What is primary syphilis. Primary syphilis. In addition to typical manifestations, atypical chancres are isolated

(Syphilis primaria)

After the incubation period (3-4 weeks), the primary period of syphilis (S. primaria) develops; characterized by the appearance of hard chancre; 7-10 days after the appearance of chancre, regional lymph nodes enlarge; at 4-5 weeks of existence of the chancre, polyadenitis develops; 3-4 weeks after the appearance of chancre, classical serological reactions (seroconversion) become positive, and therefore syphilis is distinguished: primary seronegative (S. primaria seronegativa) and primary seropositive (S. primaria seropositiva). The total duration of primary syphilis is 6-7 weeks. In the classical description, each of the listed features has characteristic features.

At the site where the infection occurred, i.e., the introduction of Treponema pallidum, a Chancre(primary syphiloma, syphilitic ulcer; ulcus durum, cancre - ulcer, French word) - The initial and characteristic sign of primary syphilis. Chancres are classified according to their location: genital (accounting for about 90%) and extragenital (some of them may be associated with sexual infection, for example, in the pubic area, abdomen, thighs). Of the genital chancres, the most common localization is the glans penis (in men), labia, posterior commissure (in women). Extragenital chancre can be on any part of the skin and mucous membranes (lips, tonsils, etc.). Chancres can be observed on the cervix, inside the urethra, in the rectum and other places (which presents difficulties in diagnosis). Moreover, the location of the chancre depends on the place of introduction of the pathogen (“with syphilis, the first place to be punished is the place where the sin was committed”).

A chancre is an erosion or superficial ulcer; more often single, round or oval in shape, with smooth, non-undermined edges, without signs of perifocal inflammation (around the chancre, the skin and mucous membranes retain their normal appearance). The bottom of the chancre is even, smooth, the meat is red. The main feature of primary syphiloma is the density at its base

(parchment, cartilaginous) - this is what the name “chancre” is associated with. Characteristic of chancre is its painlessness and the absence of other subjective sensations. When the primary syphiloma is pressed from the sides (or lightly massaged with a loop), a liquid appears - serum (the chancre “cries”); When examining the discharge (under a microscope in a darkened field of view), a pale spirochete can be detected. The size of chancre is on average equal to the size of a 10-15 kopeck coin, but can vary. In this case, chancres can be smaller (dwarf) or large (giant). Consequently, the small size of the erosion, its painlessness, without signs of acute inflammation are insidious features of syphilis (the patient may not pay attention to these minor manifestations and not consult a doctor!). Healing of erosive chancre occurs after 20-30 days (by epithelization; no trace remains in its place); a syphilitic ulcer regresses over a longer period of time and is observed in the secondary period of syphilis (with scar formation). Modern descriptions of the characteristics of primary syphilis often differ from the “classical” interpretations. Chancres began to occur more often - multiple, ulcerative and mixed (erosive-ulcerative), with weak basal compaction; cases of microchancres (dwarf syphilomas, in the form of abrasions, scratches, herpetic erosions, etc.) have become more frequent. With combined infections (syphilis and gonorrhea, chlamydia, scabies, genital herpes, etc.), primary syphiloma may have atypical manifestations.

Diagnosis and timely treatment continue to be difficult Atypical Chancrs:

-indurative edema- in this case, the infiltrate is not limited to the edges of syphiloma, but spreads beyond its limits; the affected area is sharply enlarged and compacted (in contrast to banal edema - pressing on the area of ​​infiltration does not leave a hole, since the compaction is based not on an accumulation of fluid, but on a cellular infiltrate;

-chancre-amygdalitis- hard chancre is located on the tonsil; unlike vulgar tonsillitis, there is a unilateral lesion; at the same time, the tonsil is sharply enlarged and thickened, there is no pain, increased body temperature and other subjective symptoms; occurs with painless enlargement of regional lymph nodes. Differentiation from the oncological process is also necessary. In the discharge of syphiloma, it is possible to detect Treponema pallidum, and thereby make a timely diagnosis;

Significant features - in relation to the clinic and course it has Chancre felon- ulcer at the end of the finger of the hand (usually the index finger). In this case, unlike ordinary chancre, it occurs with severe pain, pronounced inflammatory changes, which

Diagnosis is difficult. The lesion resembles a banal panaritium (can occur among medical workers - midwives, gynecologists, surgeons, pathologists, etc., as an occupational disease);

Atypical chancre includes syphiloma Like herpes or balanoposthitis.

Atypical chancre and complications of primary syphiloma (especially with secondary infection) significantly complicate the diagnosis of syphilis. Severe complications include circulatory and trophic disorders, leading to gross tissue destruction, gangrenization, phagedenism, phimosis, paraphimosis - with possible lymphangitis and reactive edema of the scrotum. As an outcome of some of these conditions, spontaneous amputations of the penis, disfiguring scarring, and dysfunction are described.

7-10 days after the appearance of chancre, an increase in the lymph nodes closest to syphiloma occurs, the so-called specific, syphilitic Regional sclera-denitis(“just as a shadow follows its owner, so regional scleradenitis always accompanies chancre”). Enlarged lymph nodes are oval, mobile, and not fused to each other or surrounding tissues; dense consistency, painless; the skin over them is not changed. One of the nodes is usually the most enlarged (in a figurative expression it is called the “mayor of the city”). When chancre is localized on the genitals, the inguinal lymph nodes on the same side enlarge, then after a few days - on the other side. Enlargement of the nearest lymph nodes is a natural phenomenon (an obligatory companion to primary syphiloma), but in some localizations of chancre they cannot be determined by palpation (with syphilomas on the cervix, in the rectum, the pelvic lymph nodes react).

