Clinical Staging of Syphilis: (1) Latent Syphilis Latent Syphilis refers to a patient who has been diagnosed with syphilis. During a certain period of time, there is no abnormality in skin, mucosa, any organ system and cerebrospinal fluid examination, physical examination, chest X-ray lack of clinical manifestations of syphilis, and cerebrospinal fluid examination is normal, but only syphilis serum is positive, or there is a clear history of syphilis infection, and there has never been any clinical manifestations. (2) The average incubation period of primary syphilis is 3-4 weeks, and the typical damage is chancre (hard ulcer). Because of sexual infection, the damage of chancre mostly occurs in vulva and sexual contact parts. Hard chancre is often complicated with foreskin edema. Some patients may have lymphangitis on the back of penis, showing hard linear damage. Women's hard chancre is more common in labia majora, clitoris, urethral orifice, pubic mound, especially in the cervical region, and it is easy to be missed. A week after chancre appeared, the nearby lymph nodes were swollen, showing no pain, no redness and swelling on the skin surface, no adhesion with surrounding tissues and no ulceration. It is called painless transverse scrotum (painless lymphadenitis). If the chancre is not treated, it will heal itself after 3-4 weeks. After effective treatment, it can heal quickly, leaving superficial atrophic scars. After 2-3 weeks of chancre, syphilis serum reaction began to be positive. In addition to chancre, a few patients with primary syphilis can still have hard and tough edema in labia majora, foreskin or scrotum. Like an elephant skin, it is called edema and induration. If the patient is infected with chancre caused by Haemophilus Dukley or erosive ulcer caused by lymphogranuloma of venereal disease, it is called mixed chancre. (3) Secondary syphilis is a generalized period of syphilis. The period from the disappearance of chancre to the appearance of secondary syphilis rash is called the second incubation period. Secondary syphilis usually occurs 3-4 weeks after chancre subsides, which is equivalent to 9- 12 weeks after infection. Secondary syphilis is a widespread damage caused by Treponema pallidum entering the blood through lymph nodes. Papules and maculopapules are also common in clinic, accounting for about 40% of secondary syphilis. It happened a little later than the macula. According to its symptoms and clinical course, it can be divided into large papules and small papules. In addition to causing skin damage, it can also invade internal organs and nervous system. Influenza-like syndrome (headache, low fever, limb acid fatigue) may occur before the onset of secondary syphilis. These precursors last about 3-5 days and disappear after the eruption. The serum reaction of syphilis in this period was strongly positive. The DNA of Treponema pallidum was positive by PCR. Syphilitic alopecia: About 10% of secondary syphilis patients occur. This is caused by syphilis infecting hair follicles, blocking fine blood vessels in the hair area and poor blood supply. Characterized by syphilis alopecia areata or diffuse alopecia. The former is bald spot about 0.5cm, which is moth-eaten. Diffuse alopecia, large area, sparse, uneven hair length. Syphilitic leukoplakia is more common in female patients. It usually occurs 4-5 months or 65,438+0 years after infection, and it usually occurs on both sides of the neck, as well as chest, back, breast, limbs, armpits, vulva and perianal regions. The pigment in the affected part is completely lost, and the surrounding pigment is increased, similar to vitiligo. Syphilis-associated nephropathy: mainly occurs in acquired secondary syphilis, with a low incidence. The clinical manifestations of acquired syphilis renal damage are varied, such as acute nephrotic syndrome, membranous glomerulonephritis and acute progressive glomerulonephritis. (4) The occurrence time of tertiary syphilis (late syphilis) is generally 2 years after onset, but it can also be as long as 3-5 years. It happens between the ages of 40 and 50. Mainly due to insufficient anti-syphilis treatment or insufficient treatment time and dosage. There is also a certain relationship between the imbalance of the internal and external environment of the body. Patients with excessive drinking, dysphagia, physical weakness and chronic diseases such as tuberculosis have poor prognosis. The characteristics of tertiary syphilis are: ① the onset time is late (2- 15 years after infection) and the course of disease is long. If left untreated, it can last as long as 10-20-30 years or even a lifetime; ② The symptoms are complex, which can involve any tissues and organs, including skin, mucosa, bones, joints, internal organs, etc. It is easy to invade the nervous system, easily confused with other diseases, and difficult to diagnose; ③ Treponema pallidum is rare in body and skin lesions, with weak infectivity, but strong tissue destructive power, which often causes tissue defects and organ damage, resulting in disability and even life-threatening; ④ Anti-plum therapy is effective, but it can't repair damaged tissues and organs. ⑤ The serum reaction of syphilis is unstable, the negative rate can reach more than 30%, and the cerebrospinal fluid often changes. 