Syphilis

[méi dú]

A chronic systemic sexually transmitted disease caused by Treponema pallidum infection

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Yang Xueyuan	(Chief Physician) Review	Dermatology Hospital of Chinese Academy of Medical Sciences
Wang Qianqiu	Reviewed by (researcher)	Department of Clinical Prevention and Treatment of Venereal Diseases, Dermatology Hospital, Chinese Academy of Medical Sciences

Syphilis is caused by pallor (syphilis) Spirochete Chronic and systematic Sexually transmitted diseases 。 It is mainly transmitted through sexual means and can be clinically manifested as Primary syphilis 、 Secondary syphilis 、 Tertiary syphilis 、 Latent syphilis and Congenital syphilis （ Fetal transmission Syphilis), etc. Yes《 Law of the People's Republic of China on the Prevention and Treatment of Infectious Diseases 》In, it is listed as the disease of Class B prevention and control management.

Foreign name: syphilis
Alias: Bayberry sore 、 Willow disease

Visiting department: the skin department
infectivity: yes
Route of transmission: Sexual transmission, mother to child

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seven prognosis
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epidemiology

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Syphilis is prevalent all over the world, according to WHO It is estimated that there are about 12 million new cases in the world every year, mainly in South Asia 、 Southeast Asia And Sub Sahara Africa 。 Syphilis has grown rapidly in China in recent years and has become the largest number of reported cases STD 。 Among the reported syphilis, Latent syphilis Majority, I Secondary syphilis It is also common, and the number of reported cases of congenital syphilis is also increasing.

The skin and mucosa of syphilis patients contain Treponema pallidum , the person who is not sick is Sexual contact If there is slight damage to the skin or mucous membrane, you can get sick. Very few can be transmitted through blood transfusion or channels. Acquired syphilis (The day after tomorrow) Early syphilis patients are Infectious agent , 95% or more is through dangerous or unprotected a sexual behavior Infections, a few of which are transmitted through kissing, blood transfusion, contaminated clothing, etc. Fetal syphilis is transmitted by pregnant women with syphilis. If the pregnant women with primary, secondary and early syphilis are latent, the probability of transmission to the fetus is quite high.

1. Infectious source

Syphilis is a unique disease of human beings. Patients with overt and covert syphilis are the source of infection. Treponema pallidum is contained in the skin lesions, secretions and blood of people infected with syphilis. The first two years after infection are the most infectious, and after four years Sexual transmission The infectivity of. Treponema pallidum can be transmitted to the fetus through the placenta, and pregnant women with early syphilis are at great risk of transmitting it to the fetus.

two Route of transmission

Sexual contact is the main route of syphilis transmission, accounting for more than 95%. The early infection of syphilis is the strongest. With the extension of the disease period, the infectivity becomes smaller and smaller. It is generally believed that the infectivity of sexual contact more than 4 years after infection is very weak.

Pregnant women with syphilis can be transmitted to the fetus through the placenta, causing the fetus intrauterine infection , which may lead to abortion, premature delivery, stillbirth, or syphilis transmission in childbirth. It is generally believed that the earlier the syphilis period of pregnant women, the greater the chance of fetal infection. Pregnant women are also infectious even if they have asymptomatic recessive syphilis.

clinical manifestation

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1. Acquirability dominance Syphilis

（1） Primary syphilis The characteristic clinical feature is hard chancre. The most common sites are the penis glans 、 Coronary sulcus 、 Prepuce 、 Urethral orifice ； size Labia labia 、 clitoris Cervix; Anus Anal canal Etc. It can also be seen on lips, tongue, breast, etc. ① Hard chancre is characterized by It appears 7~60 days after TP infection. Most patients with hard chancre are single, painless, itching free, round or oval, with clear boundary ulcer , higher than the skin surface, the sore surface is relatively clean Secondary infection They have more secretions. There is cartilaginous hardness on contact. The duration is 4-6 weeks, which can heal itself. Hard chancre can coexist with secondary syphilis chancroid 、 Genital herpes , fixed drug eruption, etc Genital ulcer Sexual diseases Phase identification. ② Enlargement of lymph nodes in guards One to two weeks after hard chancre, some patients groin Or the guard lymph nodes may be enlarged, either single or multiple. The enlarged lymph nodes are different in size, hard, non adherent, non ulcerative, and painless.