2-3 weeks after the appearance of hard chancre, serological reactions (including Wasserman, sediment) turn from negative to positive - in connection with this, primary syphilis is divided into primary seronegative and seropositive. And from about 3-4 weeks after the appearance of chancre, all lymph nodes enlarge - a specific Polyadenitis(lymph nodes have a dense elastic consistency, painless, the skin over them is not changed, they are not fused to each other and the surrounding skin). Moreover, their sizes are usually smaller than the size of regional lymph nodes (in the same patient).

At the end of primary syphilis - a few days before the appearance of the rash of the secondary period, prodromal phenomena (harbingers) may be observed: weakness, malaise, headache, arthropathy; increase in body temperature.

Diagnosis of primary seronegative syphilis Placed on the basis of:

-clinics(hard chancre, enlargement of nearby lymph nodes - regional scleradenitis);

Confirmed Detection of Treponema pallidum(in the discharge of primary syphiloma or, if it is impossible to detect there, in the punctate of a regional lymph node).

In this case, CSR (carried out throughout the entire treatment, at least once every 5 days) must be persistently negative. In the laboratory diagnosis of primary seronegative syphilis, polymerase chain reaction (PCR) can be used. Any erosion or ulcer in the genital area (as well as the perineum, anus) should be examined for syphilis.

The diagnosis of primary seropositive syphilis is confirmed:

-characteristic clinic(hard chancre, development on 7-10 days

After this regional scleradenitis, after 4 weeks - polyadenitis); - detection and microscopic identification Pale

Treponema;

Positive DCS results are important - from the 3-4th week after the formation of syphiloma. It is legal to begin treatment only after laboratory verification.

Primary syphilis must be differentiated from other diseases - cancerous ulcers, genital herpes, chancriform pyoderma, erosive balanoposthitis, scabies ecthyma. You should also remember about diseases such as tuberculous ulcers, diphtheria ulcers, acute vulvar ulcers, trichomonas and gonorrheal ulcers.

Thus, we can draw an important conclusion from a practical point of view: any erosion or ulcer on the genitals, in the perineum, anus (especially painless, with basal compaction) must be excluded (or confirmed!) of syphilis within a short period of time. A doctor of any specialty should not begin treatment for such manifestations, and the patient must be urgently referred to a dermatovenerological institution. At the same time, a doctor of any specialty should be on “venereological alertness,” especially if the patient has “unusual,” “doubtful” erosive and ulcerative manifestations. In this case, early diagnosis and specific treatment are possible, which is important for the patient himself and those around him.

Primary syphilis- this is the initial stage of syphilis, manifested by chancre, often genital, with accompanying lymphadenitis. Extragenital and atypical primary lesions may occur. Previously, primary syphilis was divided into primary seronegative (the very initial stage with negative serological reactions) and seropositive (with positive serological reactions).

What causes Primary syphilis: The causative agent of syphilis is Treponema pallidum, belonging to the order Spirochaetales, family Spirochaetaceae, genus Treponema. Morphologically, treponema pallidum (pale spirochete) differs from saprophytic spirochetes (Spirochetae buccalis, Sp. refringens, Sp. balanitidis, Sp. pseudopallida). Under a microscope, Treponema pallidum is a spiral-shaped microorganism that resembles a corkscrew. It has on average 8-14 uniform curls of equal size. The total length of the treponema varies from 7 to 14 microns, thickness - 0.2-0.5 microns. Treponema pallidum is characterized by pronounced mobility, in contrast to saprophytic forms.

It is characterized by translational, rocking, pendulum-like, contractile and rotatory (around its axis) movements. Using electron microscopy, the complex morphological structure of Treponema pallidum was revealed. It turned out that the treponema is covered with a thick cover of a three-layer membrane, a cell wall and a mucopolysaccharide capsule-like substance. Under the cytoplasmic membrane there are fibrils - thin filaments that have a complex structure and cause diverse movement. Fibrils are attached to the terminal turns and individual sections of the cytoplasmic cylinder using blepharoplasts. The cytoplasm is finely granular, containing a nuclear vacuole, nucleolus and mesosomes. It was established that various influences of exo- and endogenous factors (in particular, previously used arsenic preparations, and currently antibiotics) had an impact on Treponema pallidum, changing some of its biological properties. Thus, it turned out that pale treponema can turn into cysts, spores, L-forms, grains, which, when the activity of the patient’s immune reserves decreases, can reverse into spiral-shaped virulent varieties and cause active manifestations of the disease. The antigenic mosaic nature of Treponema pallidum has been proven by the presence of multiple antibodies in the blood serum of patients with syphilis: protein, complement-fixing, polysaccharide, reagin, immobilisin, agglutinin, lipoid, etc.

