Lesson 20 Secondary period of syphilis

1. Theme urgency

The secondary period of syphilis is characterized by a wide variety of morphological lesions localized on the skin and visible mucous membranes, as well as by (to a less extent) changes in the internal organs, nervous system and motor apparatus. The primary sore may or may not be present. But serologic tests are always positive. The motor changes have no specific features, as a rule, and should rather be referred to the body's reaction to the generalized infectious process. This period is divided into secondary early syphilis (syphilis II recens), when the eruptions appear for the first time, and secondary recurrent syphilis (syphilis II recidiva) when the eruptions reappear after an interval. The secondary period of syphilis develops—2.5-3, less frequently 4 months after infection. In non-treated cases recurrences may be suffered several times within 2-4 years and more. The diagnosis of secondary latent syphilis (syphilis II latens) is made in the interval between the eruptions. The appearance and disappearance of the eruptions in the secondary period, as well as their number and morphological character are linked with the periods of the activity of the treponemas and their immunological interrelationship with the patient's organism.

In a retrospective study of 34 patients with secondary syphilis who had been seen previously by community phisicians, only 40% of physicians listed secondary syphilis as the primary diagnosis. Another 14% included secondary syphilis in their differential diagnosis. In sum, almost one-half of physicians did not consider the diagnosis.

2. Concrete Objectives:

Students must know:

1. Classification of secondary period of syphilis..

2. Clinical features of secondary period of syphilis.

3. Investigations of secondary period of syphilis.

4. Diagnosis of secondary period of syphilis.

5. Differential diagnosis of secondary period of syphilis.

Students should be able to:

1. To collect the medical history of patient with secondary period of syphilis.

2. To inspect the patient with secondary period of syphilis.

3. To define secondary stage of syphilis and describe its respective clinical manifestations.

4. To differentiate eruptions of secondary period of syphilis from those similar of others dermatoses.

3. Tasks for Self-study during preparation for lesson.

3.1. Theoretical questions for the lesson:

1. The course of secondary period of syphilis.

2. The difference between secondary fresh syphilis and secondary recurrent syphilis.

3. Macular syphilids.

4. Papular syphilids.

5. Pustular syphilids.

6. Secondary syphilids of the mucous membranes.

7. Syphilitic alopecia.

8. Syphilitic leucoderma.

The subject-matter:

Secondary period of syphilis (syphilis secundaria)

The secondary period of syphilis often begins with prodromal phenomena usually preceding secondary syphilids by 7 to 10 days. They are mostly encountered in females or weakened patients and coincide in time with the dissemination of treponemas in the patient's body by the hematogenous route. There are weakness, diminished working capacity, adynamia, headache, pain in the muscles, bones and joints (intensified at night, which is characteristic of syphilis); body temperature elevates (to moderate values, less frequently to 39°-40° C). This condition is often mistaken by the patient and physician for influenza, which delays timely diagnosis of syphilis. Blood leucocytosis and anemia may be encountered in this period.

The prodromal phenomena, which happen, but not in all patients, disappear with the appearance of the symptoms of the secondary period of syphilis, as a rule.

The secondary period of syphilis is characterized by a wide variety of morphological lesions localized on the skin and visible mucous membranes, as well as by (to a less extent) changes in the internal organs, nervous system and motor apparatus. The motor changes have no specific features, as a rule, and should rather be referred to the body's reaction to the generalized infectious process. This period is divided into secondary early syphilis (syphilis II recens), when the eruptions appear for the first time, and secondary recurrent syphilis (syphilis II recidiva) when the eruptions reappear after an interval. The secondary period of syphilis develops—2.5-3, less frequently 4 months after infection. In non-treated cases recurrences may be suffered several times within 2-4 years and more. The diagnosis of secondary latent syphilis (syphilis II latens) is made in the interval between the eruptions. The appearance and disappearance of the eruptions in the secondary period, as well as their number and morphological character are linked with the periods of the activity of the treponemas and their immunological interrelationship with the patient's organism.