（2） Secondary syphilis It is characterized by secondary syphilitic eruption and has systemic symptoms, which generally recur after the disappearance of hard chancre at an interval of asymptomatic period. TP spreads with blood circulation, causing multiple lesions and lesions. Invasion of skin, mucosa, bone, viscera cardiovascular 、 nervous system 。 When syphilis enters phase II, syphilis Serological test Almost 100% positive. Systemic symptoms occur in rash Before occurrence, fever headache 、 joint Pain Hepatosplenomegaly Lymph node enlargement. Male incidence rate About 25%; About 50% women. It will improve in 3-5 days. Syphilis rash followed, with recurrent characteristics. ① Cutaneous syphilid 80%~95% of patients. It is characterized by multiple and recurrent rash types, extensive and symmetrical, painless, and no lingering after recovery scar The treatment of eliminating plum blossom subsided rapidly. The main rash types are Macular rash Sample papule Sample Pustular syphilid And flat condyloma, palmoplantar syphilis, etc. ② Recurrent syphilid After the initial syphilitic rash subsided, about 20% of secondary syphilis patients recurred within one year, with ring-shaped papules being the most common. ③ Mucosal lesion About 50% of patients have mucosal damage. Occurs in the lips, mouth tonsil And pharynx and larynx, which are mucosa spots or mucositis, with Exudate , or grayish white membrane, red and swollen mucosa. ④ Syphilitic Hair loss accounts for about 10% of patients. Mostly sparsity , unclear boundary, such as insect erosion; A few are diffuse. ⑤ Bone and joint damage Periostitis 、 Osteitis 、 osteomyelitis and arthritis 。 With pain. ⑥ Secondary ocular syphilis Syphilis iritis Iridocyclitis 、 Choroiditis , retinitis, etc. Usually bilateral. ⑦ Phase II Neurosyphilis Most of them have no obvious symptoms, abnormal cerebrospinal fluid, and positive cerebrospinal fluid RPR. Available meningitis or Meninges Vascular symptoms. ⑧ whole body Superficial lymph node enlargement

（3） Tertiary syphilis One third of untreated overt TP infections developed tertiary syphilis. Among them, 15% are benign late syphilis, and 15%~20% are severe late syphilis. ① Skin and mucosa damage Nodular syphilis usually occurs on the scalp, scapula, back and the extended side of the limbs. Gumma It often occurs in the lower leg and is a deep ulcer, atrophic scar ； When it occurs on the forehead, Tissue necrosis , perforation; If it occurs in the nasal septum Bone destruction , forming Saddle nose ； Tongue is a perforated ulcer; Vaginal damage is ulceration, which can form vesicovaginal leakage or rectovaginal leakage. ② Proximal articular tubercle It is a slow growing subcutaneous fibrous nodule of syphilitic fibroma, Symmetry . Different size, hard texture, inactivity, no ulceration, normal epidermis, no inflammation, no pain, and self relieving. ③ Cardiovascular syphilis It mainly invades the aortic arch and may occur Aortic valve insufficiency , causing syphilitic heart disease. ④ Neurosyphilis The incidence rate is about 10%, which can occur in the early stage of infection or several years or decades later. It may be asymptomatic or syphilitic meningitis 、 Cerebrovascular Syphilis, meningeal gumma, paralytic dementia. The gumma of meninges is on the involved side Cerebral hemisphere Subcortical Lesions of Intracranial hypertension 、 headache And local brain compression symptoms. Substantive Neurosyphilis is the substance of the brain or spinal cord STD Damage, the former forms paralytic dementia, and the latter shows the posterior root of spinal cord and Posterior funiculus Of Degenerative change , Yes Paresthesia 、 Ataxia Etc Symptoms , i.e Tabes medullaris 。

2. Acquirability Recessive syphilis

The acquired TP infection did not form dominant syphilis and showed no symptoms, or the symptoms of dominant syphilis temporarily subsided after a certain period of activity, Syphilis serum test Positive Cerebrospinal fluid examination Normal is called recessive (latent) syphilis. It is called early stage within 2 years after infection Latent syphilis ； Those infected for more than 2 years are called late latent syphilis.

three gestation Syphilis

Pregnancy syphilis is a dominant or recessive syphilis occurring during pregnancy. When pregnant with syphilis, TP can pass through the placenta or Umbilical vein Congenital syphilis that is transmitted to the fetus and forms the baby born later. The placental tissue of pregnant women is necrotic due to small arteritis abortion 、 premature delivery 、 Stillbirth Only a few pregnant women can have healthy babies.

