Syphilis
Syphilis (syphilis) is a chronic, systemic sexually transmitted disease caused by the pale spirochete. It can be divided into acquired syphilis and fetal syphilis (congenital syphilis). Acquired syphilis is further divided into early and late syphilis. Early syphilis refers to infection with the syphilis spirochete within 2 years, including stage I, stage II and early recessive syphilis, and stage I and II syphilis can also overlap. Late syphilis has a duration of more than 2 years and includes stage III syphilis, cardiovascular syphilis, and late recessive syphilis. Neurosyphilis can occur in both the early and late stages of syphilis. Fetal syphilis is further divided into early stage (onset within 2 years after birth) and late stage (onset after 2 years of birth).
I. Diagnosis
1, a syphilis.
(1) epidemiological history: unsafe sex, multiple sexual partners or history of sexual partner infection.
(2) Clinical manifestations: ①Hard chancre: incubation period is usually 2 to 4 weeks. It is often single, but can also be multiple. It is a nodule of corn grain size above the skin surface, and later develops into a round or oval shallow ulcer of about 1 to 2 cm in diameter. The nodules are usually well-defined, with slightly elevated margins and a flat, clean surface; the infiltration is obvious on palpation and is cartilage-like in hardness; there is no obvious pain or mild tenderness. (2) Swollen lymph nodes in the groin or near the affected area: unilateral or bilateral, painless, isolated from each other and not adherent, medium in quality, not purulent or broken, without redness, swelling or heat on the surface skin.
(3) Laboratory examination: (1) Dark-field microscopy or silver-plated microscopy can be used to detect syphilis spirochetes by taking the exudate of sclerosing chancre or lymph node puncture fluid, but the detection rate is low; (2) non-syphilis spirochete serological test is positive. If the infection is less than 2 to 3 weeks, the test may be negative and should be rechecked after 4 weeks of infection; (3) Positive syphilis spirochete serology test, which may be negative at the very early stage.
(4) diagnostic classification: ① suspected cases: should meet both the clinical manifestations and laboratory tests in ②, may or may not have epidemiological history; or meet both the clinical manifestations and laboratory tests in ③, may or may not have epidemiological history; ② confirmed cases: should meet both the requirements of suspected cases and laboratory tests in ①, or meet both the requirements of suspected cases and both types of syphilis serological test is positive.
2, phase II syphilis.
(1) Epidemiological history: history of unsafe sex, multiple sexual partners or sexual partner infection, or history of blood transfusion (the blood donor is a patient with early syphilis).
(2) Clinical manifestations: There may be a history of stage I syphilis (usually 4-6 weeks after the onset of hard chancre), and the disease lasts for 2 years. (1) Skin and mucous membrane damage: The types of lesions are diverse, including macules, maculopapular rash, papules, scaly lesions, follicular rash and pustular rash, etc. They are distributed on the body and extremities, and are often generalized and symmetrical. Dark erythematous and desquamative macules on the palms and plantars, and eczema or flat warts on the vulva and perianal area are the characteristic damages. The rash is usually not pruritic. Oral mucosal plaques and worm-like alopecia may occur. The number of second-stage recurrent syphilis lesions is small, and the lesions are peculiar in shape, often in the form of rings or arcs or arcs; ② the superficial lymph nodes of the body may be enlarged; ③ syphilitic bone and joint, eye, visceral and neurological damage may occur.
(3) laboratory tests: ① using dark field microscopy or silver-plated staining microscopy method, take the second-stage skin lesions, especially flat warts, wet papules, can be detected syphilis spirochetes. Oral mucosal spots are not easily distinguished from other spirochetes in the oral cavity, so this method is not used; ② positive serological test for non-syphilis spirochetes; ③ positive serological test for syphilis spirochetes.
(4) diagnostic classification: ① suspected cases should meet both the clinical manifestations and laboratory tests in ②, may or may not have an epidemiological history; ② confirmed cases should meet both the requirements of suspected cases and laboratory tests in ①, or both the requirements of suspected cases and both types of syphilis serological tests are positive.
3, stage III syphilis.
(1) Epidemiological history: history of unsafe sex, multiple sexual partners or sexual partner infection, or history of blood transfusion.
(2) Clinical manifestations: there may be a history of stage I or II syphilis, and the duration of the disease is more than 2 years. (1) Late syphilis: a. Skin and mucous membrane damage: nodular syphilis rash on the head, face and extremities, subarticular nodules near large joints, dendritic swelling of the skin, mouth, tongue and throat, and mucous membrane dendritic swelling of the palate and nasal septum can lead to perforation of the palate and septum and saddle nose. b. Bone syphilis, ocular syphilis, other visceral syphilis involving the respiratory tract, digestive tract, liver and spleen, genitourinary system, endocrine glands and skeletal muscles. (2) cardiovascular syphilis, which can occur as simple aortitis, aortic valve atresia insufficiency, aortic aneurysm, etc.