Using an electron microscope, it was found that treponema pallidum in lesions is most often located in intercellular spaces, periendothelial space, blood vessels, nerve fibers, especially in early forms of syphilis. The presence of pale treponema in the periepineurium is not yet evidence of damage to the nervous system. More often, such an abundance of treponemes occurs during septicemia. During the process of phagocytosis, a state of endocytobiosis often occurs, in which treponemes in leukocytes are enclosed in a multimembrane phagosome. The fact that treponemes are enclosed in polymembrane phagosomes is a very unfavorable phenomenon, since, being in a state of endocytobiosis, treponema pallidums persist for a long time, protected from the effects of antibodies and antibiotics. At the same time, the cell in which such a phagosome has formed seems to protect the body from the spread of infection and progression of the disease. This precarious balance can persist for a long time, characterizing the latent (hidden) course of a syphilitic infection.

Experimental observations by N.M. Ovchinnikov and V.V. Delectorsky are consistent with the works of the authors who believe that when infected with syphilis, a long-term asymptomatic course is possible (if the patient has L-forms of Treponema pallidum in the body) and “accidental” detection of infection in the stage of latent syphilis (lues latens seropositiva, lues ignorata), i.e. e. during the presence of treponemes in the body, probably in the form of cyst forms, which have antigenic properties and, therefore, lead to the production of antibodies; this is confirmed by positive serological reactions to syphilis in the blood of patients without visible clinical manifestations of the disease. In addition, in some patients, stages of neuro- and viscerosyphilis are detected, i.e., the disease develops as if “bypassing” the active forms.

To obtain a culture of Treponema pallidum, complex conditions are required (special media, anaerobic conditions, etc.). At the same time, cultural treponemes quickly lose their morphological and pathogenic properties. In addition to the above forms of treponema, the existence of granular and invisible filterable forms of pale treponema was assumed.

Outside the body, treponema pallidum is very sensitive to external influences, chemicals, drying, heating, and exposure to sunlight. On household items, Treponema pallidum retains its virulence until it dries. A temperature of 40-42°C first increases the activity of treponemes and then leads to their death; heating to 60°C kills them within 15 minutes, and to 100°C kills them instantly. Low temperatures do not have a detrimental effect on treponema pallidum, and currently, storing treponemes in an oxygen-free environment at temperatures from -20 to -70 ° C or frozen dried is a generally accepted method for preserving pathogenic strains.

Pathogenesis (what happens?) during Primary syphilis: The reaction of the patient's body to the introduction of Treponema pallidum is complex, diverse and insufficiently studied. Infection occurs as a result of penetration of Treponema pallidum through the skin or mucous membrane, the integrity of which is usually compromised. However, a number of authors admit the possibility of the introduction of treponema through an intact mucous membrane. At the same time, it is known that in the blood serum of healthy individuals there are factors that have immobilizing activity against Treponema pallidum. Along with other factors, they make it possible to explain why infection is not always observed upon contact with a sick person. Domestic syphilidologist M.V. Milich, based on his own data and analysis of the literature, believes that infection may not occur in 49-57% of cases. The variation is explained by the frequency of sexual intercourse, the nature and localization of syphilides, the presence of an entrance gate in the partner and the number of pale treponemas that have penetrated the body. Thus, an important pathogenetic factor in the occurrence of syphilis is the state of the immune system, the tension and activity of which varies depending on the degree of virulence of the infection. Therefore, not only the possibility of no infection is being discussed, but also the possibility of self-healing, which is considered theoretically acceptable.

Symptoms of Primary syphilis: International Classification of Diseases X Revision International Statistical Classification of Diseases and Related Health Problems 10th Revision Version for 2006 currently classifies primary syphilis as follows.
- Primary syphilis of the genital organs.
- Primary syphilis of the anal area.
- Primary syphilis of other localizations.

In exceptional cases, primary syphilis can be asymptomatic - the so-called "decapitated" syphilis.

The primary period of syphilis in the classical course begins 3-4 weeks after infection and lasts 5-6 weeks. Currently, there is a shortening (up to 2 weeks) or lengthening (up to 6 months) of the incubation period of syphilis. An extension of time may be associated with taking even a small dose of antibiotics from the tetracycline, erythromycin (macrolides), and penicillin groups.

7-10 days after the appearance of the primary affect (lesion), an increase in inguinal lymph nodes (syphilitic lymphadenitis) is observed. At the same time, positive serological reactions to syphilis become. Even in the absence of treatment, healing occurs within 1-2 months with a superficial scar that retains the shape of the chancre.

Clinical picture of primary syphilis characterized by the manifestation of primary syphiloma (hard chancre), regional lymphadenitis and sometimes lymphangitis, developing in the direction from the hard chancre to nearby enlarged lymph nodes.

