epidemiology
Syphilis is prevalent all over the world. According to WHO estimates, there are about120,000 new cases worldwide every year, mainly in South Asia, Southeast Asia and sub-Saharan Africa. In recent years, syphilis has grown rapidly in China and has become the sexually transmitted disease with the most reported cases. Latent syphilis accounts for the majority of reported syphilis, primary and secondary syphilis are also common, and the reported cases of congenital syphilis are also increasing.
Treponema pallidum is contained in the skin and mucous membrane of syphilis patients. In the process of sexual contact with syphilis patients, those who are not sick can get sick with slight damage to their skin or mucous membrane. Very few can be infected by blood transfusion or route. Acquired syphilis (acquired syphilis) Early syphilis patients are the source of infection. More than 95% of them are infected through dangerous or unprotected sex, and a few are infected through kissing, blood transfusion and contaminated clothes. Fetal syphilis is transmitted by pregnant women with syphilis. If pregnant women have primary, secondary and early latent syphilis, the probability of transmission to the fetus is quite high.
1. source of infection
Syphilis is a unique disease of human beings, and patients with dominant and recessive syphilis are the source of infection. Treponema pallidum is contained in the skin lesions, secretions and blood of syphilis-infected people. The first two years after infection are the most contagious, but after four years, the infectivity of sexual transmission is greatly reduced. Treponema pallidum can be transmitted to the fetus through the placenta, and pregnant women with early syphilis are at great risk of transmission to the fetus.
2. Transmission routing
Sexual contact is the main route of transmission of syphilis, accounting for more than 95%. Syphilis is most easily transmitted in the early stage. With the extension of the course of the disease, the infectivity becomes less and less. It is generally believed that 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 intrauterine infection, which can lead to abortion, premature delivery, stillbirth or delivery of fetal syphilis. It is generally believed that the earlier pregnant women suffer from syphilis, the greater the chance of fetal infection. Pregnant women are contagious even if they have asymptomatic recessive syphilis.
2 Clinical manifestations
1. Acquired dominant syphilis
(1) The characteristic clinical feature of primary syphilis is chancre. The most common parts are penis, glans penis, coronary sulcus, foreskin and urethral orifice. Labia majora, clitoris and cervix; Anal, anal canal, etc. It can also be seen in lips, tongue and breasts. ① chancre is characterized by appearing 7-60 days after TP infection. Most patients with chancre are single, painless, round or oval ulcers with clear boundaries, which are higher than the skin surface, with clean sore surface and more secretions from secondary infected people. It feels like cartilage It lasts for 4 ~ 6 weeks and can heal itself. Hard chancre can coexist with secondary syphilis, and should be differentiated from genital ulcer diseases such as hard chancre, genital herpes and fixed drug eruption. ② 0 ~ 2 weeks after 65438+guard lymph node enlargement appeared chancre, some patients appeared inguinal or guard lymph node enlargement, which could be single or multiple. The swollen lymph nodes are hard, non-adherent, non-festering and painless.
(2) Secondary syphilis is characterized by secondary syphilis rash with systemic symptoms, which usually recurs after asymptomatic chancre subsides for a period of time. TP spreads with blood circulation, causing multiple lesions, and the lesions are diverse. Invasion of skin, mucosa, bones, internal organs, cardiovascular system and nervous system. When syphilis entered the second stage, the serological test of syphilis was almost 100% positive. Systemic symptoms, including fever, headache, osteoarthralgia, hepatosplenomegaly and lymphadenopathy, appeared before the rash appeared. The incidence of male is about 25%; About 50% are women. Get better in 3 ~ 5 days. Syphilis rash comes one after another, and it is characterized by recurrence. ① 80% ~ 95% of patients with cutaneous syphilis. It is characterized by various types of rash, repeated attacks, extensive and symmetrical, painless, no scar left after healing, and rapid regression after plum-expelling treatment. The main types of rash are macula-like, papule-like, pustular syphilis, condyloma plana, palmoplantar syphilis and so on. ② About 20% patients with secondary syphilis recurred within one year after the initial syphilis subsided spontaneously, with round papules being the most common. ③ About 50% patients have mucosal injury. Occurred in the lips, mouth, tonsils and throat, it is mucosal plaque or mucositis, with exudate or gray-white film, and the mucosa is red and swollen. ④ Syphilitic alopecia accounts for about 10% of patients. Most of them are sparse and unclear, such as insect erosion; A few are diffuse. ⑤ Osteoarthritis, osteitis, osteomyelitis and arthritis. With pain. ⑥ Secondary ocular syphilis iritis, iridocyclitis, choroiditis, retinitis, etc. Usually bilateral. ⑦ Secondary neurosyphilis has no obvious symptoms, abnormal cerebrospinal fluid and positive RPR. There may be meningitis or meningeal vascular symptoms. Today's systemic superficial lymphadenopathy.
