Syphilis infection

Introduction Syphilis is a chronic infectious disease. It is caused by Treponema pallidum. It has a long course of illness, early violation of the genitals and skin, late invasion of various organs of the body, and a variety of symptoms and signs. It can be transmitted to each other through sexual behavior and can be transmitted to the mother. The fetus threatens the next generation. Very few patients are infected by kissing, breastfeeding, and daily necessities for patients with contagious damage.

Cause

(1) Causes of the disease

The syphilis pathogen in the mother of congenital syphilis is transmitted to the fetus through the placenta. The acquired syphilis patients are mainly infected by sexual behavior.

(two) pathogenesis

After entering the blood, the Treponema pallidum can enter the cerebrospinal fluid and invade the central nervous system for 1 to 3 months.

1. Asymptomatic neurosyphilis (asymptomatic neurosyphilis): pathological changes in the brain are unknown, because patients with this disease are not easy to obtain autopsy, but it is speculated that most of them mainly involve the meninges, and a few can involve both the brain and blood vessels.

2. Meningeal neurosyphilis Pathological changes: Although the disease is meningeal inflammation, but often there is mild cortical damage. The diffuse inflammatory reaction of the pia mater is visible to the naked eye, thickening or turbidity. Mung-ma is sometimes seen in the thickened meninges or on the heavily infected meninges, which resembles miliary tuberculosis, but the two can be distinguished by microscopic examination.

Microscopic examination of the fibrous tissue of the meninges, mainly lymphocyte infiltration, can also be found in a small number of plasma cells, and lymphocytes infiltration around the meningeal vessels. Inflammatory changes in the convex surface of the brain can be found in the lymphatic and plasma cell infiltration around the Virchow-Robin gap.

Meningeal inflammation at the bottom of the brain often causes damage to the cranial nerves, showing interstitial inflammatory damage such as oculomotor, trochlear and facial nerve. The accumulation of exudate at the bottom of the brain can block the circulation of cerebrospinal fluid, and even block the median or paraventricular hole of the fourth ventricle, leading to pathological changes of hydrocephalus. The ependymal layer of the ventricular wall is sand-like or granular, which is caused by the proliferation of astrocytic cells under the ependym. In the thickened meninges, if you look at the gum-like swelling, you can see fibroblasts, multinucleated giant cells, and plasma cells in the center. There are necrotic tissues in the center, and the net protein from the reticular tissue can also be found. Reticulin), which can be distinguished from tuberculous nodules, because no protein is contained in the cheese-like necrotic tissue of tuberculous nodules. If the diameter of the gum is swollen to a few centimeters, the adjacent nerve tissue can be compressed. According to its location and size, it causes clinically different focal symptoms. At the damaged pia, it is sometimes seen that fibrous astrocytes proliferate in the cerebral cortex and protrude into the subarachnoid space. In the blood vessels of the meninges and brain, endovascular inflammation and vascular inflammation are common, sometimes leading to brain softening.

Syphilitic meningeal damage, such as limited to the spinal cord, is called syphilitic spinal arachnoiditis, and involving the dura mater is called spinal dural inflammation.

3. Vascular neurosyphilis Pathological changes: vascular neurosyphilis mainly involves the middle and small arteries of the brain and spinal cord, syphilitic endarteritis and softening of the brain and spinal cord tissues in the corresponding areas. Commonly damaged arteries have branches of the anterior cerebral artery returning to the artery. This branch mainly supplies the anterior lower part of the caudate nucleus, the adjacent caudate nucleus and the forearm of the internal capsule. The middle cerebral artery and its branches can also be affected. The latter supplies the nucleus of the blood crust, the caudate nucleus, the lower part of the forelimb of the internal capsule, the dorsal part of the posterior branch of the internal capsule, and the globus pallidus. The vertebral artery, basilar artery and anterior spinal artery can be involved.