Chancre is formed in patients after the end of the incubation period and is located at the site of penetration of pale treponema into the skin or mucous membranes. Hard chancre is most often localized on the skin and mucous membranes of the genital organs (head of the penis, area of ​​the preputial sac, anus in homosexuals, labia majora and minora, posterior commissure, cervical area), less often on the hips, pubis, and abdomen. Extragenital chancre, which is much less common, occurs on the lips, tongue, tonsils, eyelids, fingers and any other area of ​​the skin and mucous membranes where the penetration of pale treponema occurred. In these cases, they talk about the extragenital location of primary syphiloma. Extragenital hard chancres, as well as when they are localized on the cervix (according to some data, in 11-12% of cases) are often not detected, and primary syphilis is not diagnosed in a timely manner. The clinical picture of chancre is, as a rule, very characteristic. More often it is a single erosion of regular round or oval shape, saucer-shaped with sharp clear boundaries, usually the size of the little fingernail, but it can be larger. The color of the erosions is meat-red or similar to the color of spoiled lard, the edges are slightly raised and gently descend to the bottom (saucer-shaped). The erosion discharge is serous, scanty and gives the chancre a shiny, “varnished” appearance. The most characteristic sign of hard chancre is an infiltrate of dense elastic consistency, which is palpated at the base of the erosion (hence the name - ulcus durum). In ulcerative chancroid, the edges protrude higher above the bottom, the infiltrate is more pronounced. After healing, ulcerative chancroid leaves a scar, while erosive chancre heals without a trace. Much less common are several chancre. Primary syphiloma is characterized by slight pain or complete absence of subjective sensations. Treponema pallidum is easily found in the discharge of primary syphiloma when examined in a dark field.

In recent years, the number of changes in the clinical picture of chancroid has increased. If, according to many authors, previously one of the significant features of primary syphiloma was its solitary nature (80-90% of cases), then in recent decades the number of patients with two or more chancre has increased significantly. Along with this, there is a significant increase in the proportion of ulcerative chancre and their complication by pyogenic infection. The number of patients with chancre in the anogenital area has increased. A certain amount of chancre in the mouth and anus is associated with sexual perversion. Thus, the proportion of oral chancre is much higher in women. In men with extragenital localization, chancre is most often located in the anus. One of the features of the modern course of primary syphilis is the absence in some cases of a clearly defined compaction at the base of primary syphiloma.

Atypical forms of primary syphiloma are relatively rare; usually they can be of several varieties: chancre-amygdalitis, chancre-felon and indurative edema.

On the fingers, hard chancre can occur in the usual clinical form, but it can occur atypically (chancre-felon). This localization of chancre is observed mainly among medical personnel (laboratory assistants, gynecologists, dentists, etc.).

Chancre felon the clinical picture resembles a banal panaritium of streptococcal etiology (club-shaped swelling of the terminal phalanx, severe pain), however, recognition is facilitated by the presence of a dense infiltrate, the absence of acute inflammatory erythema and, most importantly, the presence of characteristic regional (in the area of ​​the ulnar lymph nodes) lymphadenitis.

Indurative edema as a manifestation of primary syphilis, it is located in the area of ​​the labia majora, scrotum or foreskin, i.e. places with a large number of lymphatic vessels. Swelling of these areas is noted. Characterized by a pronounced compaction of tissues, when pressure is applied to them, indentations do not form.

The diagnosis of atypical chancre in the form of indurative edema is also facilitated by the presence of characteristic regional lymphadenitis, anamnesis, examination data of the sexual partner and positive results of a serological blood test for syphilis (in the second half of the primary period).

In a number of patients, primary syphiloma is complicated by an associated secondary bacterial infection. In these cases we speak of complicated chancre.

For chancre-amygdalitis characterized by enlargement and thickening of one tonsil in the absence of erosion or ulcer on it (if there is an erosion or ulcer on the tonsil of the primary period of syphilis, then they speak of primary syphiloma located on the tonsil).

When localized on the tonsil, hard chancroid can have one of three forms: ulcerative, sore throat-like (chancre-amygdala) and combined: ulcerative against a background of tonsillitis-like. In the ulcerative form, the tonsil is enlarged and dense; against this background, a fleshy-red oval ulcer with flat, smooth edges is observed. The mucous membrane around the ulcer is hyperemic.

At sore throat-like chancre There is no erosion or ulcer, there is a unilateral significant enlargement of the tonsil. It acquires a copper-red color and is painless and dense. The process differs from angina in the one-sidedness of the lesion, the absence of pain and acute inflammatory hyperemia. There are no general symptoms, body temperature is normal.

There are no pronounced inflammatory phenomena in the circumference of the tonsil, sharp boundaries are noted, there is no temperature reaction and no pain when swallowing. When palpating the tonsil with a spatula, its elasticity is felt. In these cases, a large number of pale treponemas are easily found on the surface of the tonsil (after lightly stroking with a platinum loop). Diagnosis is facilitated by the presence of regional scleradenitis, characteristic of the primary period of syphilis, in the neck at the angle of the lower jaw (lymph nodes ranging in size from large beans to hazelnuts, mobile, densely elastic consistency, not fused with the surrounding tissue, painless) and the appearance of positive serological blood reactions.

TO complications of chancroid include balanitis, balanoposthitis, phimosis, paraphimosis, gangrenization and phagedenism. Balanitis and balanoposthitis are the most common complications of chancroid. They arise as a result of the addition of a bacterial or trichomonas infection. In these cases, swelling, bright erythema, maceration of the epithelium appear around the chancre, and the discharge on the surface of the chancre becomes serous-purulent. The latter circumstance greatly complicates the detection of Treponema pallidum and, consequently, diagnosis. To eliminate inflammatory phenomena, lotions with isotonic sodium chloride solution are prescribed (for 1-2 days), which makes it possible in most cases to establish the correct diagnosis with repeated studies.

