Primary period of syphilis: hard chancre

Primary syphilis is characterized by the development of a solid chancre (ulcus durum, primary syphiloma) at the site of the introduction of pale treponema and regional lymphangitis and lymphadenitis. Primary syphiloma begins with the formation of a red spot, which then passes into a limited infiltrate (papule). Due to a disturbance in the nutrition of the epidermis, caused by the characteristic lesion of syphilis vessels, necroticisation takes place in the center of the infiltration and erosion or ulcer is formed. 

[1], [2], [3], [4], [5]

Pathogenesis

Histologically, a typical hard chancre has a number of pathohistological signs: the absence of the epidermis (and parts of the dermis) in the central zone due to the formation of foci and necrosis zones; in the dermis - dense perivascular infiltrate, consisting of lymphocytes and plasma cells. There is a change in the blood and lymphatic vessels of the dermis in the form of proliferation and infiltration of all membranes (panvasculitis) with obliteration and thrombosis of some vessels; a lot of pale trepops in all areas (especially in the walls of the vessels and their circumference).

Regional lymphadenitis (bubonic concomitant, scleradenitis regional) develops 5-7 days after the appearance of a solid chancre and is the second mandatory clinical symptom of primary syphilis. Clinically, sclerodenitis is characterized by a peculiar increase and consolidation of the lymph nodes closest to the chancroid. When the chancre is localized on the genitals, the inguinal lymph nodes are characterized by characteristic changes. If the primary syphiloma is localized on the lips and oral mucosa, then the chin and submandibular lymph nodes increase. When the chancre is localized on the upper lip, the parotid glands are enlarged.

The lymph nodes are enlarged to the size of beans, shallow plums, sometimes pigeon eggs, dense, not soldered to each other and to surrounding tissues, are mobile, have ovoid form and are completely painless. Skin over them is not changed. When joining a secondary infection, lymph nodes may be painful. It is characteristic that not one lymph node increases, but a group ("pleiad") of nodes, one of them being the largest one. Scleradenitis can be both bilateral and one-sided, and is almost never suppressed and not opened. For 3-4 weeks the existence of a solid chancre begins to increase gradually and all lymph nodes become dense - a specific polyadenitis arises - an important concomitant symptom of the end of the primary and the onset of secondary syphilis.

Regional lymphangitis is a lymphatic vascular lesion from the chancre to the nearby lymph nodes. In this case, the lymphatic vessel is probed in the form of a dense-elastic, painless cord, sometimes having thickening in its course.

[6], [7], [8], [9]

Symptoms of the primary syphilis

The main clinical signs of a typical solid chancre: erosion (ulcer) with absence of acute inflammatory phenomena; single or single; correct (round or oval) outlines; clear boundaries; value with a small coin; elevation of the element above the surrounding healthy skin (mucous membrane); smooth, shiny ("lacquered") bottom; gently sloping edges; cyanotic red color of the bottom; scant serous discharge; densely-elastic ("cartilaginous") infiltrate in the base (nodular, lamellar, leaf-like); painlessness; resistance to local disinfectant and anti-inflammatory therapy.

At the end of the primary period, there are sometimes general flu-like disorders: headache, osteoarticular and muscular pain, general weakness, insomnia, fever.

Hard chancre is often retained until the onset of the secondary period and soon heals, rarely exists until several weeks and after the onset of generalized rash, even less often - heals until the onset of secondary manifestations. It depends mainly on its size.

A solid chancre can be single or multiple. In the case of simultaneous infection through several entrance gates, the emerging solid chancres are in the same stage of development. These are the so-called chancres-twins. If the infection occurred at different times (for example, as a result of repeated sexual intercourse with an interval of several days), chancres will appear at different times and differ from each other in a degree of maturity. These are the so-called successive chancres. The localization of a solid chancre depends on the route of infection. At sexual infection, the hard chancre occurs, as a rule, on the genitals or on the adjacent areas (skirts, stomach, inner thighs, crotch, anus region). In the case of extra-sex infection, the chancre is extragenital (for example, on the lips, tongue, mammary glands, fingers). Second place after the genitals for the frequency of localization of primary syphiloma takes the mucous membrane of the mouth (lips, gums, tongue, soft palate, amygdala). Other localizations of hard chancre are rare.

Forms

Atypical forms of solid chancre include indurative edema, chancre amygdalitis and chancre-panaritium.

With indurative edema, there is a painless dense swelling on the labia or foreskin. Characteristic of the absence of acute inflammatory phenomena, which distinguishes indurative edema from processes such as bartolinite or inflammatory phimosis. The skin in the outbreak acquires a stagnant cyanotic color or maintains a normal color.

Chancra-amygdalitis is characterized by a sharp, usually unilateral increase in the tonsils. The tonsil is dense, there are no acute inflammatory phenomena. Shankr-amygdalite is very similar to an inductive edema. This atypical chancre is often mistaken for banal angina.

Shankr-paparinium is the most atypical of all chancres. He really simulates the panaritium: the distal phalanx is edematic, cyanotic-red, accompanied by sharp, "shooting" pains, covered with a purulent-necrotic plaque. Then there are erosions and ulcers.