The lesion can be confined to one artery or a segment of an artery. The outer membrane of the damaged artery is thickened, lymphocytes and plasma cells are infiltrated, the middle layer is thinned, and the inner muscle layer and elastic fibers are destroyed, but sometimes the elastic fibers can remain intact. Inferior subperiosteal fibrosis proliferates to narrow the lumen of the blood vessel, and thrombosis is formed in the affected artery, which is mechanized and recanalized. Some arteries form occlusive endarteritis. Smaller arteries can only have intimal hyperplasia, and only the lumen is narrow and the inflammatory response is called Nissl-Alzheimer arteritis. There may be inflammatory cell infiltration around the nourishing blood vessels along the large vessel wall. Because the vascularities of syphilitic arteritis are different, the location of the damaged nerve tissue is different, the softening lesions vary in size, and sometimes there are most small infarcts in the brain.

The above vascular lesions can also be found in other types of neurosyphilis, such as meningeal vascular syphilis and paralytic dementia. If syphilitic arteritis invades the anterior or posterior spinal artery, one or several segments of the spinal cord may be softened to varying degrees and associated with good collateral circulation in the spinal cord. The softened areas showed typical infarct pathological changes. Aneurysms occur in very few cases.

4. Spinal cord sputum: The pathological changes of this disease are selective degeneration of nerve fiber bundles, and the posterior and posterior cords of the spinal cord are mainly in the lumbar, temporal and lower thoracic segments. It is generally seen that the soft membrane of the ridge, especially the dorsal side, becomes thicker and more turbid, and the posterior nerve root of the lower spinal cord becomes thinner and flatter. The dorsal spinal cord was significantly affected, and the posterior cord became narrower and wrinkled, and the sputum was harder than normal. If the optic nerve is involved, it can be seen that the intracranial segment and the optic chiasm become thinner and adhere to the surrounding pia mater.

Microscopic examination In the early stage of the disease, the vertebral membrane firstly has inflammatory changes and thickening, mainly infiltration of lymphocytes and plasma cells, and is confined to the soft membrane of the posterior root and the posterior root sleeve. There are interstitial neuritic changes in the posterior root, neurofibrosis in the roots, inflammatory cell infiltration between the fibers, and sore sheath after spinal cord, especially in thin bundles, showing myelin disintegration, nerve fibers Atrophy; late nerve fibers disappear, and astrocyte proliferation, which also contains part of connective tissue proliferation, but no necrosis and inflammatory response. These changes are particularly prone to the lower thoracic and lumbosacral segments, and sometimes can invade the sympathetic afferent fibers and anterior horn cells. Other conductive bundles in the spinal cord are not involved.

In patients with cranial nerves, their cranial nerve changes are the same as those in the posterior root of the spinal cord. Generally, the brains of III, IV, and VIII are more likely to be involved. In patients with optic neuritis, the myelin sheath of the optic nerve and the optic chiasm is lost, the inflammatory infiltrate is mainly in the peripheral part, and the arachnoid and optic nerve are closely adhered to the optic nerve. A very small number of cases involve the cervical spinal cord and its posterior root, called the cervical spinal cord (tabes dorsalis). The pathogenesis of this disease selectively involving the posterior root and posterior cord degeneration of the spinal cord has not been elucidated. It is generally considered to be a poisonous degenerative disease accompanied by a reactive inflammatory change. As for the relationship between this disease and immunology, it is still under study.

5. Paralytic dementia: pathological changes are mainly cerebral cortex. Gross observation shows that the meninges become turbid and thick, and they can adhere to the cerebral cortex and the skull outside it. The brain is reduced in size, the cerebral gyrus is narrowed, the sulci is widened, and there is more fluid in the sulcus, which is most prominent in the prefrontal cortex. Secondly, the vulnerable person is the temporal lobe. The cerebral ventricles may be enlarged on both sides of the brain, and the ventricular system wall often has a granular reaction on the ependymal wall, which is caused by granular ependymitis.