4. Congenital dominant syphilis

(1) Early congenital syphilis The baby is thin at birth, and has symptoms 3 weeks after birth. The lymph nodes of the whole body are swollen, without adhesion, pain, and hard. More syphilitic rhinitis 。 Appears about 6 weeks after birth Skin damage , presented Blister -Bullous type Skin lesion (Syphilis Pemphigus ）Or Maculopapule , papular and scaly lesions. Osteomalacia may occur Osteitis 、 Periostitis 。 Most of them have liver Splenomegaly 。 Thrombocytopenia and anemia 。 Occurring Neurosyphilis 。 No hard chancre occurs.

(2) Advanced congenital syphilis It happened after 2 years old. One is bone, tooth, eye, nerve and skin caused by early disease Permanent Damage, such as saddle nose, Hao Qinsen teeth, etc., without activity. The other is the clinical manifestation caused by active damage, such as keratitis Nervous deafness, nervous system abnormalities, cerebrospinal fluid changes, hepatosplenomegaly, nose or jaw Gumma , joint hydrops Periostitis 、 Finger inflammation And skin and mucous membrane damage.

5. Congenital latent syphilis

The mother born with syphilis has no clinical manifestation without treatment, but the syphilis serum reaction is positive. Those younger than 2 years old are early congenital latent syphilis, and those older than 2 years old are late congenital latent syphilis.

diagnosis

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one epidemiology medical history

Have a history of unsafe sexual contact; History of syphilis infection in pregnant women; History of blood transfusion.

2. Clinical manifestations

There are corresponding syphilis clinical manifestation 。 If it is latent syphilis, there is no obvious clinical manifestation.

three laboratory examination

(1) Dark field microscopy Take the patient's suspicious skin lesions (such as Hard chancre 、 condyloma latum , wet papules, etc.), examined under the dark field microscope, and movable Treponema pallidum It can be used as the basis for diagnosis of syphilis.

(2) Syphilis serological test There are many serological test methods for syphilis, and the antigens used are different Spirochete antigen （ Cardiolipin Antigen) and Treponema pallidum Specificity There are two types of antigens. The former has Rapid plasma reagin ring card test （RPR）、 Toluidine red The non heated serological test (TRUST) can be used for quantitative tests to judge the efficacy and the degree of disease activity. The latter has treponema pallidum particles agglutination test (TPPA), Treponema pallidum ELISA （TP- ELISA ）It has strong specificity and is used to confirm TP infection.

Treponema pallidum IgM Antibody test : After syphilis infection MP-IgM , with the development of disease, IgG antibody Then it appears and rises slowly. After effective treatment, IgM antibody disappeared and IgG antibody persisted. The TP IgM antibody cannot pass through the placenta. If the infant is TP IgM positive, it means that the infant has been infected. Therefore, the detection of TP IgM antibody is of great significance in diagnosing fetal syphilis in infants.

(3) Cerebrospinal fluid examination Patients with syphilis who have neurological symptoms, or who have failed to respond to the treatment of eliminating syphilis, should have a cerebrospinal fluid examination. This check is right Neurosyphilis Diagnosis, treatment and prognosis The judgment of is helpful. The inspection items shall include: Cell count 、 Total protein Determination, RPR and TPPA test, etc.

differential diagnosis

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one Primary syphilis Hard chancre Should be connected with chancroid , fixed drug eruption Genital herpes Etc.

2. Phase I syphilis guard lymph node enlargement should be associated with chancre STD To differentiate lymph node enlargement caused by sex lymphogranuloma.

3. The rash of secondary syphilis should be associated with Pityriasis rosea 、 Erythema multiforme , tinea versicolor Psoriasis , tinea corporis, etc. Condyloma plana should be associated with condyloma acuminatum Phase identification.

complication

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1. Syphilis pregnant women can infect the fetus, causing Stillbirth , miscarriage, premature delivery, resulting in congenital syphilis of infants, which seriously endangers the health of women and children.

2. Treponema pallidum invasion central nervous system , can cause meningeal vascular disease Tabes medullaris 、 Paralytic dementia 。 violation cardiovascular system , can cause Aortitis 、 Aortic valve insufficiency , aortic aneurysm, etc. Severe cases can lead to death.