(3) The dominant TP infection was untreated when tertiary syphilis occurred 1/3. Among them, 15% is benign late syphilis, and 15% ~ 20% is severe late syphilis. ① The lesions of cutaneous mucosal nodular syphilis usually occur in scalp, scapula, back and limbs. Gingival swelling often appears in the legs, which is deep ulcer and atrophic scar; When it happens on the forehead, the tissue is necrotic and perforated; Occurred in the nasal septum, the bones were destroyed, forming a saddle nose; The tongue is a perforated ulcer; Vaginal injury is ulcer, which can form vesicovaginal leakage or rectovaginal leakage. ② Proximal articular nodules are subcutaneous fibrous nodules with slow growth of syphilis fibroma, which are symmetrical, different in size, hard, inactive, non-ulcerated, normal in epidermis, non-inflammatory, painless and self-eliminating. ③ Syphilis mainly invades the aortic arch, which may lead to aortic valve insufficiency and syphilitic heart disease. ④ The incidence of neurosyphilis is about 10%, which can occur in the early stage of infection or more than several years. Symptoms can be asymptomatic, and syphilis meningitis, cerebrovascular syphilis, meningeal gingival swelling and paralytic dementia can also occur. Meningeal mucinous swelling is a subcortical lesion involving one side of the cerebral hemisphere, which is characterized by increased intracranial pressure, headache and local compression of the brain. Substantive neurosyphilis is a substantial lesion of the brain or spinal cord. The former forms paralytic dementia, while the latter is characterized by degeneration of the posterior root of spinal cord and spinal cord, with symptoms such as paresthesia and ataxia, namely spinal tuberculosis.
2. Acquired recessive syphilis
After acquired infection with TP, there is no obvious syphilis and no symptoms, or obvious syphilis symptoms temporarily subside after a certain period of activity, syphilis serum test is positive and cerebrospinal fluid examination is normal, which is called recessive (latent) syphilis. Early latent syphilis within 2 years after infection; More than 2 years after infection is called late latent syphilis.
3. Pregnancy syphilis
Syphilis gravidarum is dominant or recessive syphilis that occurs during pregnancy. When pregnant with syphilis, TP can be transmitted to the fetus through the placenta or umbilical vein, forming congenital syphilis of the baby born later. Arteritis arteriosus in pregnant women leads to placental tissue necrosis, which in turn leads to abortion, premature delivery and stillbirth. Only a few pregnant women can give birth to healthy babies.
4. Congenital dominant syphilis
(1) Children with early congenital syphilis were born thin, with symptoms three weeks after birth, swollen lymph nodes, no adhesion, no pain and hard texture. Syphilis and rhinitis are many. Skin lesions appear about 6 weeks after birth, which are vesicular bullous lesions (syphilis pemphigus) or maculopapules and papules. Osteochondritis and periostitis can occur. There are many hepatomegaly and splenomegaly. Thrombocytopenia and anemia. Neurosyphilis may occur. There will be no hard chancre.
