glass, does not straighten out, despite the pressure it experiences.

The above morphological features of treponema pallidum and its very characteristic movements have important differential diagnostic significance. In a living state, under dark-field microscopy, the movements of treponema pallidum are characterized by smoothness, elegance and elegance, which significantly distinguishes it from other treponema (treponema pallidum moves with a “sense of dignity”).

There are four main types of movement of Treponema pallidum: flexion, rotatory (screwing, rotating around the longitudinal axis), translational and contractile (wavy). The flexion (swinging, pendulum-like) movement consists in the ability of Treponema pallidum to bend its body to the sides like a pendulum. A type of flexion movement is a whip-like (scourge-like) movement, which is observed when the treponema attaches to any cell (lymphocyte, erythrocyte, etc.). In these cases, the treponema produces energetic movements, reminiscent of the blow of a whip or whip, as if trying to free itself from the cell attached to it. The forward movement is characterized by either slower or faster movement of the treponema in one direction with periods of some retreat back. Rotatory movement is caused by rotation of the treponema around its axis. Contractile movement manifests itself in the form of wave-like convulsive contractions running throughout the body of the treponema. It is generally accepted that the structure of treponema pallidum is based on an axial filament and a layer of protoplasm enclosed in a shell - a trypsin-resistant periplast.

The electron microscopic structure of Treponema pallidum is complex. Spiral Treponema pallidum has the following morphological components: a protoplasmic cylinder, including a nucleotide, cytoplasm and ribosomes, a cytoplasmic membrane; mesosomes. Fibrils pass along the length of the protoplasmic cylinder, attached to the terminal turns with the help of blepharoplasts; Outside the fibrillar bundles there is a cell wall, which includes a three-layer membrane and a peripherally located capsule-like substance [Delectorsky V.V., 1996]. Each subsequent turn of treponema pallidum repeats the structure of the main morphological structures (fibrils, membranes, segments of the protoplasmic cylinder) of the previous turn. It is this feature that ensures the reproduction of similar spiral-shaped specimens during transverse division.

In infectious forms of syphilis, characterized by intensive reproduction of treponemes, a special morphological type of pathogen is isolated, which is considered as a form of “aggression” [Delectorsky V.V., 1996].

Treponema pallidums have a complex antigenic composition (protein, polysaccharide and lipid components), and the main part of the antigens is localized in the cell wall.

Treponemas usually reproduce by transverse division. In these cases, they increase, at the site of future division they narrow, their shell stretches and breaks into several parts with a different number of curls, at the sites of division bridges and blepharo-layers are visible on both sides; newly formed fibrils and old fibrils; Mesosomes are located at the edges of the division site. Treponema pallidum can be divided not only in half, but also into many parts. Divided cells may remain closely adjacent to each other for some time. It is also believed that in addition to transverse division, treponema is capable of more complex developmental cycles, in particular, sexual reproduction.

Treponema pallidum reproduces relatively slowly: its division time is 30–33 hours (most other microorganisms reproduce every 20–40 minutes). Very short (one curl) specimens are able to pass through bacterial filters with a pore size of 0.22 microns (the pore size of filters used for sterilizing filtration of liquids).

Under unfavorable living conditions, treponema can form “survival forms” - cysts and L-forms.

Encysted treponema pallidums (cysts) have a protective shell (several layers of outer membrane coating and a capsule-like mucopolysaccharide substance) that ensures the resistance of the pathogen to adverse environmental influences. A feature of cysts is their ability to retain antigenic properties, which is revealed by positive serological reactions. The number of encysted forms of Treponema pallidum increases sharply with the duration of the disease, reaching a maximum in secondary recurrent syphilis. The presence of these cysts in the body of patients apparently explains the long-term persistence of positive serological blood reactions many years after early forms of syphilis, as well as the long asymptomatic course of syphilis when there are no early active forms of the disease, which are diagnosed by chance on the basis of positive serological reactions in blood or in the stage of damage to the nervous system and internal organs.