The common features of the eruption in the secondary period (secondary syphilids) are its appearance over the entire body, rounded contours and discrete boundaries of the lesions, absence of a tendency to coalesce, a rose-red colour with a bluish hue, absence of subjective disturbances and a benign character of the lesions (even if not treated, they disappear some time later without a trace). A vast number of treponemas are found on the eroded surfaces of the secondary syphilids (this applies in particular to eroded papules of the genitalia and oral cavity and condyloma latum) because of which they are very contagious both during coitus and in close everyday contact. Serological blood tests (Wassermann's and precipitin reactions) are sharply positive in almost 100 per cent of cases with secondary early syphilis (with a high reagin titre of 1:160, 1:320) and in 96-98 per cent of patients with secondary recurrent syphilis (in which case the reagin titre is lower). The blood immunofluorescence test (IFT) is sharply positive in almost 100 per cent of cases. The T. pallidum immobilization test (TIP) is positive in almost half the patients with secondary early syphilis (40-60 per cent immobilization) and in 60-80 per cent of patients with secondary recurrent syphilis (70-90 per cent immobilization). Up to 50 per cent of cases with secondary recurrent syphilis are attended with abnormalities in the cerebrospinal fluid with no clinical picture of meningitis (the condition is called latent syphilitic meningitis).

The beginning of antibiotic therapy in patients with secondary syphilis (the secondary early form in particular) is often attended with the exacerbation reaction (Lukashevich-Jarisch-Herxheimer reaction), which is manifested not only by elevated body temperature and other general symptoms as the case is in primary syphilis, but by an increased number of lesions and intensification of their colour. In some patients who begin treatment in the primary seropositive period of syphilis, the first penicillin injection causes the appearance of rose-coloured spots on the trunk, obliging the physician to change the diagnosis to secondary early syphilis (the attending and on-duty physicians must therefore examine the skin continuously with particular care after the beginning of specific treatment started in the primary seropositive period of syphilis). According to Skripkin and others, the exacerbation reaction is encountered in 70 per cent of females and in 80 per cent of males with secondary early syphilis and in only 10-20 per cent of patients in secondary recurrent syphilis.

Histological examination of syphilids of the secondary period reveals perivascular infiltration (of various degrees) consisting of plasma, lymphoid, epithelioid and occasional giant cells. Plasma cells predominate which permits the syphilitic infiltrate of the secondary period to be called plasmosis.

The secondary syphilids are vascular spots (roseola), papules and, less frequently, vesicles and pustules. Pigmented syphilids (syphilitic leucoderma) and syphilitic alopecia are also lesions of the secondary period. True pleomorphism is often encountered in patients when there are simultaneous eruptions of different morphological lesions (e.g. rose-coloured spots and papules) or false (evolutional) pleomorphism when similar morphological lesions (e.g. papules) are in different developmental stages.

The syphilids of the secondary early period are smaller, abundant, brighter in colour; they are localized symmetrically, mainly on the skin of the trunk, show no tendency to coalesce and do not undergo scaling as a rule. Remnants of the hard chancre and marked regional scleradenitis may be found during this period in 22 to 30 per cent of patients. Besides, polyscleradenitis is more manifest (enlarged, hard elastic, mobile, painless axillary, submandibular, cervical, cubital lymph nodes, etc.). Polyadenitis is encountered in 88 to 90 per cent of patients with secondary early syphilis.

In secondary recurrent syphilis, the lesions are larger, less abundant and are often arranged asymmetrically. They tend to form groups (figures, garlands, arches) and are paler in colour. The lesions are often localized in the perineum, inguinal folds, mucous membranes of the genitals and mouth, i.e. in places subject to irritation. A monomorphic eruption of rose-coloured spots is encountered in 55-60 per cent of patients with secondary early syphilis; in secondary recurrent syphilis, in contrast, it is observed less frequently (in approximately 25 per cent of patients); monomorphic papular eruption is encountered more often (in up to 22 per cent of cases).

It is believed that secondary recurrent syphilis is encountered more frequently than secondary early syphilis.