Balanoposthitis can lead to a narrowing of the foreskin cavity, which does not allow opening the head of the penis. This condition is called phimosis. With phimosis, due to swelling of the foreskin, the penis appears enlarged, reddened, and painful. Hard chancre, localized in these cases in the coronary sulcus or on the inner layer of the foreskin, cannot be examined for treponema pallidum. The diagnosis of syphilis is facilitated by the characteristic appearance of regional lymph nodes, in the puncture of which the pathogen is looked for. An attempt to forcibly open the glans penis in the presence of phimosis can lead to another complication called paraphimosis (“noose”), in which a swollen and infiltrated preputial ring pinches the glans. As a result of mechanical disruption of blood and lymph circulation, swelling increases. If measures are not taken in a timely manner, necrosis of the tissues of the glans penis and the cavity of the foreskin may occur. In the initial stages of paraphimosis, the doctor, having released serous fluid from the edematous cavity of the foreskin (for which the thinned skin is repeatedly pierced with a sterile needle), attempts to “reduce” the head. If there is no effect, the foreskin must be cut.

More severe, but also rarer complications of chancroid are gangrenization And phagedenism. They are observed in weakened patients and alcoholics as a result of the addition of fusospirillosis infection. A dirty-black or black scab forms on the surface of the chancre (gangrenization), which can spread beyond the primary syphiloma (phagedenism). Under the scab there is an extensive ulcer, and the process itself may be accompanied by fever, chills, headache and other general phenomena. After the gangrenous ulcer heals, a rough scar remains.

Regional lymphadenitis (scleradenitis) is the second most important symptom of primary syphilis. It appears 7-10 days after the onset of chancre. Since the time of Ricor, regional scleradenitis has been given the deeply meaningful name “accompanying bubo.” Ricor wrote: “He (skleradenite) is the faithful companion of the chancre, he invariably accompanies him, fatally he follows the chancre like a shadow... There is no hard chancre without a bubo.” Fournier noted the absence of regional scleradenitis in only 0.06% of 5000 patients with primary active syphilis. However, in recent decades, according to a number of authors, regional scleradenitis is absent in 1.3-8% of patients with primary syphilis.

The lymph nodes closest to the chancroid (most often inguinal) enlarge to the size of a bean or hazelnut, become densely elastic, they are not fused to each other, surrounding tissues and skin, and are painless; the skin over them is not changed. Regional lymphadenitis continues for a long time and resolves slowly, even despite specific treatment. When hard chancre is localized in the cervix and on the mucous membranes of the rectum, it is not possible to clinically determine regional lymphadenitis, since in these cases the lymph nodes located in the pelvic cavity become enlarged.

When primary syphiloma is localized on the genitals, inguinal lymphadenitis is most often bilateral (even in cases where the chancre is located on one side). This occurs due to the presence of well-developed anastomoses in the lymphatic system. Unilateral lymphadenitis is less common, usually observed on the side where the chancre is located, and only as an exception is it of a “cross” nature, i.e., located on the side opposite the chancre. Recently, the number of patients with unilateral lymphadenitis has increased markedly (according to Yu.K. Skripkin, they make up 27% of patients with chancroid).

Syphilitic lymphangitis(inflammation of the lymphatic vessels) is the third symptom of primary syphilis. It develops in the form of a dense, painless cord the size of a nug probe. Sometimes small, clear-shaped thickenings form along the cord. In approximately 40% of men, lymphangitis is located in the area of ​​the anterior surface of the penis (with genital chancre).

Lesions of the oral mucosa are the most common. Hard chancroid can occur on any part of the red border of the lips or the oral mucosa, but is most often localized on the lips, tongue, and tonsils.

The development of hard chancre on the lip or oral mucosa, as in other places, begins with the appearance of limited redness, at the base of which, within 2-3 days, compaction occurs due to the inflammatory infiltrate. This limited compaction gradually increases and usually reaches 1-2 cm in diameter. In the central part of the lesion, necrosis occurs and a meat-red erosion is formed, less often an ulcer. Having reached full development within 1-2 weeks, a hard chancre on the mucous membrane usually appears as a round or oval, painless flesh-red erosion or ulcer with saucer-shaped edges ranging in size from 3 mm (dwarf chancre) to 1.5 cm in diameter with dense elastic infiltrate at the base. In scraping the surface of the chancre, pale treponema is easily detected. Some erosions are covered with a grayish-white coating. When a chancre is located on the lips, significant swelling sometimes forms, as a result of which the lip sag, and the chancre lasts longer than in other places. More often one hard chancre develops, less often - two or more. If a secondary infection occurs, the erosion may deepen, resulting in the formation of an ulcer with a dirty gray necrotic coating.

When chancre is localized on the lips or oral mucosa, regional lymphadenitis develops 5-7 days after its appearance. In this case, the mental and submandibular lymph nodes usually become enlarged. They are of dense elastic consistency, mobile, not welded together, and painless. However, in the presence of a secondary infection or traumatic moments due to the development of periadenitis, the regional lymph nodes may become painful. Simultaneously with the submandibular and mental lymph nodes, the superficial cervical and occipital lymph nodes may enlarge.

Atypical forms of primary syphiloma are found when hard chancre is localized in the corners of the mouth, on the gums, transitional folds, tongue, and tonsils. In the corners of the mouth and in the area of ​​transitional folds, the chancre takes on the appearance of a crack, but when the fold in which the chancre is located is stretched, its oval outline is determined. When a hard chancre is located in the corner of the mouth, it can clinically resemble jams, which are distinguished by the absence of compaction at the base.

