Primary syphilis

Primary syphilis (Primary Syphilis) is the initial stage of the course of syphilis, manifested by a chancre, usually genital, with associated lymphadenitis. Can meet and extragenital primary atypical lesions. Previously primary syphilis is divided into primary seronegative (the initial stage with a negative serological reactions) and seropositive (positive seroreaction).

The causative agent of syphilis is Treponema pallidum (Treponema pallidum) , belonging to the order Spirochaetales, family Spirochaetaceae, the genus Treponema. Morphologically Treponema pallidum (Treponema pallidum) is different from saprofitiruyuschem spirochetes (Spirochetae buccalis, Sp. refringens, Sp. balanitidis, Sp. pseudopallida). Under the microscope pale Treponema is a spiral-shaped microorganism resembling a corkscrew. It has an average of 8-14 uniform curls of equal size. The total length of Treponema varies from 7 to 14 microns, a thickness of 0.2 to 0.5 μm. For Treponema pallidum characterized by severe mobility unlike saprofitiruyuschem forms. Her inherent progressive, swinging, pendulum, contractile and rotatory (around its axis) movement. Using electron microscopy revealed the complex structure of the morphological structure of Treponema pallidum. It turned out that Treponema covered with a thick cover of three-layer membrane, cell wall and mukopolisaharidnyh capsule substance. Under cytoplasmic membrane fibrils are thin filaments, with a complex structure and contributing to a diverse movement. Fibrils are attached to the end coils and separate sections of the cytoplasmic cylinder with blefaroplastia. The cytoplasm milagrosa, it contains the nuclear vacuole, nucleolus and mesosoma. It is established that a variety of the influence of exogenous and endogenous factors (in particular, previously used preparations of arsenic, and in present - antibiotics) have influenced the pallidum pale, changing some of its biological properties. So, it turned out that Treponema pallidum can turn into cysts, spores, L-shape, grain, by reducing the activity of the immune reserves of the patient can be reversed in a spiral virulent species and cause active disease manifestations. Antigenic mosaic acyanotic proven by the presence in the serum of patients with syphilis multiple antibodies: protein, complimentative, polysaccharide, reagin, immobilizing, agglutinins, lipid, etc.
Using the electron microscope has shown that Treponema pallidum in the lesions often located in the intercellular gaps, perinatalnom space, blood vessels, nerve fibers, especially in early forms of syphilis. Finding acyanotic in peripherie still is not proof of damage to the nervous system. Often such an abundance of treponem occurs with symptoms of septicemia. In the process of phagocytosis is often a state of endocytobiosis, wherein the Treponema in leukocytes consist in phagosome. The fact of conclusion of treponemes in premembrane phagosomas - a phenomenon quite unfavorable, as being in a state of endocytobiosis, Treponema pallidum long remain protected from the effects of antibodies and antibiotics. At the same time the cage was formed such phagosome, as if protecting the body from infection and disease progression. This fragile balance can be maintained for a long time, describing latent course of syphilitic infection.
Experimental observations N. M. Ovchinnikov and V. V. Delectorskaya are consistent with the works of authors who believe that when infection with syphilis and possibly prolonged asymptomatic course (if available in the patient L-forms acyanotic) and "accidental" detection of infection in the latent stage of syphilis (lues latens seropositiva, lues ignorata), i.e. in the period of the presence of treponemes in the body, probably in the form of a cyst-forms that possess antigenic properties and, consequently, lead to the production of antibodies is confirmed by positive serological reactions for syphilis in the blood of patients without apparent clinical manifestations of the disease. In addition, some patients find stage neuro - and viscerosomatic, i.e., the disease develops as if "bypassing" of the active form.
For culture acyanotic required complex conditions (special environment, anaerobic conditions, etc.). However, the culture of Treponema quickly lose morphological and pathogenic properties. In addition to the above forms of treponemes, it was assumed the existence of granular and invisible filterable forms acyanotic.
Outside the organism Treponema pallidum is highly sensitive to external influences, chemicals, desiccation, heat, sunlight influence. On the Housewares Treponema pallidum retains its virulence to dry. The temperature of 40-42°C first increases the activity of treponemes, and then leads to their death - heated to 60°C kills them within about 15 minutes to 100°C immediately. Low temperatures do not have a devastating impact on a pale pallidum, and in present possession of treponemes in an oxygen-free environment at a temperature of from -20 to -70°C or dried from the frozen state is a common method of preservation of pathogenic strains.