(3) Laboratory tests: ① positive serological test for non-syphilis spirochetes, very few advanced syphilis can be negative; ② positive serological test for syphilis spirochetes.
(4) diagnostic classification: ① suspected cases should meet both clinical manifestations and laboratory tests in ①, may or may not have an epidemiological history; ② confirmed cases should meet both the requirements of suspected cases and both types of syphilis serological test is positive.
4, neurosyphilis.
(1) epidemiological history: a history of unsafe sex, multiple sexual partners or sexual partner infection, or a history of blood transfusion.
(2) Clinical manifestations: (1) asymptomatic neurosyphilis: no obvious neurological symptoms and signs; (2) meningeal neurosyphilis: manifested as fever, headache, nausea, vomiting, cervical ankylosis, optic papilledema, etc.; (3) meningeal vascular syphilis: manifestation of occlusive cerebrovascular syndrome, such as hemiplegia, paraplegia, aphasia, epileptiform seizures, etc.; (4) cerebral parenchymal syphilis: psychiatric symptoms may appear, manifested as paralytic dementia, may (4) cerebral parenchymal syphilis: psychiatric symptoms, such as paralytic dementia, inattention, mood changes, delusions, mental retardation, judgment and memory, personality changes, etc.; neurological symptoms, such as tremor, speech and writing disorders, ataxia, muscle weakness, seizures, tetraplegia and incontinence, etc. If the spinal cord is damaged by syphilis spirochetes, the disease is called spinal consumption. Lightning-like pain, abnormal sensation, tactile pain and temperature perception disorders, hyperalgesia and loss of deep sensation, position and vibration perception disorders, etc. may occur.
(3) Laboratory tests: ① positive non-syphilis spirochete serology test, very few advanced patients may be negative; ② positive syphilis spirochete serology test; ③ cerebrospinal fluid examination: white blood cell count ≥ 5 × 106/L, protein amount > 500 mg/L, and no other causes of abnormalities. Positive cerebrospinal fluid fluorescent spirochete antibody absorption test (FTA-ABS) and/or venereal disease research laboratory (VDRL) test. In the absence of conditions for FTA-ABS and VDRL, the syphilis spirochete gelatin agglutination test (TPPA) and rapid plasma reactin ring card test (RPR)/toluidine red unheated serological test (TRUST) may be used instead.
(4) Diagnostic classification: ① suspected cases: should meet both the clinical manifestations, laboratory tests ①, ②, ③ in the cerebrospinal fluid routine examination abnormal (to exclude other causes of abnormalities), may or may not have an epidemiological history; ② confirmed cases: should meet both the requirements of suspected cases and laboratory tests ③ in the cerebrospinal fluid syphilis serological test positive.
5, latent syphilis (latent syphilis).
(1) Epidemiological history: history of unsafe sex, multiple sexual partners or sexual partner infection, or history of blood transfusion. (1) Early latent syphilis: duration < 2 years: a. A clear history of high-risk sexual behavior within the past 2 years, but no history of high-risk sexual behavior 2 years ago. b. Clinical manifestations consistent with stage I or II syphilis within the past 2 years, but not diagnosed and treated. c. A clear history of syphilis infection in sexual partners within the past 2 years; (2) Late latent syphilis: duration > 2 years. Those who cannot determine the duration of disease are treated as advanced latent syphilis.
(2) Clinical manifestations: no clinical symptoms and signs.
(3) Laboratory tests: ① positive non-syphilis spirochete serology test, a few advanced late-stage occult syphilis can be negative; ② positive syphilis spirochete serology test; ③ no significant abnormalities in cerebrospinal fluid examination.
(4) diagnostic classification: ① suspected cases: should also meet the laboratory tests in ①, no previous history of syphilis diagnosis and treatment, no clinical manifestations; ② confirmed cases: while meeting the requirements of suspected cases and two types of syphilis serological test are positive. If conditions are feasible cerebrospinal fluid examination to exclude asymptomatic neurosyphilis.
6, fetal syphilis.
(1) epidemiological history: the birth mother is a syphilis patient.