On the tongue, hard chancre is usually single, occurring more often in the middle third. In addition to the erosive and ulcerative forms, in persons with a folded tongue, when hard chancre is localized along the folds, a slit-like form may be observed. When a hard chancre is located on the back of the tongue, due to significant infiltration at the base, the chancre sharply protrudes above the surrounding tissue, and there is flesh-red erosion on its surface. Noteworthy is the absence of inflammation around the chancre and its painlessness. Hard chancre in the gum area has the appearance of a bright red smooth erosion, which surrounds 2 teeth in the form of a crescent. The ulcerative form of chancre of the gums is very similar to banal ulceration and has almost no signs characteristic of primary syphiloma. Diagnosis is facilitated by the presence of a bubo in the submandibular region.

Diagnosis of Primary syphilis: The diagnosis is made based on the clinical picture and laboratory confirmation by any of the following methods:
- Dark field research
- MR
- RIF, ELISA, RPGA
It must be taken into account that although in the modern classification there is no division of primary syphilis into seronegative and seropositive, within 7-14 days serological tests can be negative.

Treatment of Primary syphilis: The World Health Organization recommends that in case of a characteristic clinical picture, primary syphilis should be treated without laboratory confirmation of the diagnosis.

Treatment of syphilis consists in the use most often of durable penicillin drugs according to standard methods; in case of intolerance to penicillin, reserve drugs are prescribed.

Cure criteria: disappearance of clinical manifestations, seronegation within a year after treatment.

Sexual partners: are examined without fail, in the absence of signs of the disease and negative seroreactions, or are subject to clinical and serological control for 3 months, or receive preventive treatment.

22.06.2017

Primary Syphilis is the initial form of development of the disease syphilis, which is manifested by hard chancroid and inflammation of the lymphatic system.

Primary Syphilis lesions can be extragenital and atypical, but most oftensigns of syphilismanifest as syphilitic chancre in the genital area of ​​an infected person.

Symptoms of Primary Syphilis

According to the international classification todayprimary syphilisclassified as follows:

• Primary Syphilis of the genital organs;
• Primary Syphilis of the anal region;
• Primary Syphilis of other local places.

In some rare casessyphilis initial stagecourse of the disease, occurs without visible symptoms, which classifies it as a separate point in the classification.

Primary period of syphilisappears after the end of the incubation period. On average, the incubation period lasts from 21 calendar days to 50 days after the bacterium enters the human body. Within a period of up to 20 days from the moment of infection, even tests show a negative result for this disease.

The duration of the incubation period of syphilis disease is extended:

• a condition of the body that is accompanied by elevated temperature;
• treatment with a complex of antibiotics;
• age, the older the person, the longer this period.

During the incubation period, the spirochete infection manages to get into many organs and lymph, and begins to multiply, which causes an inflammatory process.

If a lot of treponemas enter the human body, in this case the incubation period is significantly reduced and the manifestation of the disease begins faster.

Even during the period when a person has a seronegative stage of the disease and tests show a negative result, it is possible to become infected from it through the blood.

Signs of primary syphilis

First stage of syphilismanifests itself in enlarged lymph nodes and chancre. Thissymptoms of syphilisduring the first period of the disease. Chancre is a round ulcer with a diameter of about one centimeter on the patient’s body. They are red and blue in color, sometimes they are painful, but generally the patient does not perceive pain at the site of erosion. Firstsigns of syphilisin men: formation of chancre on the head of the penis, and in womensigns of syphilisappear on the walls of the uterus and on the external genitalia. Also, these ulcers can manifest on the pubis, near the anus, on the tongue and lips.

Syphilis develops quickly, and the lymph nodes become inflamed and enlarged first, and then the formation of hard chancre.

Towards the end of this period the following symptoms appear:

• state of general malaise;
• constant headache;
• elevated temperature;
• pain in muscle tissue;
• aches and pain in the bones;
• decreased hemoglobin level;
• significant increase in leukocytes.

An undiagnosed disease in the first stage of development, and not started drug treatment, provoke the transition of syphilis to the second stage of development, which significantly aggravates the course of the disease.

Atypical chancre of primary syphilis

Signs of primary syphilisIn addition to hard chancre, atypical chancre can develop. Atypical chancre has many types:

• indurative edema is a large lump that forms on the foreskin of the penis, genitals in women and in the lip area on a person’s face;
• Panaritium is a chancre that develops on the nails and does not heal for several months. There may even be nail rejection;
• lymph nodes - increase in this period. Depending on which part of the body the chancre formed, the lymph nodes closest to the chancre become inflamed;
• a bubo is a lymph node that has a mobile shape and has no painful signs and is located closest to the chancre: on the patient’s neck, if the chancre is in the tonsils, and on the groin part of the body, if the chancre is in the genital area;
• polyadenitis is inflammation and hardening of all lymph nodes, from this moment we can assume that symptoms of secondary syphilis began to appear.

Complications of syphilis in the first period can be very serious both for the female body and also have serious consequences for the male body.

Ways of infection with syphilis

The sexually transmitted disease syphilis is transmitted in several ways:

• sexual contact not protected by a condom;
• through blood from a sick person to a healthy person;
• in utero from a sick mother to a newborn child;
• through mother's milk when feeding a baby;
• through general hygiene items;
• It is quite rare that the disease is transmitted through saliva.