(2) Late congenital syphilis occurred after 2 years old. One is the permanent damage to bones, teeth, eyes, nerves and skin caused by early pathological changes, such as saddle nose and Hao's teeth, which are inactive. The other is the clinical manifestations caused by active injury, such as keratitis, nervous deafness, abnormal nervous system performance, cerebrospinal fluid changes, hepatosplenomegaly, swelling of nose or jaw gums, joint effusion, periostitis, finger inflammation and skin and mucous membrane damage.
5. Congenital latent syphilis
The mother was born to a syphilis patient. She was untreated and had no clinical manifestations, but she was positive for syphilis serum. Those younger than 2 years old were early congenital latent syphilis, and those older than 2 years old were late congenital latent syphilis.
3 diagnosis
1. Epidemiological history
Have a history of unsafe contact; History of syphilis infection in pregnant women; Blood transfusion history.
2. Clinical manifestations
Syphilis has corresponding clinical manifestations at all stages. If it is latent syphilis, there is no obvious clinical manifestation.
3. Laboratory inspection
(1) Suspected skin lesions (such as chancre, verruca plana, wet papules, etc.). ) The movable Treponema pallidum was found under the dark field microscope, which can be used as a diagnostic basis for syphilis.
(2) Syphilis serological test There are many methods of syphilis serological test, including non-treponema pallidum antigen (cardiolipin antigen) and treponema pallidum specific antigen. The former includes rapid plasma reagin ring card test (RPR) and toluidine red unheated serological test (TRUST), which can be used as a quantitative test to judge the curative effect and the degree of disease activity. The latter, such as Treponema pallidum particle agglutination test (TPPA) and Treponema pallidum enzyme-linked immunosorbent assay (TP-ELISA), have strong specificity and are used to confirm Treponema pallidum infection.
Detection of IgM antibody of Treponema pallidum: After syphilis infection, IgM antibody first appeared, and with the development of the disease, IgG antibody appeared and rose slowly. After effective treatment, IgM antibody disappeared, while IgG antibody persisted. TP-IgM antibody cannot pass through placenta. If the baby is TP-IgM positive, it means that the baby has been infected. Therefore, the detection of TP-IgM antibody is of great significance to the diagnosis of infant fetal syphilis.
(3) Cerebrospinal fluid examination If syphilis patients have symptoms of nervous system, or those who are ineffective after the treatment of expelling plum, cerebrospinal fluid examination should be carried out. This examination is helpful for the diagnosis, treatment and prognosis of neurosyphilis. The examination items should include: cell count, total protein determination, RPR and TPPA test, etc.
4 Differential diagnosis
1. The chancre of primary syphilis should be differentiated from chancre, fixed drug eruption and genital herpes.
2. The lymphadenopathy of primary syphilis should be differentiated from the lymphadenopathy caused by chancre and lymphogranuloma of venereal diseases.
3. Secondary syphilis should be differentiated from pityriasis rosea, erythema multiforme, tinea versicolor, psoriasis and tinea corporis. Condyloma plana should be differentiated from condyloma acuminatum.
5 complications
1. Pregnant women infected with syphilis can infect the fetus, causing stillbirth, miscarriage and premature delivery, and causing congenital syphilis in infants, which seriously endangers the health of women and children.
2. Treponema pallidum invades the central nervous system and can cause meningeal angiopathy, spinal tuberculosis and paralytic dementia. Invasion of cardiovascular system can lead to Takayasu's arteritis, aortic valve insufficiency, aortic aneurysm and so on. In severe cases, it can be fatal.
3. Treponema pallidum damages bones, eyes, respiratory tract, digestive tract and other systems, resulting in tissue and organ damage, loss of function, and even disability or other adverse consequences. The prevalence of syphilis has seriously affected the social atmosphere. Due to illness, the labor force is lost and the social burden is aggravated. Syphilis can also affect family stability.
6 treatment
1. Treatment principles
Emphasize early diagnosis, early treatment, regular course of treatment and adequate amount. Regular clinical and laboratory follow-up after treatment. Sexual partners should also be investigated in the same way. Early syphilis can be cured clinically, and the infectivity can be eliminated after thorough treatment. The treatment of advanced syphilis can eliminate inflammation in tissues, but the damaged tissues are difficult to repair.