(2) Clinical manifestations: (1) early fetal syphilis: generally < 2 years old, similar to acquired stage II syphilis, dysplasia, lesions are often erythema, papules, flat warts, blisters - blisters; syphilitic rhinitis and laryngitis; osteomyelitis, osteochondritis and periostitis; generalized lymph node enlargement, hepatosplenomegaly, anemia, etc.; (2) late fetal syphilis: generally > 2 years old, similar to acquired stage III syphilis. Inflammatory damage (interstitial keratitis, neurogenic deafness, nasal or palatal gum swelling, kleaton joint, tibial periostitis, etc.) or marker damage (rounded forehead, saddle nose, peyote shin, osteochondral hypertrophy of the clavicothoracic joint, Hirschsprung’s teeth, radiolucency of the skin around the mouth, etc.); (3) latent fetal syphilis: that is, untreated fetal syphilis, no clinical symptoms, positive syphilis serology test, normal cerebrospinal fluid examination (2) The age of < 2 years is early recessive fetal syphilis, and > 2 years is late recessive fetal syphilis.
(3) laboratory tests: ① microscopic examination: using dark-field microscopy or silver-plated staining microscopy, take the skin mucosal damage or placenta specimens of children with early fetal syphilis, syphilis spirochetes can be detected; ② positive serological test for non-syphilis spirochetes, the antibody titer ≥ 2 dilutions (4 times) of the mother, or 3 months follow-up titer is on the rise has a confirmatory significance; ③ syphilis spirochetes serological test Positive IgM antibody test is of diagnostic significance, while negative test cannot exclude fetal syphilis.
(4) Diagnostic classification: suspected cases: all infants born to mothers with syphilis without effective treatment, or cases of stillbirth, stillbirth or miscarriage, where the evidence is not sufficient to confirm the diagnosis of fetal syphilis. Confirmed cases: Any of the following laboratory tests and follow-up results: (1) dark-field microscopy, or silver-plated staining to detect syphilis spirochetes in skin/mucosal damage and tissue specimens of early congenital syphilis, or positive nucleic acid test for syphilis spirochetes; (2) positive serum IgM antibody test for syphilis spirochetes in infants; (3) non-syphilis spirochete serologic test titer ≥ 4 times the mother’s titer at birth, and (3) the infant was born with a non-syphilis spirochete serological test titer ≥ 4 times the mother’s titer and a positive syphilis spirochete serological test; (4) the infant was born with a negative non-syphilis spirochete serological test or a titer that did not reach 4 times the mother’s titer, but was found to change from negative to positive during subsequent follow-up, or the titer increased with clinical symptoms and a positive syphilis spirochete serological test; (5) the infant born to a syphilis mother continued to have a positive syphilis spirochete antigen serological test until 18 months of age during follow-up.
II. Treatment
1, the general principles: ① early detection, timely formal treatment, the earlier the treatment effect is better; ② sufficient dose, the course of treatment rules. Irregular treatment may increase recurrence and promote the early occurrence of late damage; (3) After treatment, we should follow up for a sufficient period of time; (4) All sexual partners should be examined and treated at the same time.
2, treatment plan: (1) early syphilis (including stage 1, stage 2 and latent syphilis of < 2 years) recommended plan: procaine penicillin G 800,000 U/d, intramuscular injection, for 15 d; or benzathine penicillin 2.4 million U, divided into bilateral gluteal intramuscular injection, once a week, a total of 2 times. Alternative regimen: ceftriaxone 0.5 to 1 g, once daily, intramuscularly or intravenously for 10 d. For allergy to penicillin, use the following drugs: doxycycline 100 mg, twice daily for 15 d; or tetracycline hydrochloride 500 mg, four times daily for 15 d (contraindicated in hepatic and renal insufficiency).
(2) Late syphilis (stage III skin, mucous membrane, bone syphilis, late recessive syphilis or recessive syphilis where the stage of the disease cannot be determined) and stage II recurrent syphilis recommended regimen: procaine penicillin G, 800,000 U/d, intramuscular injection, 20 d for 1 course, or consider giving a second course, with 2 weeks of discontinuation between courses; or benzathine penicillin 2.4 million U, divided into bilateral gluteal intramuscular injection, once a week. 3 times in total. For penicillin allergy, use the following drugs: doxycycline 100 mg twice daily for 30 d; or tetracycline hydrochloride 500 mg four times daily for 30 d (contraindicated in hepatic and renal insufficiency).