Microscopic examination: especially in the frontal lobes and temporal lobes, there are inflammatory cell infiltration around the perivascular and meningeal vessels along the Virchow-Robin gap, mainly lymphocytes, plasma cells and phagocytic cells. The degree of inflammatory changes varies depending on the stage of the disease and the degree of infection. In the blood vessels of the cortex, the outer membrane is infiltrated by lymphocytes and plasma cells, and the intima has fibroblast proliferation, and syphilis is sometimes found therein. The neuronal cells in the cerebral cortex are diffusely degenerated and lost, and there are reactive astrocytes, especially microglia. Glial nodules can form at astrocyte hyperplasia. Iron deposits are common around small blood vessels in the brain.

In the treated cases, there are some effects on the microscopic findings, the inflammatory reaction is reduced, and even the inflammatory changes are not found, the meninges are not hyperplasia, only the nerve cells in the cerebral cortex and reactive gliosis can be seen. .

6. Congenital neurosyphilis: more stillbirth, infection in early pregnancy can cause hydrocephalus and brain malformation and difficult to survive. There may be meningeal vascular infections early in life. Adolescents with chronic development may present with paralytic dementia and spinal cord spastic lesions, and their pathological changes are basically consistent with those of adults.

an examination

Related inspection

Syphilis diagnosis test syphilis qualitative test

Clinical manifestation

1. Asymptomatic neurosyphilis: asymptomatic neurosyphilis refers to a clear primary syphilis infection or serological syphilis test positive, and CSF examination has abnormal changes, but there is no clinical nervous system Symptoms and signs of the patient. Most patients with this disease occur within 1 to 2 years after initial infection, accounting for about 10% of patients with syphilis. In the third year after infection, the incidence rate gradually decreased. This was due to the conversion of some patients to symptomatic neurosyphilis; in another part, CSF turned to normal or treated. Such patients have positive venereal disease research laboratory test (VDRL), CSF examination of leukocytosis, mainly lymphocytes showed mild, moderate increase, protein content increased, CSF-VDRL about 80% Positive. And the specific test of syphilis diagnosis, such as fluorescent treponemal antibody absorption test (FTA-ABS) can also be positive.

2. Meningeal neurosyphilis: mainly caused by syphilis spirochetes, which is more common in 1-2 years after initial infection, and a few are found in infection after 5 years. If left untreated or inadequately treated, it may turn into a primary syphilis such as paralytic dementia or spinal cord paralysis.

Easy to see in young and middle-aged men. Acute or subacute onset, may have headache, nausea, vomiting, pain in the neck, hard neck, fever, but also not fever. The Kernig sign may be positive. Fundus edema can occur in patients with severe intracranial pressure, and meningitis at the top of the brain can induce seizures or mental disorders. Cranial bottom meningitis often causes eye movements, trochules, trigeminal, spreading and facial nerve spasm, of which the above sag is particularly common. A small number of patients have focal neurological signs such as hemiparesis or sputum, suggesting that syphilitic arteritis is present in the adjacent brain tissue of meningeal inflammation. The skin mucosa of some meningeal syphilis patients often suffer from lesions such as punctate papules, scaly rashes, blisters and bullae. 3. Vascular neurosyphilis, vascular neurosyphilis, 5 to 30 years after the initial infection with syphilis, but can also be seen within a few months after infection. The interval between the onset of initial infection in young patients is shorter than that in middle-aged patients, and it is often one of the main causes of stroke in young patients. Men are more common than women. There are statistical data on vascular nerve syphilis accounting for 3 to 15% of patients with syphilis.

