This final period of syphilis in domestic medical practice in recent times is more common than in previous decades. This is due to the absence of all the necessary stages of preventive treatment, lack of consciousness and discipline of patients, as well as a certain percentage of cases resistant to treatment. However, tertiary syphilis develops only in a small number of patients, mainly elderly and senile, or vice versa of childhood, and also in the body weakened by chronic alcoholism or immunodeficiency. Tertiary syphilis occurs and slowly develops several years later (sometimes 10 or more) after an episode of infection.
Tertiary syphilis is characterized to a greater extent by damage to the internal organs, bone and joint and nervous system, than by skin manifestations. Dystrophic and destructive processes predominate. The specific gumma that are formed during the stage of tertiary syphilis can reach considerable sizes, compressing the internal organs, thereby disrupting their functions.
The reaction of Wasserman in the period of tertiary syphilis can be negative (false negative, as the disease is present). Therefore, positive results of the immunofluorescent reaction and RIBT (treponema immobilization) are more informative.
Symptoms of skin lesions
All tertiary affects on the skin are divided into two large groups: the so-called tertiary syphilides and gum (usually larger).
Classic lumpy syphilide is an infiltrative formation in the thickness of the skin, sometimes reaching subcutaneous fatty tissue. The number of tubercles is usually small, up to 2-3 dozen, their arrangement is asymmetric. Syphilitic tubercles do not tend to merge and peripheral growth. These are flat or hemispherical elements of a greyish red color, sometimes bluish in color, dense to the touch, painless. In addition to the cosmetic defect, tertiary syphilides do not deliver any other sensations (burning, itching).
For several weeks in the tertiary syphilitic tubercle necrotic processes are observed with transformation into an ulcer or phenomena of dry necrosis. The ulcer has a regular round shape and smooth edges. The ulcer is usually healed for a long time with the formation of an atrophic deep-seated scar tissue.
The so-called creeping syphilide is very rare. In the center of this vast element there is a scar tissue of merged several tubercles, followed by a zone of daughter Tertiary syphilides.
Dermal gum is the most characteristic and memorable trait of tertiary syphilis. The formation of gum occurs quite deep in the subcutaneous fatty tissue. This is a fairly large formation (up to several centimeters), of a dense consistency. As the process progresses, the gum melts with adjacent tissues and loses its mobility. Next, the softening of the central part of the gum occurs with the formation of a viscous serous exudate, which gave the name syphilitic granuloma (resembles gum arabic). At the site of softening, a deep and extensive ulcer is formed, at the bottom of which there is a rod. The rod is very slowly rejected, after which an atrophic sunken scar forms in its place. Rarely there are several skin gummas at once, usually one is observed.
The defeat of the mucous membranes in the period of tertiary syphilis can be characterized by the formation of separate gums, diffuse infiltration with gums or hillocky elements of the rash.
As well as on the skin, on the mucous membrane in the mouth, gum passes through several stages of its development. Dense, painless infiltrate develops into a formation with a rod that rejects and forms an ulcer. It is on the mucous membranes that the formation of an ulcer and the subsequent atrophic connective tissue scar causes a lot of problems to a person, since not only a cosmetic defect is significant, but also a dysfunction.
Gummy lesion of the tongue can be in the form of diffuse glossitis and as a separate gum. In the end, the resulting scar gradually tightens the tongue, seriously complicating the process of articulation, chewing and reducing taste sensations. With diffuse glossy tongue thickens on the back trophic ulcers and painful cracks occur, possibly cancerous degeneration.
Gummy defect of the hard palate is dangerous because gum penetrates and affects not only mucous, but bone tissue. As a result, an unnatural message is formed between the nasal cavity and the mouth. This makes it impossible to normal articulation, complicates the process of chewing and swallowing food, nasal secretion enters the mouth, creating the preconditions for the attachment of a secondary bacterial infection.
Gummy affect of the soft palate at the stage of scar formation significantly reduces the area of the palatine curtain, so it becomes almost impossible to adequately articulate and swallow process. Perhaps unnatural food getting into the respiratory neck due to insufficient size of the palatine curtain.
The defeat of the musculoskeletal system
It is destructive processes in the bone and cartilage tissue in tertiary syphilis that create significant difficulties for the patient and cause severe disability.
At the initial stages, only the periosteum is involved in the pathological process. Infiltrative changes resembling lace or comb are visible on radiographic images. Gradually, the process penetrates into the deeper layers of the bone. An infiltrative ridge, visible to the naked eye and well felt on palpation, that is, gum itself, is formed. A person feels pain both at rest (especially at night) and when moving. Gumma bone tissue can calcify and turn into a dense tumor-like formation.
However, its decay is more often observed. In place of the bone gum, a deep ulcer forms, which heals for a long time by secondary tension with the formation of an extensive connective tissue defect (scar).
In severe cases, in addition to the bone tissue itself, the syphilitic process penetrates the bone marrow. The clinical picture in this case is non-specific and resembles any other variant of osteomyelitis: deterioration of the general condition, temperature bend, pain in the affected bone, swelling and reddening of the skin, purulent-destructive discharge from the wound.
During the period of tertiary syphilis, joints and short bones are rarely but still affected. It is difficult to establish the defeat of the vertebrae and the small bones of the foot and hand, the final diagnosis can be suspected after effective specific therapy. The lesion of the joints has no characteristic signs, characterized by pain, swelling and serous intra-articular exudate. The result of gummy changes of the joints is their irreversible deformation.
A characteristic sign of neglected tertiary syphilis is the destruction of the nasal bones. As a result, these thin tissues melt and the nose sinks inward. It is this saddle defect that allows you to make a diagnosis with an external examination.
