Secondary Syphilis - Symptoms

The manifestations of the secondary period of syphilis are characterized by an extraordinary diversity of morphological elements, predominantly affecting the skin, visible mucous membranes and, to a lesser extent, by changes in the internal organs, nervous system, and musculoskeletal system. In this period, generalization of the syphilitic infection is noted, reaching its highest development. Eruptions on the skin and mucous membranes are called secondary syphilides. They have a number of common features:

• the rash is located everywhere;
• after resolution, secondary syphilides leave no trace (with the exception of some forms of pustular and papular syphilides), i.e. a benign course is noted;
• absence of febrile symptoms;
• absence of subjective sensations;
• absence of acute inflammatory phenomena;
• in all forms of secondary syphilides, positive serological reactions are observed;
• rapid disappearance of syphilides under the influence of antisyphilitic treatment.

The distinction between the secondary period of syphilis into fresh and recurrent is important in terms of choosing the scope of treatment and anti-epidemic measures. Secondary fresh syphilis is characterized by an abundance of rashes, small size of elements, brightness of color, absence of grouping of syphilides and their dispersion. Elements are large in size, few in number, pale in color, tend to group and form arcs, rings, figures. The intervals between attacks of secondary syphilis, when rashes on the skin and mucous membranes are absent, are called secondary latent syphilis. Rashes of the secondary period during the first half of the year are accompanied by specific polyadenitis.

There are 5 groups of changes in the skin, its appendages and mucous membranes: spotted syphilides (syphilitic roseola); papular syphilides; pustular syphilides; syphilitic baldness; syphilitic leukoderma.

Syphilitic roseola. This form is the most common syphilid of the secondary period. Syphilitic roseola is morphologically a spot the size of a lentil to the nail of the little finger, irregularly rounded, with a smooth surface, disappearing when pressed. A distinction is made between fresh and recurrent roseola. Fresh roseola occurs immediately after the end of the primary period, i.e. 6-8 weeks after the appearance of a hard chancre, and usually reaches its full development within 10 days. Roseola spots in fresh secondary syphilis are abundant, located randomly, most often on the body (especially on its lateral surfaces) and on the extremities. In secondary recurrent syphilis, roseola rash appears after 4-6 months (first relapse of the secondary period of syphilis) or 1-3 years (second or third relapse of the secondary period of syphilis).

In addition to the typical, the following varieties of syphilitic roseola are distinguished: edematous (urticarial), confluent, recurrent (large in size) and annular (in the form of rings, arcs).

Roseola spots are also found on mucous membranes, most often located in the soft palate and tonsils. They are called erythematous syphilitic angina. Clinically, they are manifested by confluent erythematous areas of dark red color with a bluish tint, sharply demarcated from the surrounding healthy mucous membrane. The lesion does not cause subjective sensations and is not accompanied by fever (with rare exceptions) and other general phenomena.

Papular syphilides. The main morphological element of papular syphilide is a papule, sharply demarcated from the surrounding healthy skin and protruding above its level. Papular syphilide is mainly observed in secondary recurrent syphilis.

The following types of papular syphilid are encountered in practice:

• lenticular (lenticular) syphilid, represented by a papule of a round shape, the size of a lentil, bluish-red in color, of a dense-elastic consistency, with a smooth shiny surface. Over time, the papules acquire a yellowish-brown hue, flatten out, and a scanty peeling appears on their surface, first in the center, and then along the periphery in the form of a collar (Biette's collar). This form of syphilid is more common in the secondary fresh period of syphilis;
• miliary syphilid, characterized by its small size (the size of a poppy seed) and conical shape. The consistency of the element is dense, red or reddish-brown in color. Often occurs in weakened patients;
• nummular, or coin-shaped, characterized by a significant size of papules (the size of a large coin or larger), a tendency to group;
• annular, characterized by annular arrangement of papules;
• seborrheic: papules are localized in seborrheic areas (face, head, forehead) and are distinguished by oily scales on their surface;
• erosive (weeping): papules are located on areas of the skin with increased moisture and sweating (genitals, perineum, armpits, under the mammary glands in women) and are distinguished by a whitish macerated, eroded or weeping surface. They are very contagious;
• broad condylomas (vegetating papules), located in places of friction, physiological irritation (genitals, anal area). They are distinguished by their large size, vegetation (growth upward) and eroded surface. They are also very contagious;
• horny papules (syphilitic calluses), which are distinguished by the powerful development of the horny layer on the surface, are very similar to calluses. They are often located on the soles;
• psoriasiform papules, often found in the secondary relapse period of syphilis and characterized by pronounced scaling on the surface, which is very reminiscent of psoriasis.

