This final period of syphilis in Russian medical practice has recently been more common than in previous decades. This is due to the absence of all necessary stages of preventive treatment, insufficient awareness and discipline of patients, as well as a certain percentage of treatment-resistant cases. However, tertiary syphilis develops only in a small number of patients, mostly 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 after several years (sometimes 10 or more) after an episode of infection.
Tertiary syphilis is characterized in a greater degree by the defeat of internal organs, osteoarticular and nervous system, than cutaneous manifestations. Dystrophic and destructive processes predominate. Specific gums that are formed in the stage of tertiary syphilis can reach considerable sizes, squeeze the internal organs, thereby violating their functions.
Wasserman's reaction in the period of tertiary syphilis can be negative (false-negative, since the disease is present). Therefore, more positive results of immunofluorescent reaction and RIBT (immobilization of treponema) are more informative.
Symptoms of skin lesions
All tertiary affects on the skin are divided into two large groups: the so-called tertiary syphilis and gum (usually larger in size).
Classical tubercular syphilis is an infiltrative formation in the thickness of the skin, sometimes reaching subcutaneous adipose tissue. The number of tubercles is usually small, up to 2-3 dozens, their arrangement is asymmetric. Syphilitic tubercles do not tend to merge and peripheral growth. These are flat or hemispherical elements of stagnant red color sometimes cyanotic in color, dense to the touch, painless. In addition to cosmetic defect, no other sensations (burning, itching) do not cause tertiary syphilis.
For several weeks in the tertiary syphilitic tubercle necrotic processes are observed with transformation into ulcers or dry necrosis phenomena. The ulcer defect has a regular rounded shape and smooth edges. The ulcer usually heals longly with the formation of an atrophic felted deep into the tissues of the scar.
A so-called creeping syphil is very rare. At the center of this extensive element is scar tissue from the fused several tubercles, followed by the zone of the daughter tertiary syphilis.
Cutaneous gum is the most characteristic and memorable trait of tertiary syphilis. The formation of the gum takes place deep enough in the subcutaneous fatty tissue. This is a fairly large formation (up to several centimeters), a dense consistency. As the process progresses, the gamma cools with the adjacent tissues and loses its mobility. Further, the central part of the gum is softened to form a viscous serous exudate, which gave the name syphilitic granuloma (similar to gum arabic). At the softening point, a deep and extensive ulcer is formed, at the bottom of which is a rod. The rod is very slowly torn away, after which an atrophic sagging scar is formed in its place. Rarely several dermal gummas are found at once, usually one is observed.
Lesion of mucous membranes
The lesion of the mucous membranes during the period of tertiary syphilis can be characterized by the formation of separate hums, diffuse infiltration by gums or tubercle elements of the rash.
As well as on the skin, on the mucous membrane in the mouth, the gum passes through a number of stages of its development. A dense, painless infiltrate develops into a formation with a stem, which is rejected and forms an ulcer. It is on the mucous that the formation of ulcers and subsequent atrophic connective tissue scar affords a lot of problems to a person, since not only a cosmetic defect, but also a function violation is significant.
Hummus lesion of the tongue can be in the form of diffuse glossitis and in the form of a separate gum. Eventually, the scar formed gradually contracts the tongue, seriously hampering the process of articulation, chewing and reducing the taste sensations. With diffuse glossitis, the tongue thickens on the back, trophic ulcers and painful cracks occur, possibly a cancerous degeneration.
Hummus defect of the hard palate is dangerous because the gum penetrates and affects not only the mucous, but bone tissue. As a result, an unnatural communication is formed between the nasal cavity and the mouth. This makes normal articulation impossible, complicates the process of chewing and swallowing food, the nasal secret enters the mouth, creating the prerequisites for attaching a secondary bacterial infection.
Gummoznoe affect of the soft palate at the stage of scar formation significantly reduces the area of the palatal curtain, therefore it becomes practically impossible for adequate articulation and swallowing process. It is possible for unnatural food to enter the windpipe due to the insufficient size of the palate.
Defeat of the musculoskeletal system
It is the destructive processes in bone and cartilage tissue in tertiary syphilis that create significant difficulties for the patient and are the cause of severe disability.
At the initial stages only the periosteum is involved in the pathological process. X-ray photographs show infiltrative changes resembling a lace or a comb. Gradually, the process penetrates deeper layers of the bone. The infiltrative roller, which is visible to the naked eye and which is well felt during palpation, is formed, that is, actually the gum. A person feels pain at rest (especially at night) and during movement. Gumma of bone tissue can be calcified and transformed into a dense tumor-like formation.
However, its disintegration is more often observed. In place of the bone gum, a deep ulcer is formed, permanently healing by secondary tension with the formation of an extensive connective tissue defect (scar).
In especially 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: worsening of the general condition, temperature turn, pain in the affected bone, swelling and redness of the skin, a purulent-destructive discharge from the wound.
In the period of tertiary syphilis, rarely, but still affected by joints and short bones. The defeat of the vertebrae and small bones of the foot and hand is difficult to establish, the final diagnosis can be suspected after an effective specific therapy. The defeat of the joints has no characteristic signs, it is characterized by pain, swelling and serous intraarticular exudate. The consequence of gummish joint changes is their irreversible deformation.