Reaction of the patient to the introduction of Treponema pallidum complex, multifaceted and poorly understood. Infection occurs as a result of penetration of Treponema pallidum through the skin or mucosa, the integrity of which is usually broken. However, some authors admit the possibility of the introduction of Treponema through the intact mucosa. At the same time, we know that in the serum of healthy individuals, there are also factors with immobilized activity against the pale treponemes. Along with other factors, they provide an opportunity to explain why after contact with a sick person is not always a infection. Domestic ifiledialog M. V. milich based on own data and analysis of the literature considers that the infection may not occur in 49-57 cases. The variation is explained by the frequency of sexual contacts, the nature and localization syphiloderm, the presence of the entrance gate of the partner and the number of acyanotic, has penetrated the body. Thus, an important pathogenetic factor in the occurrence of syphilis is the state of the immune system, the tension and the activity of which varies depending on the degree of virulence of the infection. Therefore, discussed not only the possibility of the absence of infection, but the possibility of healing, which is considered to be theoretically valid.

International classification of diseases th revision of the International Statistical Classification of Diseases and Related Health Problems 10th Revision Version for 2006 currently classifies primary syphilis following way.
- Primary syphilis genital mutilation.
- Primary syphilis anal area.
- Primary syphilis of other sites.
In exceptional cases of primary syphilis may be asymptomatic, the so - called "headless" syphilis.
The primary period of syphilis in the classical period begins 3-4 weeks after infection and lasts for 5-6 weeks. Currently, there is a shortening (up to 2 weeks) or lengthening (up to 6 months) incubation period of syphilis. Extension of the terms may be associated with taking even small doses of the antibiotic groups, tetracycline, erythromycin (macrolides), penicillin.
After 7-10 days after the appearance of primary affect (lesions) observed presence of inguinal lymph nodes (lymphadenitis syphilitic).At the same time be a positive serological reaction for syphilis. Even in the absence of treatment within 1-2 months is the healing of a superficial scar that preserves the shape of the chancre.
The clinical picture of primary syphilis is characterized by the manifestation of primary syphiloma (chancre), regional lymphadenitis, and sometimes limfangiita, the developing direction from the chancre to the nearby enlarged lymph nodes.
Chancre is formed in patients after the end of the incubation period and is located on the site of Treponema pallidum in skin or mucous membranes. Chancre most often localized to the skin and mucous membranes of the genitalia (glans penis, the area of the prepuce, anus gay people, large and small labia, back spike, cervical region), less frequently on the thighs, pubic area, abdomen. Unapologize chancre, which are much rarer, are on the lips, the tongue, tonsils, eyelids, fingers and any other part of the skin and mucous membranes where there was penetration acyanotic. In these cases speak of extragenital location primary syphiloma. Extragenital chancres, as well as their localization on the cervix (according to some reports, 11-12 cases) are often not identified, and primary syphilis is not diagnosed in a timely manner. The clinical picture of the chancre, usually very characteristic. Often this is an isolated erosion of rounded or oval shape, round shape with sharp clear boundaries, usually up to the nail of the little finger, but may be more. Color erosions meat-red or similar to the color of spoiled fat, the edges rise slightly and gently sink to the bottom (saucer shape). Detachable serous erosion, poor and gives to the chancre brilliant, "lacquered" look. The most characteristic feature of the chancre - the infiltrate was dense consistency, which is palpated at the base of erosion (hence the name - ulcus durum). Have ulcerative chancre edge above protrude above the bottom, the infiltrate is steeper. After healing ulcerative chancre leaves a scar, and erosive heals without a trace. Much less common are several shangrow. Primary syphiloma characterized by a slight soreness or complete absence of subjective sensations. In the discharge of primary syphiloma in the study in dark field easily find pallidum pale.
In recent years increased the number of changes in the clinical picture of the chancre. If, according to many authors, before one of the essential features of primary syphiloma was her odinochnoi (80-90 cases), in recent decades has significantly increased the number of patients with two or more sangrami. Along with this, there is a significant increase in the proportion of ulcerative shangrow and their complication of pyogenic infection. Increased the number of patients with sangrami in the anogenital region. A certain amount of shangrow in the mouth and the anus is associated with sexual perversions. Thus, the specific weight of shangrow the oral cavity is significantly higher in women. Men at extragenital localization chancre are often located in the anus. One of the features of the modern course of primary syphilis is the absence, in some cases, the explicit seal at the base of primary syphiloma.
Relatively rare atypical forms of primary syphiloma, usually they can be of several varieties: chancre-amygdala, the chancre-felon and indurative edema.
The fingers chancre may occur in routine clinical form, but can also occur with atypical (chancre-felon). Such localization of the chancre occurs predominantly in medical personnel (technicians, gynecologists, dentists, etc.).