3. Treponema pallidum damages bones, eyes respiratory tract , digestive tract and other systems, causing tissue and organ damage, loss of function, or even disability or other adverse consequences. Syphilis epidemic has a serious impact Social ethos 。 The labor force is lost due to illness, and the social burden is increased. Syphilis can also affect family stability.

treatment

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1. Treatment principle

Emphasize early diagnosis, early treatment, regular course of treatment, and adequate dose. Clinical and laboratory follow-up were carried out regularly after treatment. Sexual partners It is necessary to investigate and treat the same problem. Early syphilis After thorough treatment, it can be clinically recovered and eliminated infectivity 。 Treatment of advanced syphilis can eliminate inflammation in tissues, but damaged tissues are difficult to repair.

penicillin , such as aqueous penicillin Procaine penicillin 、 Benzathine penicillin It is the first choice for different stages of syphilis. Optional for those allergic to penicillin tetracycline 、 erythromycin Etc. It may occur at the beginning of penicillin treatment in some patients Jihai reaction , which can be prevented by starting with a small dose or using other drugs. The serum should be rechecked every three months within the first year after syphilis treatment, and every six months thereafter, for a total of three years. Neurosyphilis and Cardiovascular syphilis They should be followed up for life.

2. Early syphilis (including primary and secondary syphilis and early latent syphilis)

(1) Penicillin therapy Benzathine penicillin G (long-acting penicillin), divided into two buttocks Intramuscular injection , once a week, 2-3 times in total. Procaine penicillin G , intramuscular injection for 10-15 consecutive days, with a total amount of 8 million u~12 million u.

(2) Persons allergic to penicillin Tetracycline hydrochloride, oral, for 15 days. doxycycline For 15 days.

3. Advanced syphilis (including tertiary skin, mucosa, bone syphilis Late latent syphilis ）And recurrent secondary syphilis

(1) Penicillin Benzathine penicillin G, once a week, intramuscular injection, 3 times in total. Procaine penicillin G, intramuscular injection, for 20 consecutive days. The treatment can be repeated once every 2 weeks.

(2) Persons allergic to penicillin Tetracycline hydrochloride, taken orally for 30 days. Doxycycline for 30 days.

4. Neurosyphilis

Should be hospitalized for treatment. In order to avoid Gillheimer reaction during treatment, take orally the day before penicillin injection prednisone Once a day for 3 consecutive days.

(1) Aqueous penicillin G Intravenous drip for 14 days.

(2) Procaine penicillin G Intramuscular injection and oral probenecid were given for 10-14 days.

After the above treatment, Benzathine penicillin G was given by intramuscular injection once a week for three consecutive weeks.

five gestation Stage syphilis

Treat according to the syphilis treatment plan for the corresponding disease period, and apply a course of treatment within the first three months of pregnancy; One course of treatment was applied in the last 3 months of pregnancy. Those who are allergic to penicillin shall be treated with erythromycin for 15 days for early syphilis, 30 days for secondary relapse and late syphilis. Application of babies born penicillin Remediation.

six Fetal transmission Syphilis（ Congenital syphilis ）

Early congenital syphilis (under 2 years old) cerebrospinal fluid Abnormal person: treated with aqueous penicillin G or procaine penicillin G, and the specific dose shall comply with Doctor's order 。 Patients with normal cerebrospinal fluid: Benzathine penicillin G, one injection (divided into two sides gluteal muscle ）。 If there is no condition to check cerebrospinal fluid, it can be treated as abnormal cerebrospinal fluid.

7. Syphilis treatment of pregnant women

(1) Married women with a history of syphilis must undergo a comprehensive syphilis examination before pregnancy. Have been unclean sex life Or women who have been infected with syphilis should go to Regular hospital Make a comprehensive syphilis test. For those married women who have completed the treatment of syphilis and have no obvious symptoms of syphilis, they can only be pregnant after confirming that syphilis is cured.

(2) Syphilis examination and treatment during pregnancy: in the first three months and at the end of pregnancy Should be Syphilis Serological examination 。 If found to be infected with syphilis, regular treatment should be carried out to reduce the chance of fetal transmission of syphilis.

8. Jihai reaction in syphilis treatment

Within a few hours after the first administration of toxic treatment fever 、 headache 、 Arthralgia , nausea, vomiting Syphilitic eruption It is a Jihai reaction, and most of the symptoms will be relieved within 24 hours. In order to prevent Jihai reaction, penicillin can be gradually increased from small dosage to normal dosage, and a short course of treatment can be given to neurosyphilis and cardiovascular syphilis before treatment Prednisone , times Administration After 2 to 4 days of anti plum treatment, it was gradually stopped. corticosteroid It can reduce the heat of Jihai reaction inflammatory reaction The role of is uncertain.