More common in young and middle-aged men. There were persistent headaches or personality disorders, and focal signs appeared several weeks later and progressed progressively. Focal syndromes have different vascular occlusion syndromes depending on the different blood vessels involved. If the middle cerebral artery is involved, there will be contralateral hemiplegia and partial sensation of the lesion, ipsilateral hemianopia; the main side lesion may have aphasia and other cortical dysfunction. If the lesion is the anterior cerebral artery, the lesion is hemiplegia and sensory disturbance, but the lower limb is heavier than the upper limb, and often accompanied by urinary incontinence and mental disorders, such as euphoria, apathy and confusion. Spinal cord blood vessels, often root pain or numbness at the beginning of the disease, suggesting the upper boundary of spinal cord lesions. The cervical or thoracic spinal cord is easily involved, and the performance of acute transverse myelopathy occurs. Symptoms develop to peaks in hours to days. The patient's torso often has a sensory missing plane, paraplegia or quadriplegia, pathological reflex positive, and defecation or incontinence.

3. Spinal cord sputum (tabes dorsalis) is a late-onset neurogenic syphilis with a long incubation period, which occurs on average 8 to 12 years after initial infection with syphilis, and can be as short as 3 years and as long as 20 years. The age of onset is more common in 35 to 50 years old. Male cases are four times as many as women. The lesion selectively invades the posterior root and posterior cord of the spinal cord and causes degeneration. In the era of the lack of effective treatment for syphilis, this disease accounted for about a quarter of neurosyphilis, accounting for about 10% of patients with initial syphilis and inadequate treatment. Most cases are slow onset and a few are more acute. General sensory disturbances occur earlier, followed by ataxia, nutritional disorders, incontinence and impotence.

(1) Sensory disorder: Pain is the earliest symptom of spinal cord hernia. The pain is characterized by short-term pain. It lasts for a few seconds, does not radiate to other places and is fixed at one point, mostly in the lower limbs, or in the chest. abdomen. From a little pain, and quickly transferred to another, it can also be continuous pain, so it is called "lightning pain", its pain such as burning, knife cutting, electric shock, drilling, tearing, wet or cold weather Induced. As the disease progresses, the strange feelings gradually increase, and are mostly located in the trunk and lower limbs, such as ants walking feeling, wool touch feeling, acupuncture feeling, the trunk often has a band-like feeling. At the same time, the skin is allergic to pain, temperature and touch. Sometimes there are double feelings, delayed feelings, mental dual feelings, etc. In the later stage, it became a loss of feeling, and the earliest pain was lost. Common areas are at the tip of the nose, the outside of the neck, the front of the chest and calf, and the outside of the forearm. The sense of vibration and position are often extremely detrimental in the lower limbs, especially at the distal end of the limb such as the toes and fingers.

(2) dyskinesia: mainly manifested as progressive sensory ataxia, which is also a unique symptom of this disease. Due to the positional sensation of the lower limbs and the loss of the proprioception, the gait is unstable, the walking is dependent on the visual coordination, the base of the two feet is widened, the legs are raised very high, and the step is very heavy when going down. The distance between the two steps is called "spinal gait". It is also described as "elegant gait" because of the often high head when walking. Closed eyes are difficult to sign positive. Muscle strength disorder, a rare person may have muscle atrophy due to damage to the anterior or anterior horn.

(3) Muscle tone and reflex symptoms: As the proprioceptive afferent part is damaged at the posterior root, the reflex arc is impeded, the muscle tension is significantly decreased, and the joint may be over-extended. For example, the knee joint is bent backward to cause the knee reflex. Qu, generally manifested as excessive movement of joint passive movement and active movement. The sacral reflexes of the lower extremities are reduced or disappeared, especially the knee reflexes, followed by the Achilles tendon reflexes, and the degree of sacral reflexes on both sides is not consistent. Unless the cervical spinal cord is paralyzed, the upper extremity tendon reflex is not impaired. No pathological reflex can be induced.

(4) Ocular symptoms: Most of them have pupillary abnormalities, such as small pupils, irregular edges or varying sides. About half of the patients have a typical Argyll-Robertson's pupil, ie the pupil is reduced, and the direct and indirect responses to light disappear, but regulation and collective reflection still exist. It can involve one-sided or bilateral pupils, sometimes only showing dullness to light reflection and not completely disappearing. The mechanism by which A-Roche's pupil occurs is not fully understood. It is believed that the lesion is located in the front of the cerebral ventricle (pretectum), the intersecting and non-intersecting nerve fibers between the astigmatism and the ocular nucleus. This damage location only destroys the light-reflecting arc and does not affect the nuclear-like pathway of the collective reaction. About one-fifth of patients have optic atrophy, which is characterized by increasing visual loss, which is more common in primary optic atrophy. Occasionally, the nerves of the eye are stunned and there is ptosis, double vision or strabismus.