Lesion of internal organs
Only a complete lack of proper specific treatment leads to gummy changes in the internal organs.
The formation of gum in the thickness of the liver leads to a violation of the outflow of bile and the growth of obstructive jaundice. Quite serious metabolic disorders can be detected in the study of such biochemical parameters as total bilirubin and its fractions, aspartate aminotransferase and alanine amino transferase, alkaline phosphatase and lactate dehydrogenase. A person notes the increasing yellowness of the skin and mucous membranes, as well as increasing skin itching.
Syphilitic myocarditis has no particularly specific signs. A person feels persistent weakness, a feeling of lack of air and shortness of breath even with a slight load, heartbeat and arrhythmia. During the examination revealed the deafness of the tones and the pulse of a weak filling. ECG shows marked dystrophic myocardial disorders.
A typical manifestation of tertiary visceral syphilis is inflammatory and dystrophic changes in the aorta. Gradually, the expansion of its ascending division with the transformation into aneurysm. It is the aneurysm of the ascending aorta, or rather its rupture becomes the cause of death of such patients.
Organs such as the intestines, the stomach, the kidneys and the lungs are extremely rarely subjected to syphilitic changes.
Nervous system lesions
Damage to the central nervous system is typical enough for the tertiary and in some cases even for the secondary period of syphilis. It is neurological disorders, along with bone changes that cause a decrease in the quality of life and the ability to work of such patients.
In the domestic medical practice, a somewhat conditional division of the syphilis of the nervous system into early (in the first 5 years of the disease) and late, as well as mesenchymal and parenchymal ones has been adopted. In the case of mesenchymal neurosyphilis, damage is observed mainly in the meninges and the bloodstream. In the case of parenchymal - affect the actual substance of the brain. This division is conditional, since in most cases it is practically impossible to isolate only changes in the membranes without damaging the brain's substance, as a rule, these are combined processes.
It should be noted that the incidence of neurosyphilis is currently increasing, but the severity of lesions is decreasing. Dominant forms develop over a large period of time, without pronounced clinical symptoms.
The clinical options for early neurosyphilis are as follows:
- latent meningitis;
- clinically acute meningitis;
- basal meningitis;
- hydrocephalus (chronic and acute);
- meningovascular syphilis;
- lesion of individual cranial nerves.
Quite common latent meningitis (syphilitic) corresponds to its name and has no pronounced clinical symptoms. A person may experience mild headache and dizziness, low-grade fever. Often, this variant of damage to the nervous system is a random finding in patients who do not respond to treatment in the study of the cerebrospinal fluid (cerebrospinal fluid). In the process of research of the cerebrospinal fluid revealed moderate signs of inflammation, a decrease in bone conduction, especially low-frequency sounds.
Acute syphilitic meningitis does not have any typical symptoms, the clinic is similar to meningitis of a different etiology. A person feels a headache of diffuse and arching nature, fever and vomiting without nausea and not bringing relief. Lymphocytic pleocytosis is detected in the cerebrospinal fluid.
Basal meningitis, or more precisely, meningoencephalitis, is characterized by the involvement of the brain substance in the process in the area of its base (which gave the name of pathology). The clinical picture is determined by the localization of the syphilitic focus. Damage to the oculomotor nerve is manifested by squint and ptosis, facial - by asymmetry of the face, pre-vernulitkovogo - hearing loss, and so on.
Hydrocephalus occurs when a complete (acute) or partial (chronic) cessation of the output of cerebrospinal fluid from the ventricles. In the acute case, this is clinically manifested by swelling and swelling of the brain (impaired consciousness, focal neurological symptoms, convulsions ). In the chronic case, a person feels constant headaches of a non-passing nature.
Meningomyelitis also has no characteristic clinical symptoms. Manifested by motor and sensory impairments, in severe cases - paresis and paralysis of the limbs.
The most typical variant of early neurosyphilis is meningovascular. In this case, there is a diffuse lesion of the vascular network. Patient complaints are not specific. The diagnosis is established on the basis of anamnestic and laboratory data.
The clinical variants of late neurosyphilis are in many ways similar to the manifestations of the early, however, at this stage dystrophic processes predominate. There are the following options for the course of late neurosyphilis:
- latent (latent) meningitis;
- vascular syphilis;
- meningovascular syphilis;
- brain gumma;
- spinal tinder;
- progressive paralysis.
Actually vascular syphilis is characterized only by damage to the vascular bed without involvement of the meninges and the substance in the process. The clinical picture is dominated by changes in higher nervous activity: reduced intelligence, anxiety or unreasonable euphoria, depression, hallucinations, or obsessive ideas.
Spinal cord sinuses (tabes) are dystrophic processes in the posterior roots and motor neurons of the spinal cord. Occurs several decades after infection. Most often localized in the cervical (upper tabes) or lumbar (lower). The man notes the strong pains of the shooting character, which are replaced by numbness and paresis. In the case of lower tabes at the beginning, constipation and urinary retention prevail, followed by urinary and fecal incontinence.
The characteristic moment for the tabes is the irregularity of the pupils. Usually one pupil is smaller than the other, has uneven edges, there is no friendly reaction of pupils to light and convergence. In the later stages, hearing disorders, cerebellar disorders, altered gait (from heel to toe) join.
Progressive paralysis is the gradual dying off of the brain substance as a result of dystrophic processes. The clinical picture is diverse: from depressive disorders to agitation, from hearing loss to paralysis of the limbs. In severe cases, there is a combination of progressive paralysis and tabes (tabo-paralysis).
The gumma of the spinal cord or brain goes through the same stages of development as on the skin. The clinical picture is determined by its localization.
Treatment of tertiary syphilis is adequate antibiotic therapy and symptomatic treatment aimed at restoring lost functions.
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