9. Food Precautions

Post syphilitic Diet and recuperation And others Infectivity As for diseases, people should eat fresh vegetables and fruits rich in vitamins, eat less greasy food, avoid spicy and stimulating food, quit smoking and drink, and drink more water properly, which is good for health endotoxin Exclusion of.

prognosis

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How to judge whether syphilis is cured after treatment, usually with syphilis serology RPR (rapid plasma reagin ring card test) and TPPA (treponema pallidum particle agglutination test) are commonly used in major hospitals. RPR is a non-specific serological test for syphilis, which is often used to judge the efficacy. Specificity of TPPA in serum Treponema pallidum antibody , with higher susceptibility And specificity. Once the test is positive, it usually remains positive for life regardless of treatment or disease activity titer The change has nothing to do with whether syphilis is active or not, so it cannot be used to evaluate the efficacy or determine whether recurrence is related to Reinfection It can only be used as a confirmation test for syphilis.

For those diagnosed with syphilis, RPR quantitative test is the best before treatment. Two differences in titre change between two quantitative tests Dilution Only when the above conditions are met can the titer be determined to be decreased. After regular treatment, syphilis patients should have RPR rechecked every three months, and after half a year, they should have RPR rechecked every half a year, followed up for 2 to 3 years, and observed and compared the RPR titer changes between the current and previous times. Three to six months after treatment, the titer dropped more than four times, indicating that the treatment was effective. The titer continued to decline and even turned negative. If the results of three or four consecutive tests are negative, the patient's syphilis can be considered clinically cured.

After anti syphilitic treatment, there are generally three possible changes in the serum reaction of syphilitic patients:

1. Serum turns negative.

2. The serum titer is not negative, or the serum is resistant.

3. After turning negative, it becomes positive again, or it rises again in the process of continuous decline, indicating recurrence or reinfection.

The negative conversion rate of serum reaction may be different in different stages of syphilis treated with different drugs. 1、 The seroconversion rate of secondary syphilis is high after any anti syphilis drug treatment, which usually reaches 70%~95% within 1~2 years. When Primary syphilis After 12 months of regular anti syphilis treatment and 24 months of secondary syphilis treatment, the serum reaction remains positive, which is clinically called seroresistance or Serum fixation , the cause may be that there are still potential activities in the body STD Change, patient Decreased immunity The insufficient dose of anti plum treatment or drug resistance are related, and the reason is not found. For such patients, cerebrospinal fluid examination AIDS Comprehensive physical examination including examination to find possible causes and give corresponding treatment. If there is no special abnormality found, you can follow up regularly and do not give antibiotics blindly Overtreatment 。

prevention

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Firstly, health education and publicity should be strengthened to avoid unsafe sexual behaviors. Secondly, the following measures should be taken preventive measure And precautions.

1. Track the patient's sexual partner and find out the patient's ownership Contacts , preventive examination, follow-up observation and necessary treatment shall be carried out, and sexual behavior shall be prohibited before cure.

2. Suspicious patients should be checked for prevention and syphilis serum test, so as to find patients early and treat them in time.

3. Pregnant women suffering from syphilis should be given effective treatment in time to prevent syphilis infection to the fetus. Unmarried people infected with syphilis had better be cured before marriage.

4. If you need to donate blood, you should go to the regular blood collection point and do a comprehensive work before blood donation Blood test To prevent infection. If blood transfusion is required, the blood transfusion unit shall show the examination certificate of the blood transfusion to prevent unnecessary trouble.

5. Syphilis patients should pay attention to the combination of work and rest, and carry out necessary Functional exercise , keep a good attitude for recovery.

6. Attention trifling matters of everyday life To prevent the infection of others: early syphilis patients have strong infectivity, while late syphilis patients have gradually reduced infectivity, but they should also be carefully protected. Clean your underwear and towel separately in time, Boiling disinfection , do not bath with others. It can be used when hard chancre or flat condyloma of vulva and perianal area occurs clearing away heat and toxic material , Dehumidifying and Insecticidal Chinese Herbal Medicine Fried Water Fumigation and washing a hip bath.

7. Syphilis patients should not have sex until they are cured. If it happens, they must use condoms.

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