(5) Visceral crisis: paroxysmal visceral pain accompanied by paroxysmal visceral dysfunction. The stomach crisis is more common, and the disease can appear early. Unbearable sharp pain in the stomach and upper abdomen, accompanied by nausea and vomiting. The vomit has a strong acid odor, and sometimes the attack only manifests as nausea. The duration of a general episode lasts from a few hours to a few days. The crisis can suddenly appear and disappear on its own. The pain is difficult to relieve, and it is difficult to eat with vomiting, which can lead to dehydration and alkalosis. Visceral crisis can also be manifested in other organs, but less common, such as laryngeal crisis manifested as asphyxia and cough; intestinal crisis manifested as diarrhea and abdominal pain; bladder rectal crisis manifested as bladder and rectal pain; urethra crisis It is characterized by severe pain in the urethra.

(6) Nutritional disorders: also due to the disappearance of afferent nerve function to the central nervous system.

1 Charcot's joint. It is a common neuropathic joint disease and is easy to invade the knees, ankles, elbows and joints of the hands and feet. Rapid development, the first joint swelling has exudate, cartilage hyperplasia, late cartilage destruction, joint surface hypergloss, new bone formation, joint edema and bone atrophy and hyperplasia can produce various joint deformities. The formation of the joints of Xia Ke may be related to excessive relaxation of muscles and ligaments around the joints and normal pain and loss of position.

2 penetrating ulcers are painless gangrenous ulcers. Easy to see at the base of the big toe or small toe. First, the epidermis is thin, and after the ulceration, the ulcer deepens day by day, sometimes exposing the bone, and the edge is relatively intact and difficult to heal.

(7) Sphincter dysfunction: When the lesion is located in the posterior root of the phrenic nerve, the bladder disorder can appear early; the lesion is located in other parts and later appears. Sometimes the patient has a large amount of urine retention without painful feeling, which is caused by a decrease in bladder tension. In addition, urinary incontinence and impotence can occur. Because syphilis is easy to get treatment in the early stage, the typical manifestations of spinal cord spasm are difficult to find, and the new manifestations of this disease may increase such as bladder dysfunction, flaccid paraplegia of both lower extremities, and summer cauda equine puncture and other symptoms.

4. Paralytic dementia: Dementia paralytica, also known as general paralysis, is a chronic meningoencephalitis caused by Treponema pallidum entering the brain parenchyma. If left untreated, it will die from systemic muscle paralysis for 2 to 3 years. This disease is more common in 10 to 15 years after infection with syphilis, more common in early syphilis without thorough treatment, and the patient's incubation period is longer. More common in 30 to 50 years old, males are 8 times as many as female patients. Because the patient's mental symptoms are prominent, he is often treated in a mental hospital. The onset is extremely slow, and it is not easy to be noticed. It only shows emotional instability, irritability, headache, gradual mental abnormalities, changes in living habits, memory loss and finger muscle tremors. In the late stage, it manifested as mental dysfunction, general weakness, and finally died.

(1) Psychiatric symptoms: The personality changes and behaviors are abnormal. For example, the original behavior is dignified and cautious, and the words are changed without words. If they are quiet or good at managing money, they will become arrogant and wasteful. Often mistaken accounts, long-term memory can still be partially retained, while recent and immediate memory damage is most significant, analysis and judgment, orientation and self-knowledge. Early sexual desire is hyperthyroidism, and later is reduced. There can be language confusion and various delusions and hallucinations. According to mental abnormalities, they can be divided into the following types:

1 exaggerated large: the most common one, its exaggerated content is based on the ability to think of superhuman, the world's richest, followed by smug and happy.