The chancre is a felon according to the clinical picture resembles banal felon streptococcal etiology (club-shaped swelling of the terminal phalanx, sharp pain), but the recognition facilitates the presence of a dense infiltrate, absence of acute inflammatory erythema and, most importantly, the presence of a characteristic regional (in the cubital lymph nodes lymphadenitis.
Indurative edema as a manifestation of primary syphilis is in the area of the labia majora, scrotum or prepuce, ie places with a large number of lymphatic vessels. There is swelling of these areas. Is pronounced induration, when pressed on which the recesses are not formed.
The diagnosis of atypical chancre in the form of indurative edema also contributes to the presence of a characteristic regional lymphadenitis, history and survey of the sexual partner and the positive results of serological testing of blood for syphilis (in the second half of the first period).
In some patients the primary syphiloma complicated by acceding to secondary bacterial infection. In these cases, talk about complicated solid sangrah.
For chancre-amigdalite characterized by enlargement and induration of one of the tonsils in the absence of erosion or ulceration (if the amygdala is erosion or ulcer of the primary period of syphilis, we talk about the primary syphiloma located on the amygdala).
With the localization of the amygdala chancre can have one of three forms: ulcerative, angelopoulou (chancre-amigdalite) and combination: ulcerative amid aminobutanol. In ulcerative form tonsil is enlarged, firm, against this background, the observed meat-red oval shallow ulcer with smooth edges. The mucous membrane around the ulcer hyperemic.
When anginophobia the chancree erosion or ulcer is missing, there is a one-sided significant increase in the tonsils. She becomes copper-red, painless, dense. The process differs from angina the unilateralism of the lesion, absence of pain and acute inflammatory hyperemia. General manifestations are absent, the body temperature is normal.
In the circumference of the tonsil no pronounced inflammation, there was a sharp boundary, there is no temperature reaction and pain when swallowing. Palpation tonsils trowel felt its firmness. In these cases, on the surface of the tonsils (after a light stroking of the platinum loop) easily find a large number of acyanotic. Diagnosis is driven by the availability characteristic for the primary period of syphilis regional Sclerotinia on the neck angle of the lower jaw (lymph nodes ranging in size from large beans to the hazelnut, motile, dense consistency, not cohesive with the surrounding tissue, painless) and the emergence of positive serological reactions of blood.
To complications of the chancre include balanitis, balanoposthitis, phimosis, paraphimosis, gangrenosa and fagedenizm. Balanitis and balanoposthitis are the most frequent complications of the chancre. They arise as a result of secondary bacterial or Trichomonas infection. In these cases around the chancre appear swollen, bright erythema, maceration of the epithelium, and discharge on the surface of the chancre becomes sero-purulent. The latter circumstance greatly complicates the detection of acyanotic and therefore diagnosis. To resolve inflammation prescribe lotions with isotonic sodium chloride solution (1-2 days), which makes it possible in most cases with repeated testing to establish the correct diagnosis.
Balanoposthitis may lead to a narrowing of the cavity of the foreskin that prevents access to the head of the penis. This condition is called phimosis. When phimosis due to the swelling of the foreskin of the penis appears to be enlarged, reddened, and painful. Chancre localized in these cases, the coronal sulcus or on the inner foreskin cannot be investigated on a pale pallidum. Diagnosis of syphilis facilitates the characteristic form of regional lymph nodes, in which punctate looking for the pathogen. The attempt by the violent opening of the glans penis in the presence of phimosis may lead to another complication called paraphimosis ("stranglehold"), which was edematous and infiltrated the preputial ring restrains the head. As a result of mechanical disorders of the blood and lymph circulation swelling increases. If not promptly take measures that can lead to necrosis of the glans penis and the foreskin cavity. In the initial stages of paraphimosis the doctor, releasing a serous fluid from the edematous foreskin cavity (for which a sterile needle repeatedly pierces thinning of the skin), makes an attempt to "reposition" head. If no effect is necessary to cut the foreskin.
More severe but less frequent complications of the chancre are gangrenizatsiya and fagedenizm. They are observed in immunocompromised patients and alcoholics as a result of accession fuzospirilleznogo infection. On the surface of the chancre appears dirty-white or black eschar (gangrenizatsiya), which may extend beyond the primary syphiloma (fagedenizm). Under the scab is extensive ulcer, and the process may be accompanied by fever, chills, headache and other common phenomena. After healing gangrenous ulcers remains a gross scar.
Regional lymphadenitis (scleredema) is the second most important symptom of primary syphilis. It appears 7-10 days after appearance of the chancre. From the time of recora regional sclerogenic has had deep meaning to the name "collateral bubo". RIKOR wrote: "He (scleredema) - faithful companion chancre, he invariably accompanies it, fatally, he follows the chancre, as a shadow... No chancre without bubo". Fournier noted the lack of regional Sclerotinia only 0,06 5000 patients with primary active syphilis. However, in recent decades, according to several authors, the regional sclerogenic absent from 1.3 to 8 patients with primary syphilis.