Papular eruptions on the mucous membranes clinically correspond to erosive (weeping) papules. In the oral cavity, erosive papular syphilid most often occupies the area of the soft palate and tonsils (syphilitic papular tonsillitis). Papular eruptions on the mucous membrane of the larynx lead to hoarseness. Papules can not only erode, but also ulcerate. As a result of the addition of a secondary infection, pain and a hyperemic zone are noted around the papular elements. Papules located in the corners of the mouth often erode and become painful (syphilitic angular cheilitis).

Pustular syphilides are a rare manifestation of secondary syphilis. They are usually observed in the secondary relapse period in weakened patients with a severe (malignant) course of the process.

There are five types of pustular syphilid: - acneiform: small conical pustules appear on a dense papular base, similar to simple acne. They quickly dry into crusts, forming papulo-crustal elements;

• impetiginous: superficial pustules that form in the center of the papules and quickly dry up into a crust, sometimes merging to form large plaques;
• pox-like: characterized by spherical pustules the size of a pea, the center of which quickly dries into a crust. The pustules are located on a dense base, which resembles an element in smallpox;
• syphilitic ecthyma: is a deep round pustule that quickly dries into a thick crust, which when rejected, forms an ulcer with sharply cut edges and a peripheral ridge of a specific infiltrate of a purple-blue color. Ecthymas are usually single, leaving a scar;
• syphilitic rupia - an ecthyma-like element that occurs as a result of eccentric growth of the infiltrate and its subsequent suppuration. In this case, cone-shaped crusts are formed, layered on top of each other. Usually single, heal, leaving a scar.

Pustular-ulcerative syphilides can rarely be located on mucous membranes. When localized on the tonsils and soft palate, the process has the appearance of pustular-ulcerative angina.

Syphilitic baldness is usually observed in secondary recurrent syphilis. There are two clinical varieties of syphilitic baldness - diffuse and small focal. When they are combined in the same patient, they are called a mixed form.

Hair loss in syphilis is associated with the development of a specific infiltrate in the hair follicle, which leads to trophic disorders. On the other hand, pale spirochetes in the infiltrate can have a toxic effect on the hair follicles.

Diffuse syphilitic baldness is not clinically different from alopecia of other etiologies. The scalp is most often affected. The acute onset and rapid progression of the process are noteworthy; sometimes the number of hairs remaining on the head or pubis is counted in units.

In the case of the microfocal variety, multiple small bald spots of irregularly rounded outlines appear, randomly scattered over the head (especially in the temples and back of the head). This clinical picture is compared to "fur eaten by moths". A distinctive feature of this type of alopecia is that the hair in the affected areas does not fall out completely, but rather a sharp thinning of the hair occurs. The skin in the bald spots is not inflamed, does not peel, and the follicular apparatus is completely preserved.

The defeat of eyebrows and eyelashes is characterized by their gradual loss and sequential regrowth. As a result, they have different lengths - "step-like" eyelashes (Pincus symptom). Syphilitic alopecia exists for several months, after which there is a complete restoration of the hair.

Syphilitic leukoderma (pigmented syphilid) is typical for secondary recurrent syphilis and is more common in women. Leukoderma mainly appears in patients with cerebrospinal fluid pathology. Elements are often located on the lateral and posterior surfaces of the neck ("necklace of Venus"), but can be found on the chest, shoulder girdle, back, abdomen, and lower back. On the affected areas, gradually increasing diffuse hyperpigmentation first appears, with time hypopigmented round spots being noted against its background. Syphilitic leukoderma can be spotted, lacy, or mixed.

One of the common symptoms of secondary syphilis is polyadenitis.

In the secondary period, the pathological process may involve internal organs (gastritis, nephrosonephritis, myocarditis, hepatitis), the nervous system (early neurosyphilis) and the musculoskeletal system (polyarthritic synovitis, diffuse periostitis, painful swellings with a doughy consistency and night pain in the bones).

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