2 arrogant type: excited, wild and multi-lingual, often with destructive behavior as activities increase.

3 depression type: emotional depression, pessimism, disappointment, self-blame and self-incrimination, or chattering, suspected of suffering from incurable diseases.

4 simple decline type: emotional apathy, mental decline, slow movement, intelligent retardation.

(2) Symptoms of the nervous system: The language is ambiguous with mental decline, and the lips, tongue, eyelids, and finger muscles tremble, and the writing is trembling and of different sizes. The pupil size is not equal, the edges are not neat, and the typical A-Roche pupil is often present. The patient was faltering, and the closed eyes were more likely to be positive. The sputum reflexes, but the late stage may be due to dystrophic reflexes, and there may be pyramidal tract signs, occasional seizures, and even epileptic seizures.

5. Congenital neurosyphilis is congenital neurosyphilis. Mothers with syphilis during pregnancy, syphilis can infect the fetus via the placental circulation. The incidence of congenital neurosyphilis is generally related to the mother's period of syphilis, that is, the longer the mother suffers from syphilis, the less chance that the fetus will be born. In addition, fetuses within 4 months of age are often not susceptible to infection by Treponema pallidum. Therefore, mothers with syphilis can prevent fetus from contracting syphilis if they can receive adequate treatment for jaundice in the first trimester of pregnancy.

Children with congenital neurosyphilis who have survived may have hydrocephalus and hearing loss, often accompanied by chorioretinitis, interstitial keratitis and Hutchinson's teeth and saddle nose. With age, juvenile paralytic dementia or juvenile taboparesis occurs gradually, and the degree of dementia is related to age and extent of disease. Simple juvenile spinal cord spasm is extremely rare.

Differential diagnosis

First, syphilitic meningitis should be differentiated from the following diseases

1. Tuberculous meningitis: tuberculous meningitis has a history of tuberculosis, or fever, weight loss, night sweats and severe poisoning symptoms, cerebrospinal fluid glucose content is significantly reduced, syphilis serological test is negative.

2. Intracranial space-occupying lesions: In addition to increased intracranial pressure, there are often focal symptoms. The cerebrospinal fluid syphilis response test was negative. Imaging examination can show signs of compression and displacement of a certain brain tissue.

3. Congenital aneurysm or arteriovenous malformation: This disease often has headache, coma, convulsion history and single eye nerve palsy, or eye movement nerve palsy, but also hemiplegic and meningeal irritation, skull, eyelid and skull bottom sometimes Blood vessel murmurs can be heard. Cerebral angiography or digital subtraction can determine the size and location of vascular lesions.

Second, the cerebral vascular syphilis should be differentiated from cerebrovascular disease and need to be differentiated from ischemic cerebrovascular disease. The incidence of cerebral thrombosis is more than 50 years old. There is a history of hypertension arteriosclerosis, physical examination with hypertension, fundus arteriosclerosis, and elevated blood lipids and blood viscosity. Blood and cerebrospinal fluid syphilis tests were negative in patients with cerebral embolism.

Third, the spinal cord should be differentiated from the following diseases

1. Arthritis, neuralgia, and radiculopathy: It is not difficult to distinguish by detailed medical history inquiry combined with physical examination.

2. Multiple peripheral neuritis: There is no lightning-like pain in this disease, the sensory disorder is terminal type, and there is limb paralysis, blood syphilis reaction is negative, cerebrospinal fluid is normal.

3. Spinal cord hereditary ataxia: more often in childhood, with a family history, normal cerebrospinal fluid. In addition to the spinal cord and cerebellar damage, there are still pyramidal tract signs, and with somatic abnormalities such as arched feet, blood syphilis reaction is negative.

Fourth, paralytic dementia should be differentiated from dementia caused by brain organic disorders, the latter has no cerebrospinal fluid abnormalities, and the syphilis response test is negative.

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