Next to chancre lymph nodes (usually inguinal) increase to the size of a bean or hazelnut, become dense, they are not soldered together, surrounding tissues and skin, painless - the skin over them is not changed. Regional lymphadenitis continues for a long time and allowed slowly, even despite specific treatment. With the localization of the chancre in the area of the cervix and the mucous membranes of the rectum clinically to determine regional lymphadenitis is not possible, as in these cases, swollen lymph nodes in the pelvic cavity.
In the localization of primary syphiloma on the genitals inguinal lymphadenitis is most often bilateral (even in cases when the chancre is situated on the same side). This occurs due to the presence in the lymphatic system is well developed anastomoses. Unilateral lymphadenitis is less common, usually occurs on the side of the localization of the chancre, and only as an exception is "cross", i.e. is located on the opposite side from the chancre. Recently the number of patients unilateral lymphadenitis has increased notably (according to Yu. K. Skripkin, they account for 27 patients with chancre).
Syphilitic lymphangitis (inflammation of lymphatic vessels) is a third symptom of primary syphilis. It develops in the form of dense painless cord size noguchii probe. Sometimes in the course of the cord formed a small beaded thickenings. Approximately 40 men lymphangitis is arranged on the front surface of the penis (genital hard chancre).
Lesions of the oral mucosa are the most common. Chancre may occur in any part of the vermillion border of the lips or oral mucosa, but most often localized on the lips, the tongue, tonsils.
The development of the chancre on the lip or oral mucosa, as in other places, begins with the appearance of limited redness, based within 2-3 days seal occurs due to the inflammatory infiltrate. This is a limited seal gradually increases and reaches usually 1-2 cm in diameter. In the Central part of the lesion necrosis formed by erosion and meat-red, rarely ulcers. Reaching full development in the course of 1-2 weeks., chancre on the mucosa of the is typically round or oval, painless erosion meat-red or ulcer with round edges size from 3 mm (dwarf chancre) to 1.5 cm in diameter with a dense infiltrate in the base. In scraping the surface of the chancre should be easy to detect Treponema pallidum. Some erosion covered with grayish-white coating. When the location of the chancre on the lips there is significant swelling, due to which the lip droops, and the chancre lasts longer than other places. More likely to develop one chancre, rarely two or more. If joins a secondary infection, erosion can be exacerbated, this forms an ulcer with a dirty-gray necrotic touch.
With the localization of chancre on the lips or oral mucosa 5-7 days after his appearance develops regional lymphadenitis. This usually increase the submental and submandibular lymph nodes. They are dense consistency, movable, not soldered together, painless. However, if you have a secondary infection or a traumatic moments due to the development of periadenitis regional lymph nodes can become painful. Simultaneously with submandibular and submental may increase superficial cervical and occipital lymph nodes.
Atypical forms of primary syphiloma meet with the localization of the chancre in the corners of the mouth, on the gums, transitional folds, tongue, tonsils. In the corners of the mouth and in the field of transitional folds chancre becomes cracked, but when you stretch the folds, which is a chancre, is determined by its oval shape. When the location of the chancre in the corner of his mouth he clinically may resemble perleches, which differ in the absence of a seal at the base.
In the language of the chancre is usually single, occurs more frequently in the middle third. In addition to erosive and ulcerative forms, in individuals with the folded tongue with the localization of the chancre along the folds may be a slit-like shape. When the location of the chancre on the back of the tongue due to significant infiltration at the base of the chancre dramatically extends above the surrounding tissue on its surface a meat-red erosion. Noteworthy is the absence of inflammation around the chancre and its painless. Chancre in the area of the gums has the appearance of bright red smooth erosion, which in the form of populonia 2 surrounds the tooth. Ulcerative form of the chancre gums very similar to banal ulceration and hardly has any signs characteristic of primary syphiloma. Diagnosis facilitates the presence of a bubo in the submandibular region.

jpg" alt="Primary syphilis" />

The diagnosis is done on the basis of clinical and laboratory confirmation by any of the following methods:
- A study in dark field
- Mr
REEF,ELISA,TPHA
Be aware that although modern classification there is no division of primary syphilis seronegative and seropositive within 7-14 days serological tests can be negative.

The world health organization recommends that when characteristic clinical picture treatment of primary syphilis without laboratory confirmation of diagnosis.
Treatment of syphilis is the application most often Duranty of penicillin by standard methods, in case of intolerance to penicillin are assigned to backup drugs.
Criteria of cure: disappearance of clinical manifestations, seronegativity during the year after treatment.
Sexual partners: examined on a mandatory basis, in the absence of symptoms and negative seroreaction or are subject to clinical and serological monitoring for 3 months or receive preventive treatment.

Venereal diseases