The most common causes of syphilis are unprotected sexual contact and the use of one syringe among drug addicts. The best way to protect yourself from infection is to use a condom. Even if you used a condom during sexual intercourse with a casual partner, it is necessary to treat the genitals with antiseptics. In order to make sure that this sexual contact did not bring you “surprises,” you need to consult a doctor. Testing for syphilis takes place almost a month after exposure.

All ulcers and erosions on the body of a person suffering from syphilis are very dangerous, because the separated fragments of these wounds are contagious and can infect a healthy person through contact if he has abrasions and microtraumas on the skin.

From the very first day until the final period of recovery, the patient’s blood has an infectious form and there are possible ways to transmit syphilis through a shared razor, syringe, during procedures in beauty parlors, during manicures and pedicures.

Diagnosis of syphilis after the incubation period

In order to establish a diagnosis of syphilis, it is necessary to conduct an examination of the body for the presence of syphiloma in the body. It is necessary, first of all, to visit the office of a venereologist, who will examine the patient and refer him for tests. Only after a person’s skin, genitals and lymph nodes have been examined, as well as the results of laboratory tests, can a correct diagnosis be made and treatment prescribed.

For laboratory confirmation of syphiloma in the body, you need to submit for analysis a scraping from a chancre ulcer or a smear of syphilitic discharge from the genitals.

20-21 days after syphiloma enters the body, the seropositive stage of the disease begins, and tests show a positive result for the presence of syphilis.

Differential diagnostic testing of primary syphilis is carried out:

• with traumatic erosion of the genital organs;
• with allergic balanitis or trichomonas balanitis, with balanoposthitis, in people who do not maintain intimate hygiene;
• with balanoposthitis, which passes into the stage of gangrene, which can develop either independently or be a complication of diseases of the genital area;
• with chancre, genital lichen, staphylococcal infection, streptococcal infection or fungal diseases;
• with ulcers and erosions caused by gonococcal infection and Trichomonas;
• with ulcers on the labia of female adolescents.

Diagnosis of syphilis consists of several types of examinations and tests:

• serological diagnosis is the detection of Treponema bacteria from scraping of chancre. Based on the results of this examination, the doctor makes a diagnosis;
• Treponema immobilization reaction;
• immunofluorescence reaction;
• Wasserman reaction;
• microreaction on glass;
• linked immunosorbent assay;
• microprecipitation reaction;
• passive hemagglutination reaction.

Based on a diagnostic examination and laboratory results, a venereologist draws up a treatment regimen for syphilis in the primary stage.

Treatment of syphilis at the first stage of disease development

At the primary stage, the task is to cure the infection and prevent syphilis from moving into the second stage. Syphilis is a disease that takes a long time to treat. If syphilis was diagnosed at the first stage, in this case treatment can take up to 90 calendar days.

If the diagnosis showed syphilis at the second or later stage, then drug treatment can last for up to 2 years. All family members should undergo examination and undergo a complex of treatment for prevention.

The main drugs used in the treatment of primary syphilis are antibiotics of different groups and directions:

• penicillins;
• macrolites;
• tetracyclines;
• fluoroquinolones.

Together with antibiotics, the following are involved in the treatment of primary syphilis:

• antifungal drugs;
• immunomodulators;
• multivitamins;
• probiotics.

Treatment of primary syphilismethod: administration of penicillins every 3 hours for 24 days in a hospital setting. Patients with early hidden appearance are treated in the clinic for at least 3 weeks. After this, you can continue treatment on an outpatient basis. The duration of treatment depends on the stage of the disease and its severity. In case of allergy to penicillin, the patient is administered macrolides, fluoroquinolones and tetracyclines and medicines based on bismuth and iodine. This complex of drugs can increase the effect of the antibiotic in the body. Also, when treating a disease, in addition to antibiotics, vitamins and immunostimulants are prescribed to the patient.

When diagnosed with syphilis - treat both sexual partners are necessary.

At the time of therapy, the patient is prescribed a diet in which protein foods predominate and the consumption of fats and carbohydrates is limited.

At this stage Smoking and drinking alcohol are contraindicated, and it is also necessary to reduce physical stress on the body.

The main condition for quality treatment is to observe the rules of personal hygiene and refrain from sexual contact during the treatment period, even if they are protected by a condom.

Primary syphilis treatmentyou need to start with antibiotics:

• Josamycin 750 mg 3 times a day;
• Erythromycin - 0.5 mg taken 4 times a day;
• Doxycycline - 0.5 mg taken 4 times a day;
• Extensillin - intramuscular injections, two injections are enough;
• Bicillin - injections, two injections, every 5 days.

For local treatment of chancre with primary syphilis, lotions on the chancre using the drug benzylpenicillin and the drug dimexide are necessary.

It is necessary to lubricate the syphilitic chancre with heparin ointment, erythromycin ointment, ointment based on mercury and bismuth. Synthomycin ointment and levorin ointment help remove pus from the ulcer.

Chancres that are in the mouth must be rinsed with solutions:

• furatsilina;
• boric acid;

The earlier an infection is detected in the body, the sooner treatment of the disease will begin, and the duration of the course of drug treatment may be minimal. In this case, self-medication is unsafe for the body. Only a competent doctor can establish a diagnosis and prescribe the necessary treatment.