Penicillin, such as aqua penicillin, procaine penicillin and benzathine penicillin, is the first choice for syphilis at different stages. Those who are allergic to penicillin can choose tetracycline and erythromycin. Some patients may have Chi Hai reaction at the initial stage of penicillin treatment, which can be prevented by starting with a small dose or using other drugs. The serum should be rechecked every 3 months in the first year after syphilis treatment, and then every 6 months, ***3 years. Neurosyphilis and cardiovascular syphilis should be followed up for life.
2. Early syphilis (including primary and secondary syphilis and early latent syphilis)
Penicillin treatment (1) Benzathine penicillin G (benzathine benzylpenicillin for injection) was injected into bilateral gluteal muscles, once a week, ***2-3 times. Procaine penicillin G was injected into muscle for 0/200/0/5 days, with a total amount of 8 million U/0/20,000 U.
(2) Patients who are allergic to penicillin take tetracycline hydrochloride 15 days orally. Doxycycline 15 days.
3. Late syphilis (including tertiary syphilis of skin, mucosa and bones, late latent syphilis) and secondary recurrent syphilis.
(1) penicillin benzathine penicillin g, 1 time/week, intramuscular injection, ***3 times. Procaine penicillin G, intramuscular injection for 20 days. Treatment can be repeated after 2 weeks 1 time.
(2) For those allergic to penicillin, take tetracycline hydrochloride orally for 30 days. Doxycycline for 30 days.
4. Neurosyphilis
Should be hospitalized, in order to avoid Gieher reaction during the treatment, the day before penicillin injection, oral prednisone, 1 time/day, for 3 consecutive days.
(1) penicillin g intravenous injection 14 days.
(2) intramuscular injection of procaine penicillin G and oral administration of probenecid * * */kloc-0 ~14 days.
After the above treatment, benzathine penicillin g/kloc-0 was injected intramuscularly for 3 weeks.
5. Syphilis during pregnancy
According to the treatment plan of syphilis in the corresponding disease stage, a course of treatment is applied in the first 3 months of pregnancy; Apply a course of treatment in the third trimester of pregnancy. People who are allergic to penicillin are treated with erythromycin. Take 15 days for early syphilis, and take it for 30 days for secondary recurrence and late syphilis. The baby they gave birth to should be treated with penicillin.
6. Fetal syphilis (congenital syphilis)
Early congenital syphilis (less than 2 years old) with cerebrospinal fluid abnormalities: penicillin G or procaine penicillin G, the specific dose is as prescribed by the doctor. Patients with normal cerebrospinal fluid: Benzathine penicillin G, one injection (divided into gluteal muscles on both sides). If cerebrospinal fluid is examined unconditionally, it can be treated as abnormal cerebrospinal fluid.
7. Syphilis treatment for pregnant women
(1) Married women with a history of syphilis must have a comprehensive syphilis examination before pregnancy. Women who have had unclean sex or been infected with syphilis should go to a regular hospital for a comprehensive syphilis test before planning pregnancy. For those married women who have completed syphilis treatment and the symptoms of syphilis are not obvious, they can only get pregnant after confirming the cure of syphilis.
(2) Examination and treatment of syphilis during pregnancy: serological examination of syphilis should be done in the first three months and at the end of pregnancy. If syphilis is found, it should be treated regularly to reduce the chance of fetal syphilis.
8. Qihai reaction in syphilis treatment
Symptoms such as fever, headache, joint pain, nausea, vomiting and syphilis rash can appear within a few hours after the first treatment with poison, which belongs to Jihai reaction, and most of the symptoms will be relieved within 24 hours. In order to prevent the Chi-Hai reaction, penicillin can be gradually increased from a small dose to a normal dose. For neurosyphilis and cardiovascular syphilis, prednisone can be given for a short course before treatment, and it can be given in batches, and the drug is gradually stopped after 2 ~ 4 days of anti-plum treatment. Corticosteroids can reduce the pool-hai reaction of fever, but the effect on local inflammatory reaction is uncertain.