A characteristic feature of the launched tertiary syphilis is the destruction of the nasal bones. As a result, these thin tissues are melted and the nose sinks inward. It is this saddle-shaped defect that makes it possible to diagnose already with an external examination.
Lesion of internal organs
Only complete absence of proper specific treatment leads to gummy changes in 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 mechanical jaundice. Significantly serious metabolic disturbances can be detected when studying such biochemical parameters as total bilirubin and its fractions, aspartate aminotransferase and alanine aminotransferase, alkaline phosphatase and lactate dehydrogenase. The person notices the increasing yellowness of the skin and mucous membranes, as well as the increasing pruritus.
Syphilitic myocarditis does not have purely specific signs. A person feels an impassable weakness, a feeling of lack of air and shortness of breath even with a slight load, palpitation and arrhythmia. At examination, the deafness of the tones and the pulse of weak filling are revealed. On ECG observed pronounced dystrophic disturbances of the myocardium.
A typical manifestation of tertiary visceral syphilis is inflammatory-dystrophic changes in the aorta. Gradually, there is an expansion of its ascending department with transformation into an aneurysm. It is the aneurysm of the ascending aorta, or rather, its rupture becomes the cause of death of such patients.
Very rarely syphilitic changes are exposed to such organs as the intestines, stomach, kidneys and lungs.
Disorders of the nervous system
Damage to the central nervous system is typical enough for 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 ability to work of such patients.
In the domestic medical practice, a somewhat conditional division of the syphilis of the nervous system into the early (in the first 5 years of the disease) and late, as well as mesenchymal and parenchymal. In the case of mesenchymal neurosyphilis, lesions are observed mainly in the meninges and the vascular bed. In the case of parenchymal - affect the actual substance of the brain. This division is arbitrary, since in the majority of cases it is practically impossible to isolate only changes in the shells without damaging the brain substance, as a rule, these are combined processes.
It should be noted that the frequency of occurrence of neurosyphilis is currently increasing, but the severity of lesions decreases. The latent forms prevailing over a long period of time dominate, without pronounced clinical symptoms.
Clinical variants of early neurosyphilis are as follows:
- hidden meningitis;
- clinically acute meningitis;
- basal meningitis;
- hydrocephalus (chronic and acute);
- meningovascular syphilis;
- defeat of individual cranial nerves.
Sufficiently widespread latent meningitis (syphilitic) corresponds to its name and has no significant clinical symptoms. A person can feel mild headache and dizziness, subfebrile temperature. Often this variant of nervous system damage is a random finding in patients who do not respond to treatment, when examining cerebrospinal fluid (cerebrospinal fluid). In the process of investigation of the cerebrospinal fluid, moderate signs of inflammation, a decrease in bone conduction, especially low-frequency sounds, are revealed.
Acute syphilitic meningitis does not have any typical signs, it resembles the meningitis of another etiology. A person experiences a headache of diffuse and bursting nature, fever and vomiting without nausea and not bringing relief. In the cerebrospinal fluid, lymphocytic pleocytosis is detected.
Basal meningitis, or more precisely meningoencephalitis, is characterized by the involvement of the brain in the process 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 strabismus and ptosis, facial asymmetry of the face, pre-ulceration by hearing loss and so on.
Hydrocephalus occurs with complete (acute) or partial (chronic) cessation of the exit of cerebrospinal fluid from the ventricles. In an acute case, this is manifested clinically by edema-swelling of the brain (impaired consciousness, focal neurological symptoms, convulsions ). In a chronic case, a person feels constant headaches are not passing character.
Meningomiitis also has no characteristic clinical symptoms. It manifests as motor and sensory disorders, in severe cases - paresis and paralysis of the limbs.
The most typical variant of early neurosyphilis is meningovascular. In this case, a diffuse lesion of the vasculature is noted. Complaints of patients are not specific. The diagnosis is established by the totality of anamnestic and laboratory data.
Clinical variants of late neurosyphilis are in many respects similar to manifestations of early neurosyphilis, but at the same time dystrophic processes predominate at this stage. The following variants of the course of late neurosyphilis are distinguished:
- latent (latent) meningitis;
- vascular syphilis;
- meningovascular syphilis;
- Gum of the brain;
- progressive paralysis.
Actually vascular syphilis is characterized only by damage to the vascular bed without involvement in the process of the meninges and substance. The clinical picture is dominated by changes in higher nervous activity: decreased intelligence, anxiety or unreasonable euphoria, depression, hallucinations or obsessions.
Spinal cord (tabes) is a dystrophic process in the posterior roots and motoneurons of the spinal cord. Occurs several decades after infection. Most often localized in the cervical (upper tabes) or lumbar (lower). The person marks strong pains of shooting character which are replaced by a numbness and a paresis. In the case of the lower tabes, constipation and urinary retention prevail, followed by urinary and fecal incontinence.
Characteristic for the taba moment is the unevenness 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. At later stages, hearing disorders, cerebellar disorders, altered gait (from the heel to the sock) are added.
Progressive paralysis is the gradual withering away of the brain matter 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 especially severe cases, a combination of progressive paralysis and tabes (taboralic) is observed.
Gunma of the spinal cord or brain passes through the same stages of development as on the skin. The clinical picture is determined by its localization.
Treatment of tertiary syphilis consists of adequate antibiotic therapy and symptomatic treatment aimed at restoring lost functions.
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