1. Nodular syphilis: It mostly occurs within 3-4 years after infection, and the damage mostly occurs in the head, shoulders, back and limbs. It is a group of infiltrative nodules with a diameter of about 0.3- 1.0cm, with copper-red color, smooth surface or thin scales, hard texture, and patients have no conscious symptoms. The evolution of nodules may have two outcomes. One is the flattening and absorption of nodules, leaving atrophic spots and dark brown pigmentation for a long time. The other outcome is central necrosis, forming a small abscess, ulceration after rupture, forming nodular ulcerative syphilis rash, leaving a shallow scar after healing. There is pigmentation around the scar, which shrinks smoothly and thins, and new damage can appear on the edge. This is the characteristic of this disease. Old and new rashes break out one after another, and new ones appear again, which can be delayed for several years. 2.gumma is more common in tertiary syphilis, accounting for 6 1% of tertiary syphilis. It's deep under the skin. At first, it was as big as a pea, and it gradually increased. For example, broad beans are as big as plums or larger, hard to the touch, movable and uncertain in quantity. At first, the color was normal, and with the increase of nodules, the color gradually turned into light red, dark red or even purple red. Nodules are easy to be necrotic, can gradually soften, rupture and flow out gelatinous secretions, and can form specific circular, oval and horseshoe-shaped ulcers with clear boundaries, neat and convex edges like dams, surrounded by brown or dark red infiltration, and feel hard. Often one end heals, and the other end still spreads like a snake. 3. Syphilitic cardiovascular disease: It is a cardiovascular disease caused by Treponema pallidum invading human body in the late stage (the third stage), including syphilitic aortitis, syphilitic aortic valve insufficiency, syphilitic aortic aneurysm, coronary artery stenosis, myocardial mucinous swelling, etc. Pregnancy-associated syphilis infection: (1) Pregnancy complicated with syphilis: syphilis and pregnancy can interact. Pregnancy syphilis can be transmitted to the fetus through the placenta. Syphilis gravidarum is prone to miscarriage, premature delivery or stillbirth because of placental vascular obstruction, which affects fetal nutrition. Although full-term delivery is possible, about 64.5% of the fetuses have been infected with syphilis and congenital syphilis has occurred, of which 65,438+05% ~ 20% are early-onset congenital syphilis. (2) Congenital syphilis: Congenital syphilis is transmitted to the fetus through the placenta by pregnant women with syphilis during pregnancy, so it is also called fetal syphilis. Usually about four months pregnant, the placenta spreads, and the fetus can die or miscarry. If pregnant women are infected with syphilis for more than five years, it is unlikely that the fetus will be infected in the uterus. Early congenital syphilis was found within 2 years old, and late congenital syphilis was found over 2 years old. It is characterized by no chancre, the early pathological changes are more serious than acquired syphilis, the late cardiovascular involvement is less, and more sensory systems such as bones, eyes and nose are involved. 1. Late stage of congenital syphilis: generally, the onset begins at the age of 5-8. 13- 14 years old, and the late stage symptoms can only appear at the age of 20. Late congenital syphilis mainly invades skin, bones, teeth, eyes and nerves. 2. Congenital latent syphilis: no clinical symptoms, syphilis serological positive for congenital latent syphilis. 3. Fetal syphilis: Treponema pallidum enters the fetus and can cause pathological changes of various organs. The severity of the damage is related to the mother's illness and the time when the fetus was infected. 4. Congenital syphilis cirrhosis: 80% of patients with congenital syphilis involve the liver, which may be caused by Treponema pallidum passing through the placenta, entering the umbilical vein and finally reaching the liver. Both congenital syphilis and polycythemia can lead to jaundice, which is easy to be confused, but the serological examination of children with congenital syphilis is positive. 