[10], [11], [12], [13], [14], [15]

Complications and consequences

In case of chancre complication, phimosis, paraphimosis, gangrenization of primary syphiloma can develop, in women - vulvitis and vulvovaginitis.

[16], [17], [18], [19],

Treatment of the primary syphilis

Four decades of clinical use show that parenteral penicillin G is effective for resolving local lesions (healing lesions and preventing sexual transmission), as well as to prevent long-term consequences. However, adequate comparative tests to determine the optimal scheme for administering penicillin (dose, duration of treatment, drug) were not conducted. Even less data is available regarding the use of other drugs.

Recommended scheme for adults

Patients with primary or secondary syphilis should be treated according to the following scheme:

Benzathine penicillin G 2.4 million units IM in / m once

NOTE: Recommendations for the treatment of syphilis in pregnant women and HIV-infected patients are discussed in the relevant sections.

Recommended scheme for children

After the neonatal period in children diagnosed with syphilis, CSF should be examined to exclude neurosyphilis, it is also necessary to carefully study the history of both the child and the mother, to determine whether syphilis is congenital or acquired (see Congenital Syphilis). Children with acquired primary or secondary syphilis should be examined (including counseling in Child Protection Services) and treated according to the scheme for the treatment of syphilis in children (see Sexual Harassment of Children or Rape).

Benzathine penicillin G, from 50,000 units / kg IM to adult dose 2.4 million units IM per unit in single dose

Other observations on patient management

All patients with syphilis should be tested for HIV. In areas with high HIV prevalence, patients with primary syphilis should be re-tested for HIV after 3 months if the first reaction was negative. In case of seroconversion, intensive antiviral therapy should be started immediately.

Patients with syphilis who also have lesions of the nervous system or vision organs should be carefully examined (including the examination of CSF and the study of the eyes with a slit lamp). These patients should be treated according to the results of the survey.

The penetration of T. Pallidum in CSF, accompanied by pathological changes in CSF, occurs in adults with primary or secondary syphilis. However, only a small number of patients develop neurosyphilis after treatment according to the schemes presented in this review. Therefore, despite the presence of clinical signs and signs of involvement of the nervous system and the organs of vision, spinal puncture is not recommended for routine examination of patients with primary or secondary syphilis.

Follow-up

The absence of the effect of treatment can be observed when applying any scheme. However, evaluation of the response to treatment is often difficult, and there are no specific criteria for its effectiveness. Serologic test ticks can decrease more slowly in patients with a previous syphilitic infection. Repeated clinical and serological examination is performed after 3 months and again after 6 months; with uncertain results, a survey can be conducted more often.

In patients with persistent or relapsing symptoms and signs, as well as in patients who have a 4-fold increase in titers compared to the baseline or titer obtained in the previous study, these signs indicate either treatment failure or reinfection. After testing for HIV infection, these patients should be re-treated. Despite the possibility of reinfection, it is necessary to perform a spinal puncture.

If at 6 months after treatment in patients with primary or secondary syphilis there is not a fourfold decrease in the titers of non-treponemal tests, then treatment is considered ineffective. Such patients should be rechecked for HIV infection. The optimal tactics for managing these patients is unclear. At a minimum, such patients should undergo additional clinical and serological controls. HIV-infected patients should be monitored more frequently (ie, after 3 months instead of 6). If there is no guarantee that follow-up will be carried out, it is recommended that repeated treatment be performed. Some experts recommend CSF research in such situations.

For repeated treatment, most experts recommend 3 weekly injections of benzathine penicillin G for 2.4 million units IM in / m if the CSF test does not indicate the presence of neurosyphilis.

[20], [21], [22], [23], [24], [25],

Special Remarks

• Allergy to penicillin

In men and non-pregnant women with penicillin allergy with primary or secondary syphilis, treatment should be performed according to one of the following schemes, while it is very important to monitor the cure.

Recommended schemes

Doxycycline 100 mg orally 2 times a day for 2 weeks

Or Tetracycline 500 mg orally 4 times a day for 2 weeks.

Data on the clinical use of doxycycline in comparison with tetracycline is less, but the tolerance of doxycycline is better. In the treatment of patients who do not tolerate doxycycline or tetracycline, a guarantee is required that they will completely undergo treatment and will be for follow-up.

The pharmacological and antimicrobial properties of ceftriaxone and limited studies suggest that ceftriaxone is effective, but these data are insufficient to judge the long-term consequences of its use. The optimal dose and duration of treatment for ceftriaxone are not established, but the proposed regimen of 1g daily can be used if the treponemocidal level of the antibiotic in the blood is maintained for 8-10 days. A single dose of ceftriaxone for the treatment of syphilis is ineffective.

In men and non-pregnant women who can be guaranteed complete treatment and follow-up, an alternative regimen can be erythromycin perorally 4 times a day for 2 weeks with its tolerability. However, erythromycin is less effective than other recommended drugs.

With intolerance of the above drugs and the inability to conduct follow-up, patients should be desensitized and prescribed penicillin. If possible, it is recommended to conduct skin allergic tests for penicillin (see Management of patients with penicillin allergy).

Pregnancy

Pregnant patients with penicillin allergy should be desensitized, if necessary, and then treated with penicillin (see Management of patients with penicillin allergy and Syphilis during pregnancy).