The second form of preservation of Treponema pallidum in the patient’s body is L-transformation of the microbial cell (L-form). This transformation is a general biological pattern inherent in all infectious diseases, especially chronic ones. The L-form of Treponema pallidum is characterized by partial or complete loss of the cell wall, decreased metabolism, and disruption of cell division processes with intense DNA synthesis. The most typical morphological variant of the L-forms of pale treponema is a large spiral shape, with a diameter of 0.5 to 2 μm or more. L-forms have a high reproductive capacity and retain the ability to revert into the usual spiral-shaped pallidum treponema. It has been established that the L-forms of Treponema pallidum are extremely resistant to external adverse influences, for example, to the effects of penicillin, their resistance to which increases tens and hundreds of thousands of times. L-forms of Treponema pallidum do not have antigenic properties or they are very weakly expressed, and therefore classical serological reactions do not develop in patients. The diagnosis of syphilis in these cases can be established on the basis of positive immobilization reactions of Treponema pallidum (TRI) or immunofluorescence (RIF), which, unfortunately, also occurs in the later stages of the disease, sometimes on the basis of severe damage to the nervous system and internal organs.

Treponema pallidums do not grow from the patient’s body on artificial nutrient media.

Treponema pallidum is not very resistant to various external influences. The optimal temperature for their existence is 37°C. At 40–42°C outside the human body they die within 3–6 hours, and at 55°C – within 15 minutes. In whole blood or serum at 4°C, microorganisms remain viable for at least 24 hours, which is important for blood transfusions. Treponema pallidum is resistant to low temperatures. Lowering the temperature within -7°C does not have much effect on the viability of the syphilis pathogen; when frozen at – 18°C, it does not lose its infectiousness for rabbits throughout the year.

In the tissues of a corpse, especially when kept in the cold, Treponema pallidum remains viable for 2–3 days or longer. They quickly die when dried. Outside the human body (in biological substrates, on household items), Treponema pallidum remains infectious until it dries. She is very sensitive to chemicals. Various antiseptic materials have a detrimental effect on the causative agent of syphilis. In 40% ethanol, mobility is maintained for 30–40 minutes; in 50–60% ethanol, treponemes lose mobility immediately. Acids and alkalis quickly kill treponema. In a 0.5% solution of caustic alkali, they immediately lose mobility and become deformed; in soap suds they also quickly lose mobility. In diluted acetic acid, treponemes die within a few minutes, and in a 0.5% solution of hydrochloric acid they instantly lose mobility. Treponemas quickly die in foods containing acids (port wine, lemonade, sour milk, kvass, vinegar). They instantly lose mobility and die in the presence of arsenic, mercury and bismuth compounds. The bactericidal activity of these substances increases with increasing body temperature. Penicillins also have treponemocidal activity even in low concentrations. However, Treponema pallidums die very slowly, which is explained by the slow reproduction of these bacteria and their low metabolic activity.

In order of decreasing treponemocidal activity, antibiotics are arranged in the following order: benzylpenicillin, magnamycin, erythromycin, terramycin, aureomycin, chlormycetin, streptomycin. Resistance to the most effective antibiotic benzylpenicillin in Treponema pallidum, compared to other microbes, develops much weaker and slower, which has allowed some authors to deny the acquired resistance of Treponema pallidum to this antibiotic.

Of practical interest are data on the infectivity of Treponema pallidum found in preserved blood. It has been established that 5-day preservation is sufficient to inactivate the pathogen.

Pathogenesis

The course of syphilis, like any other infectious disease, is primarily determined by the properties and interaction of the microorganism (treponema pallidum) and the macroorganism (human), occurring under certain environmental conditions. The main role in the clinical course of syphilis is played by the state of the macroorganism, and factors that weaken or enhance the body’s resistance can accordingly strengthen or weaken the pathogenic effect of treponema pallidum, and sometimes successfully protect a person from infection with syphilis. Factors that weaken the body's reactivity and adversely affect the course of syphilis include early childhood or old age, difficult working and living conditions, physical and mental fatigue, nutritional deficiencies, various acute and chronic infections, intoxication (especially alcoholism, drug addiction), and trauma. The successful resistance of the human body to syphilis infection is facilitated by the physiological protective properties of the skin, especially the impermeability of the intact stratum corneum of the epidermis in relation to Treponema pallidum; the presence of thermolabile treponemostatic and treponemocidal substances in the blood serum of some healthy people, as well as, possibly, genetically determined immunity of individuals to infection. The human body, which is the environment for Treponema pallidums that have entered it, actively influences their virulence, which leads to the emergence of special avirulent forms, the preservation and reproduction of the pathogen (cysts, L-forms). Despite the loss of virulence, these forms of treponema in the human body remain viable throughout his life (carriage). Under unfavorable conditions, these forms of Treponema pallidum again become virulent and cause active manifestations of syphilis. It is possible that these features of the interaction between macro- and microorganisms partly explain the long asymptomatic course of syphilis.