Compliance with all doctor’s instructions, a healthy lifestyle, and hygiene will give a positive result in curing syphilis at the first stage of the disease.

Treatment of the disease is carried out with penicillin drugs, which are administered intramuscularly every three hours, twice a day - novocaine salt and benzylpenicillin, or combination drugs according to the regimen. The duration of treatment and dosage depends on the form of primary syphilis.

Patients who are on penicillin are prescribed dixycycline and tetracycline.

It is imperative to examine and treat all the patient’s sexual partners.

Complications of primary syphilis

The disease is quite often accompanied by trichomonas or secondary bacterial infection, which leads to the development of or.

The localization of chancre in the eternal sulcus significantly complicates diagnosis, since its examination is impossible. An attempt by the patient to open the head on his own can lead to its pinching and development.

Much less frequently, a complication occurs in the form of gangrenization caused by fusospirillosis infection. In this case, the chancre is covered with a black scab.

At the end of treatment, patients with seronegative primary syphilis must undergo clinical observation for another year, and those with seropositive primary syphilis for three years. During this period, constant monitoring is carried out by conducting an RPR test. Primary syphilis is the first stage of syphilis, which occurs after infection with Treponema pallidum and begins with skin manifestations at the site of its penetration.Primary syphilis

characterized by the appearance of primary syphiloma (hard chancre) on the mucous membrane or skin, followed by the development of regional lymphadenitis and lymphangitis.

Modern medicine notes an increase in ulcerative forms of chancroid and forms of primary syphilis, complicated by pyoderma. Also more common are hard chancres located on the mucous membrane of the mouth, in the anus.

Syphilis is primarily transmitted through sexual contact and is therefore classified as a sexually transmitted disease or sexually transmitted infection (STI). Syphilis can be transmitted through blood (in injection drug addicts when using shared syringes, when using shared toothbrushes or razors in everyday life, when receiving blood transfusion from a donor infected with syphilis).

The household route of infection with syphilis is not excluded, but it is rare and requires close contact with a person who has tertiary syphilis and has disintegrating syphilitic gummas and open syphilitic ulcers.

It is possible for a child to become infected through mother's milk.

Symptoms of primary syphilis

Symptoms of primary syphilis appear 10-90 days after infection. The site of appearance of chancre corresponds to the site of introduction of Treponema pallidum. Most often these are the genital organs: the glans penis, foreskin - in men, labia, mucous membrane of the cervix, vagina - in women. Recently, extragenital (outside the reproductive system) location of the chancre has become increasingly common with primary syphilis: on the fingers, mucous membrane or skin of the anus, thighs, abdomen, pubis, mucous membrane of the tongue, lips, oral cavity.

Chancre is a fleshy-red, round erosion with a diameter of up to one centimeter. It has raised edges, which gives it a saucer-shaped appearance, and the serous discharge makes the erosion surface seem varnished. At the base of the erosion, a dense infiltrate is determined. As a rule, primary syphilis is not accompanied by subjective sensations. Resolution of chancre occurs without leaving any marks on the skin or mucous membrane.

Sometimes primary syphilis occurs with the appearance of atypical forms of chancre: indurative edema, chancre-felon, chancre-amygdalitis. Indurative edema occurs in the area of ​​the foreskin, scrotum or labia majora. Chancroid-amygdalitis is manifested by thickening of the tonsil and unilateral painless enlargement, accompanied by a red-copper coloration. Chancroid felon most often develops in medical workers. It is characterized by swelling and hardening of the terminal phalanx of the finger.

Diagnostics

Identification of chancre, as well as the presence of information about unprotected sexual intercourse, is the main point in diagnosing primary syphilis.

To clarify the diagnosis, a study of the chancre discharge is carried out to detect treponema pallidum. Sometimes a puncture sample taken during a lymph node biopsy is examined for treponema pallidum.

Serological reactions (RIBT, RIF, RPR test) become indicative 3-4 weeks after the onset of the disease. In the early period of primary syphilis, PCR diagnostics are used.

Classification

• primary seronegative syphilis - serological tests give a negative result;
• primary seropositive syphilis - with a positive serological reaction to syphilis;
• latent primary syphilis - the disease occurs with the absence of clinical manifestations, and can be seronegative or seropositive.

Patient Actions

If symptoms of syphilis (chancroid) appear, you should consult a dermatovenerologist.

Treatment of primary syphilis

Treatment of primary syphilis is carried out with antibacterial agents of the penicillin series. It is also important to examine and treat the patient’s sexual partners.

Patients with an allergic reaction to penicillin may be treated with tetracycline or doxycycline.

After treatment, patients with seronegative primary syphilis are subject to mandatory clinical observation for a year, with seropositive primary syphilis - for 3 years. Throughout the entire period of clinical observation, cure is monitored by conducting an RPR test. If necessary, additional treatment is prescribed.

Complications

Primary syphilis is most often complicated by trichomonas or secondary bacterial infection with the development of balanoposthitis or balanitis. Balanoposthitis can lead to narrowing of the foreskin and the occurrence of phimosis and paraphimosis.

A rarer complication is gangrenization. The spread of the process beyond the chancre indicates the development of phagedenism.

Prevention of primary syphilis

It is necessary to avoid casual sexual contact, use barrier methods of contraception, and also use antiseptics (hexicon, etc.) after each sexual intercourse.