9. Dietary precautions
Like other infectious diseases, the diet after syphilis should eat more fresh vegetables and fruits rich in vitamins, eat less greasy food, avoid spicy food, quit smoking and drinking, and drink more water, which is conducive to the elimination of toxins in the body.
7 forecast
How to judge whether syphilis is cured after treatment is usually judged by syphilis serological test. At present, RPR (rapid plasma reagin ring card test) and TPPA (Treponema pallidum particle agglutination test) are widely used in major hospitals. RPR is a serological test of nonspecific syphilis, which is often used to judge the curative effect. TPPA has high sensitivity and specificity in detecting specific Treponema pallidum antibody in serum. Once this method is positive, no matter whether it is treated or whether the disease is active, it usually remains positive for life, and its titer change has nothing to do with whether syphilis is active or not, so it can not be used as an index to evaluate the curative effect or judge the recurrence and reinfection, but only as a confirmation test of syphilis.
Anyone diagnosed with syphilis had better do RPR quantitative test before treatment. Only when the difference of titer change between two quantitative tests exceeds 2 dilutions can the titer decrease be judged. Syphilis patients were reexamined every three months after regular treatment, and every six months after half a year. They were followed up for 2 ~ 3 years, and the changes of RPR titers were observed and compared. After 3 ~ 6 months of treatment, the titer decreased by more than 4 times, indicating that the treatment was effective. The titer can continue to decrease or even turn negative. If the results of three or four consecutive tests are negative, it can be considered that the patient's syphilis has been clinically cured.
There are three possible changes in serum reaction of syphilis patients after anti-plum therapy:
1. Serum turned negative.
2. The serum titer does not turn negative, or the serum is resistant.
3. After turning negative, it turns positive, or it rises again in the process of continuous decline, indicating recurrence or reinfection.
Syphilis is treated with different drugs at different stages, and the negative rate of serum reaction can be different. After receiving any anti-plum drugs, the seroconversion rate of primary and secondary syphilis is high, usually 70% ~ 95% within 1 ~ 2 years. Regular anti-May treatment 12 months for primary syphilis, and 24 months for secondary syphilis, the serum reaction remains positive, which is clinically called serum resistance or serum fixation. The reasons may be related to potential active lesions in the body, decreased immunity of patients, insufficient anti-May therapy dose or drug resistance, and some reasons cannot be found. For such patients, a comprehensive physical examination including cerebrospinal fluid examination and AIDS examination should be done to find out the possible causes and give corresponding treatment. If there is no special abnormality, you can follow up regularly and don't blindly give antibiotics over-treatment.
8 prevention
First, we should strengthen health education and publicity to avoid unsafe sexual behavior, and then take the following preventive measures and precautions.
1. Follow-up the sexual partners of patients, find all sexual contacts of patients, conduct preventive examination, follow-up observation and make necessary treatment, and prohibit sexual behavior before it is cured.
2. Preventive examination and syphilis serum test are carried out for all suspicious patients, so as to find patients early and treat them in time.
3. Pregnant women with syphilis should be given effective treatment in time to prevent syphilis from being transmitted 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 a regular blood collection point and do a comprehensive blood test before donating blood to prevent infection. If blood transfusion is needed, the blood transfusion unit needs to show the test certificate of blood transfusion to prevent unnecessary trouble.
5. Syphilis patients should pay attention to the combination of work and rest, carry out necessary functional exercises, and maintain a good attitude to facilitate rehabilitation.
6. Pay attention to the details of life to prevent others from being infected: early syphilis patients are highly contagious, and although the infectivity of late syphilis is gradually decreasing, attention should be paid to protection. Underwear and towels should be washed separately in time, boiled and disinfected, and don't bathe with others. When chancre or vulvar and perianal condyloma plana occurs, Chinese herbal medicines with the functions of clearing away heat and toxic materials, eliminating dampness and killing insects can be decocted, fumigated and bathed.
7. Syphilis patients should be forbidden to have sex before being cured, and condoms must be used if it happens.