Confirmation of the above features of the pathogenesis of syphilis are clinical observations of sick people and the results of experimental studies on animals. The most valuable information was obtained from studying the fate of untreated syphilis patients who were examined many years after infection. So, in 1891–1910. prof. C. Boeck refused specific treatment with mercury and iodine preparations for 2000 patients with syphilis. He proceeded from the assumption that patients with syphilis do not need this treatment, since the body’s immune forces will successfully cope with the early manifestations of the disease and thereby prevent the development of later complications. In order to exclude infection of surrounding healthy people, these patients were hospitalized in the clinic and remained there until the clinical manifestations of the disease disappeared (from 1 to 12 months, on average 3–6 months). In 1955, T. Giestland published information about the further fate of 1,147 patients from the C. Boeck clinic. The results of this study were as follows: 23.6% had relapses of the disease, 10.8% (15.4% of men and 8% of women) died directly from syphilis; 15.8% (16.4% of men and 14.4% of women) developed tubercular and gummous tertiary syphilis, 10.4% (14.9% of men and 8% of women) developed syphilis of the cardiovascular system, and 6 .6% (9.7% of men and 5% of women) – neurosyphilis.

Thus, the results of this study indicate that 40% of untreated patients developed late manifestations of syphilis. Of the remaining 60% of people examined, 30% had only positive serological reactions and 30% had no clinical or serological evidence of syphilis decades after infection.

In 1933 in the USA in the state of Alabama, D. Rockwell et al. 412 patients with syphilis were left without treatment. After 30 years, these patients were examined and the results were identical to the data obtained at the C. Boeck clinic.

The results of the natural course of untreated syphilis in 1964 were summed up by R. Shtokh. In his opinion, in these cases, 30% of patients experience self-healing, confirmed by the absence of clinical symptoms and negative serological reactions. Almost 30% of patients do not develop any clinical signs of syphilis, but serological reactions remain positive for life. In these people, postmortem examination can reveal microscopic signs of syphilis, but death occurs from other causes. Of the remaining 40%, almost half have gummas, and 25% have syphilis of the cardiovascular or nervous system.

Syphilis can also develop differently in experimental animals. It has been proven that in some infected rabbits, generalization of the infection occurs with the penetration of Treponema pallidum into all organs and the appearance of positive serological reactions, but no clinical signs of the disease occur (“nullers”).

The introduction of Treponema pallidum into the skin and mucous membrane leads to the development in the body of an infected person of two parallel processes: intensive reproduction of Treponema at the site of their inoculation and rapid spread through the lymphatic and blood vessels to all organs and tissues of the body. In addition, a small amount of pale treponema very early enters the perineural lymphatic spaces, from where they penetrate along the nerve fibers into the central nervous system. Evidence of the rapid spread of Treponema pallidum is their detection in the lymph nodes of rabbits within 24–48 hours after infection. This is indirectly confirmed by personal prevention data, which consists of local treatment of the genitals with disinfectants after sexual intercourse with a sick person. The best effect is observed only when such prophylaxis is carried out in the first 2–4 hours after sexual intercourse.

The spread of Treponema pallidum at the onset of the disease does not cause any clinical symptoms, however, under the influence of the antigenic properties of the pathogen, from the very beginning of the disease the reactivity of the body undergoes profound changes. This is manifested, on the one hand, by an increase in the body’s defense against the pathogen (immunity), and on the other hand, by a change in the sensitivity of tissues to treponema pallidum (allergy). These two biological phenomena (immunity and allergy) should be considered as two sides of the same biological process - a change in the body's reactivity under the influence of a syphilitic infection. Possessing one causal relationship, they have different, sometimes parallel, sometimes opposite development, causing a rich and varied range of clinical, physiological and pathomorphological changes, that is, the evolution of syphilitic infection. The above features of the evolution of the syphilitic process suggest various options for its clinical course.