(3) Recommended regimen for cardiovascular syphilis: If there is heart failure, treat heart failure first, and when the heart function can be compensated, inject penicillin, which needs to be started at a small dose to avoid the occurrence of Jihai’s reaction, which may cause aggravation of the disease or death. Aqueous penicillin G, 100,000 U on day 1, 1 intramuscular injection; 100,000 U on day 2, 2 intramuscular injections daily; 200,000 U on day 3, 2 intramuscular injections daily; from day 4 onwards, the following regimen: procaine penicillin G, 800,000 U/d, intramuscular injection, 20 d for 1 course, 2 courses (or more) in total, with 2 weeks of withdrawal between courses; or benzathine penicillin 2.4 million U, divided into bilateral gluteal intramuscular injection, 1 time per week, 3 times in total. For those who are allergic to penicillin, the following drugs are used: doxycycline 100 mg twice daily for 30 d; or tetracycline hydrochloride 500 mg four times daily for 30 d (prohibited for those with hepatic and renal insufficiency).
(4) Recommended regimen for neurosyphilis and ocular syphilis: 18-24 million U of aqueous penicillin G intravenously (3-4 million U every 4 hours) for 10-14 d. If necessary, follow with benzathine penicillin G 2.4 million U intramuscularly once a week for 3 times. Or procaine penicillin G, 2.4 million U/d, 1 intramuscular injection, together with oral propofol, 0.5 g each time, 4 times a day for 10-14 d. If necessary, follow with benzathine penicillin G 2.4 million U, 1 intramuscular injection once a week for 3 times. Alternative regimen: Ceftriaxone 2 g, administered intravenously once daily for 10-14 d. For those allergic to penicillin, use the following drugs: doxycycline 100 mg twice daily for 30 d; or tetracycline hydrochloride 500 mg four times daily for 30 d (contraindicated in hepatic and renal insufficiency).
(5) Recommended regimen for early fetal syphilis (< 2 years old): for cerebrospinal fluid abnormalities: aqueous penicillin G, 100,000-150,000 U?kg-1?d-1, for neonates within 7 d of birth, at 50,000 U/kg per dose, intravenously every 12 hours, and every 8 hours thereafter, until a total course of 10-14 d. Or procaine penicillin G, 50,000 U?kg-1?d-1, intramuscularly once daily. If the cerebrospinal fluid is normal: benzathine penicillin G, 50,000 U/kg, 1 intramuscular injection in both buttocks. If there is no condition to check the cerebrospinal fluid, it can be treated as abnormal cerebrospinal fluid. For those who are allergic to penicillin, there is no evidence of effective use of other treatment regimens, erythromycin treatment can be tried.
(6) Late fetal syphilis (> 2 years old) recommended regimen: aqueous penicillin G, 150,000 U?kg-1?d-1, intravenous infusion in divided doses for 10 ~ 14 d, or procaine penicillin G, 50,000 U/kg daily, intramuscular injection for 10 d as a course of treatment (penicillin dosage for older children should not exceed that for adult patients of the same age). For normal cerebrospinal fluid: benzathine penicillin G, 50,000 U/kg, 1 injection in both gluteal muscles. Alternative regimen: For those who are allergic to penicillin and have used cephalosporin antibiotics in the past without allergy under close observation: Ceftriaxone 250 mg, once daily, intramuscularly for 10 to 14 d. < Tetracycline is contraindicated in children 8 years of age.
(7) Syphilis in pregnancy: pregnant women newly diagnosed with syphilis during pregnancy should be treated according to the appropriate syphilis staging. The treatment principles are the same as for non-pregnant patients, but tetracycline and doxycycline are prohibited, and a quantitative non-syphilis spirochete serological test is performed once a month after treatment to observe for recurrence and reinfection. One course of anti-syphilis treatment is recommended for patients with syphilis in pregnancy in the early 3 months of pregnancy and one course in the last 3 months of pregnancy. In patients allergic to penicillin and cephalosporins, since tetracyclines cannot be applied during pregnancy and lactation, macrolides can be tried instead: erythromycin 500 mg four times daily for 15 d in early syphilis and 30 d in late syphilis and syphilis of unknown stage. erythromycin is poorly effective in the treatment of syphilis, and clinical and serological follow-up should be intensified after treatment. After cessation of breastfeeding, retreatment with doxycycline is required.
(8) Treatment of syphilis patients with HIV infection: ① all HIV-infected patients should be screened for syphilis serology; all syphilis patients should be screened for HIV antibodies; ② if the diagnosis cannot be determined by routine syphilis serology, skin lesion biopsy should be taken and immunofluorescent staining or silver staining should be done to find syphilis spirochetes; ③ all syphilis patients with HIV infection should be considered for lumbar puncture examination of cerebrospinal fluid to (3) All syphilis patients, who are co-infected with HIV, should be considered for lumbar puncture examination of cerebrospinal fluid to exclude neurosyphilis; (4) Whether syphilis patients with HIV infection should increase the dose or course of treatment for syphilis is still unclear.