5. Syphilitic uveitis: 5% ~ 10% of secondary syphilis patients have uveitis. Other types of syphilis: (1) neurosyphilis: a disease caused by Treponema pallidum (Treponema pallidum) infecting the nervous system. Can be divided into congenital syphilis and acquired syphilis. This disease is mainly caused by unclean sexual intercourse, and can also infect human body through mucous membrane and contact with blood with pathogens. Several common neurosyphilis in clinic are: ① asymptomatic neurosyphilis; ② Meningeal neurosyphilis; ③ Vascular neurosyphilis; ④ Spinal tuberculosis; ⑤ Paralytic dementia; Congenital neurosyphilis. (2) Syphilis complicated with HIV infection: In recent years, many cases of syphilis patients complicated with HIV infection have changed the clinical course of syphilis. Because genital ulcer of syphilis patients is an important risk factor for acquiring and spreading HIV infection; Moreover, HIV can cause meningeal lesions, which makes Treponema pallidum easily cross the blood-brain barrier and cause neurosyphilis. (3) Syphilitic arthritis: It usually occurs at the age of 20 ~ 40. Some patients have joint symptoms after an incubation period of more than 10 years after being infected with syphilis. There is also latent syphilis, which causes joint syphilis under the inducement of trauma, childbirth and infection. . (4) Non-venereal syphilis: it is an endemic disease caused by Treponema pallidum type II, which is caused by non-sexual transmission. The transmission between people is mainly through mucosal contact. (5) Spinal syphilis: It is an important type of syphilis in the central nervous system, including dorsal syphilis of spinal cord, meningeal vascular syphilis of spinal cord and syphilitic myelitis. Syphilitic myelitis often involves the spinal cord membrane due to pathological changes. (6) Stomach syphilis: It is a rare stomach disease caused by Treponema pallidum invading the stomach wall. (7) Esophageal syphilis: Dysphagia is the most common symptom of esophageal syphilis, mostly painless, characterized by a long course of disease and slow progress, which is different from esophageal cancer. When the disease progresses, swallowing liquid can also cause dysphagia, accompanied by retrosternal pressure, which can lead to weight loss, dehydration, anemia, and even cachexia due to insufficient intake. (VIII) Syphilitic scleritis: The common eye diseases include stromal keratitis, uveitis, chororetinitis, optic neuritis, optic nerve atrophy, ptosis, strabismus, chancre at eyelid margin or corneal margin, orbital periostitis, argyle-Robertson pupil and scleritis or episcleritis. The diagnosis of syphilis should be very cautious, because it is similar to many other diseases, diverse, complex, long course, and long-term latent. When making a diagnosis, we must combine the medical history, physical examination and laboratory examination results to make a comprehensive analysis and judgment, and if necessary, we need to carry out follow-up, family investigation and experimental treatment. I. Medical history: (1) History of unclean sexual intercourse: The patient should be asked about the history of whoring or other unclean sexual intercourse as much as possible to determine the source of infection. If the anus has chancre, ask if there is a history of anal sex. Asking about the time of unclean sexual intercourse is very necessary to determine the incubation period of syphilis. (2) Past history: whether there is a history of pudendal ulcer, skin erythema, papules, condyloma, etc., and whether there is a history of chancre, secondary and tertiary syphilis. Serological detection of syphilis. (3) Marriage history: whether there are foreign-related marriages, the number of marriages, and whether the spouse has clinical manifestations of sexually transmitted diseases or suspected sexually transmitted diseases. (4) Delivery history: whether there is a history of threatened abortion, premature delivery, abortion or stillbirth, and whether there is a history of delivering a child with fetal syphilis in the past. (5) If there is suspected congenital syphilis, parents should be asked whether they have had syphilis, the infection of brothers and sisters, and whether I have symptoms and signs of early and late syphilis. (6) If latent syphilis is suspected, ask about the history of infection and whether there is any disease that causes false positive in serum test biology. (7) Treatment history: whether you have received the treatment of expelling plum, the dosage and course of treatment, whether it is regular, and whether you have a history of drug allergy. Second, physical examination (a) general examination: whether the growth and development situation is good, mental state; (2) Skin mucosa: According to the skin damage characteristics of early and late syphilis, carefully check the whole body skin, mucosa, lymph nodes, hair, reproductive organs, anus, mouth and so on. (3) Special examination: in-depth examination or specialist examination of eyes, skeletal system, heart and nervous system. Third, laboratory examination: (1) Early syphilis should be examined by dark field microscope of Treponema pallidum. (2) Syphilis serum reagin test (such as VDRL, USR or RPR test), and treponema pallidum antigen test (such as FTA-ABS or TPHA test) if necessary. (3) Examination of cerebrospinal fluid, except neurosyphilis, especially asymptomatic neurosyphilis. Early syphilis can cause nerve damage, and 35% of patients with secondary syphilis have abnormal cerebrospinal fluid, so cerebrospinal fluid examination should be done. (4) Gene diagnosis and detection. Nanjing Dongda Medical Research Institute wishes you good health.