The first variant of the course of acquired syphilis is classic and was developed by Ricord in the 30s of the 19th century. With this option, the main features of a syphilitic infection are most clearly revealed: 1) a wave-like change of active manifestations with periods of latent infection; 2) gradual clinical and pathomorphological changes in damage to organs and tissues caused by treponema pallidum, in particular the skin and mucous membranes, becoming more and more pronounced and severe over time [Pavlov S. T. et al., 1985]. According to the periodization proposed by Ricord, the classic course of syphilitic infection is divided into the following periods: 1) incubation; 2) primary; 3) secondary; 4) tertiary. After the discovery of classical serological reactions, primary syphilis was divided into seronegative and seropositive.

Incubation period syphilis (the time from the moment of infection to the appearance of the first clinical symptoms of the disease) averages 3–4 weeks. The incubation period may be reduced to 10–15 days or increased to 108–190 days. A reduction in the incubation period is observed with reinfection of syphilis and with the so-called “bipolar” location of chancre. With reinfection, a reduction in the incubation period is observed with repeated, consecutive sexual intercourse with a person with syphilis. In these cases, the first chancre develops in the usual time frame, and subsequent chancre (ulcera indurativa succentuaria) develops much faster. After 10–12 days from the appearance of the first chancre, new, successive chancre no longer appears. An increase in the incubation period is observed in elderly and weakened people, as well as its significant (up to 6 months) artificial increase - as a result of the use of relatively small doses of treponemocidal drugs, especially antibiotics, for other diseases (sore throat, influenza, pneumonia, gonorrhea, etc.) . In this case, the usual sequence of the course of a syphilitic infection can be distorted to one degree or another. Prolongation of the incubation period is also observed in cases of antibiotic intake by the source of infection. Patients who are simultaneously infected with syphilis and gonorrhea deserve special attention. Since the incubation period of gonorrhea is 3–5 days, its treatment in these patients can significantly increase the incubation period of syphilis. Therefore, patients with gonorrhea with unknown sources of infection, who have a permanent place of residence and work, after treatment are subject to careful clinical and serological monitoring for 6 months. Patients with acute gonorrhea with an unknown source of infection, if it is impossible to establish long-term clinical observation for them, are subject to preventive anti-syphilitic treatment.

Primary period Syphilis is characterized by the appearance of erosion or ulcers (primary syphiloma, chancre, ulcus durum) at the site of penetration of Treponema pallidum on the skin or mucous membranes. 5–7 (up to 10) days after the onset of primary syphiloma, the second symptom of primary syphilis appears - regional lymphadenitis (accompanying bubo). The primary period of syphilis is divided into primary seronegative, when standard Wasserman reagin reactions and sediment reactions are negative, and primary seropositive, when these reactions become positive, which occurs on average 3-4 weeks after the onset of primary syphiloma.

Secondary period Syphilis begins on average 2 1/2 months after infection and is characterized by generalized rashes on the skin and mucous membranes. Its duration without treatment is up to 15 years (usually 2–4 years). With secondary syphilis, the infectious process occurs in waves: periods of active clinical manifestations (secondary fresh and recurrent syphilis) alternate with periods of latent asymptomatic disease (latent syphilis).

Tertiary period Syphilis is characterized by the formation of tubercles or gummas on the skin and mucous membranes, as well as severe damage to internal organs (cardiovascular system, liver, etc.), nervous system, bones, and joints. Tertiary lesions develop more often in the period from the 3rd to the 6th year from the onset of the disease, but sometimes decades after infection. Tertiary syphilis, like secondary syphilis, occurs with clinical relapses (active tertiary syphilis) and remissions (latent tertiary syphilis).

Syphilis without chancre(“headless” syphilis) is a clinical type of syphilis that occurs when Treponema pallidum enters the human body without passing through the skin or mucous membranes. Infection occurs through deep injections, cuts (for example, during surgery) or through transfusion of infected blood (transfusion syphilis). Clinical symptoms usually appear after 2–2 1/2 months and correspond to the secondary period of syphilis. The further course of syphilis does not differ from normal.

Malignant syphilis(syphilis maligna) is a rare form of the secondary period of syphilis. Occasionally it occurs as a relapse at 5-6 months of illness. A feature of the clinical manifestations of malignant syphilis is the relatively frequent tendency of chancre to necrosis and peripheral growth, the reduction of the primary period to 3–4 weeks, the predominance on the skin and mucous membranes in the secondary period, in addition to macular and papular inflammation, pustular syphilides (ecthym, rupees, impetigo ). The eruptions, especially on the mucous membranes, are prone to ulceration. Specific polyadenitis is usually absent; pale treponema in pustular syphilides is difficult to detect. Serological reactions to syphilis (Wassermann reaction and treponemal reactions) are sometimes negative. The Wasserman reaction may become positive after the start of penicillin therapy.

Malignant syphilis is characterized by disturbances in the general condition of the patient, prolonged fever, and symptoms of intoxication. Involvement of internal organs in the process is rare, but aggravates the course. In untreated patients for many months, the pathological process does not tend to go into a latent state, relapses of the disease occur one after another, with almost no latent periods. The therapeutic effect of benzylpenicillin is very good.

The severe course of malignant syphilis is associated with a sharp decrease in the body's defenses under the influence of various common diseases and intoxications, primarily alcoholism. It is also possible that patients with malignant syphilis have a hyperergic reaction to Treponema pallidum, since they have a high hypersensitivity to Treponema pallidum antigens.

Hidden syphilis(syphilis latens) is diagnosed in people without clinical manifestations of the disease based on the detection of positive serological reactions. Syphilis can be latent from the very beginning of the disease (primary latency of syphilitic infection, latent unspecified syphilis, “unknown syphilis” - syphilis ignorata), or the emergence of latent periods is preceded by clinical symptoms of syphilis (secondary latency of syphilitic infection). In cases of hidden unknown syphilis, the patient does not know the time of his infection, and the doctor cannot determine the period and timing of the disease. The second group of latent syphilis consists of patients who previously had clinical manifestations of the disease, but they disappeared under the influence of antibiotics in doses insufficient to cure the disease or spontaneously. Latent syphilis can occur in any period of the disease (primary, secondary and tertiary).

Preventive screening of the population is important for identifying patients with latent syphilis. It is believed that the increase in the number of patients with latent syphilis is facilitated by the pathomorphism of syphilis with an increase in the frequency of erased cases of the disease, which is facilitated by the widespread use of antibiotics in medical practice.

Long-term asymptomatic course of acquired syphilis. Syphilis can be asymptomatic for a long time. These patients do not have early active forms of the disease, and it is diagnosed, as a rule, by chance on the basis of positive serological reactions already in the stage of late latent syphilis or in the stage of neurosyphilis and syphilis of internal organs. M. V. Milich (1987) considers this variant of the course of syphilis to be as frequent and characteristic as ordinary classical syphilis, described in detail by Ricord in 1838.

With a long asymptomatic course of syphilis, its early latent stage is not diagnosed, since classical serological reactions are either negative for a long period of time or they are not studied. The reason for this asymptomatic course is a change in the biological properties of treponema pallidum due to its transformation into cysts (then the serological reactions are positive) or into L-forms (then the serological reactions are negative).

As evidence of the regularity of the duration of the asymptomatic course of syphilis, M. V. Milich cites the following facts: 1) in 70–90% of patients with late forms of syphilis, there is no indication in the anamnesis of earlier forms of the disease; 2) there is a significant group of patients identified on the basis of positive serological reactions in the blood, in whom, after prolonged sexual contact, one of the spouses and children, as a rule, remain healthy. There have been cases where people, due to the nature of their work, were under medical supervision for a long time, including serological examination, and no evidence of syphilis was found in them. However, they later turned out to be sick with tabes dorsalis or other late forms of syphilis. There have also been cases of asymptomatic congenital syphilis.

Immunity. It is currently believed that there is no true immunity for syphilis, and, therefore, a person does not have natural immunity to syphilis. It is believed, however, that this issue cannot be considered finally resolved, especially in connection with the problem of some people not being infected with syphilis in cases where it would seem to inevitably happen. It is possible that further research will prove that there are people with genetically determined resistance to syphilis infection [Milich M.V., 1987].