Syphilitic arthritis
Introduction
Introduction to syphilitic Syphilitic arthritis (syphiliticsrthritis) generally develops from 20 to 40 years old. Some patients develop joint symptoms after more than 10 years of incubation after infection with syphilis. There are also latent syphilis, causing the onset of joint syphilis in the cause of trauma, childbirth, infection and so on. The incidence of congenital syphilitic arthritis is mainly from 6 to 10 years old, and the incidence is rare after 20 years old. Syphilitic joint pain needs to be differentiated from neuralgia and snoring. Syphilitic osteoarthritis needs to be differentiated from common osteoarthritis. White swollen joint syphilis is differentiated from tuberculous arthritis. Edema of edema joint often requires tuberculosis. Synovitis, joint effusion, chronic rheumatoid arthritis, joint effusion, or non-specific joint synovitis, identification of joint fluid. basic knowledge The proportion of illness: 10-15% (the above is the incidence rate among multiple sexual partners) Susceptible people: 20 to 40 years old Mode of transmission: sexually transmitted mother-to-child transmission of blood transmission Complications: syphilitic arthritis edema synovitis osteopetrosis osteonecrosis
Cause
Cause of syphilitic arthritis
(1) Causes of the disease
The syphilis pathogen was discovered by Schaudinn and Hoffman in 1905. From early infectious damage, they observed spiral pathogens, Treponema pallidum, which is the syphilis pathogen, and other pathogenic spirochetes, including the leucocytic snails that cause yaws. The species (T. palliaum subspecies pertenue) is closely related to the T. carateum of Pinta.
Treponema pallidum is a slender spiral bacterium, about 0.15m wide and 6~50m long. It usually has 6~14 spirals, and the ends are tapered. Because the bacteria are too slender, it can be seen by Gram staining, but it can be Dark-field microscopic examination of wet sheets (see below) or by silver staining or fluorescein-labeled antibody method.
It is found that several characteristics of the outer membrane of P. sinensis may be instructive to the pathogenesis of syphilis. Unlike most bacterial outer membranes, the outer membrane of Treponema pallidum mainly consists of phospholipids and is revealed by the surface. The protein is very small, and it is believed that due to this feature, syphilis can still develop in the case of active antibody (for non-surface-exposed internal antigens), with 6 axes between the outer membrane and the peptidoglycan cell wall. Silk, silk ends are interconnected, spanning the center of the cells, they are similar in structure and biochemistry to flagella, which is capable of moving.
Although Treponema pallidum can be cultured in vitro, long-term culture in vitro is still difficult to achieve, and the harvest is extremely small. Therefore, the application in culture is limited, and it is not practical for clinical use. The spirulina pallidum can be serially passaged in rabbits. Without loss of virulence, the number of strains isolated from rabbits is very small. After intensive research, the genetic diversity is very small. All the isolates studied are sensitive to penicillin and similar in antigenicity. Rabbit infection has long been untreated and can produce immunity against homologous strains. It is known that the natural host of Treponema pallidum is only human, some monkeys and higher apes.
(two) pathogenesis
P. pallidum can penetrate into the normal mucosa and can also enter from the tiny lesions on the epithelial surface. In experimental rabbit syphilis, within 30 minutes after inoculation, the lymphatic system has a spiral body, and soon after that, blood can also appear. The occurrence of transfusion syphilis is due to the fact that the blood transfused is provided by the patient who is in the syphilis incubation period. It can be seen that human syphilis is also the same. From the very beginning, it is a systemic disease. The initial sore appears at the initial vaccination, probably because there is A large number of Treponema pallidum enters. In animal experiments, the amount of Treponema inoculation is inversely related to the time required for the appearance of skin sores. It is not known that the minimum amount of bacteria required for infection may be established by a Treponema pallidum. The rate is very slow. The splitting time in rabbits is about 33 hours. The chronic process and incubation period of syphilis are relatively long, and may be partly related to its slow growth in the human body.
It has not been found that Treponema pallidum can produce any toxin. Although it has specificity for the attachment of host cells, it is not known whether such attachment will damage the host cells. Most Treponema pallidum is in the intercellular space, and there are also some Treponema pallidum. Within phagocytic cells; however, there is no evidence of long-term survival within the cell.
Prevention
Syphilitic arthritis prevention
At present, the control of syphilis can only rely on the doctor's clinical vigilance, find cases to report to the public health department in a timely manner, actively carry out epidemiological investigations, and pay close attention to the preventive treatment of sexual contacts, and should be treated with whole body treatment, but with nerves. Symptoms of syphilis are similar. It is very difficult to cure. It is necessary to carry out reasonable treatment for plum blossoms for a long time. It should not be satisfied with temporary relief or temporary cure. It can only be terminated until the Kanghua reaction turns negative. It is reported that mercury preparations treat joint syphilis. There are special effects, penicillin, arsenic vanadium, iodine combined application, the effect of driving plum is good, joint syphilis rarely requires surgery.
Complication
Syphilitic arthritis complications Complications syphilitic arthritis edema synovitis osteosclerosis osteonecrosis
1. Acute and subacute syphilitic arthritis occur in patients with middle-aged and late syphilis. Single or multiple joints are common at the same time. Onset, there may be persistent fever or relaxation, and the joints appear red, swollen and painful. Joint swelling and pain increase at night, and joint effusion can occur.
2. Chronic syphilitic arthritis of white swollen joint syphilis, later osteophytes, or osteonecrosis, edema joint syphilis can be complicated by synovitis, joint effusion, a small number of patients can be seen with bone rubbery.
Symptom
Symptoms of syphilitic arthritis Common symptoms Pustular pain, herpes, convulsions, secondary infection, keratitis, inflammation, personality, heart failure, heart failure
1. Clinical stage of syphilis
(1) Primary syphilis: The primary damage of primary syphilis is a painless indurated ulcer with a basement cleansing. The lower jaw begins with a papule, and the surface layer festers to form a typical ulcer. The edge is raised and hard, but sometimes It can cause painful damage due to secondary infection. Most of the sputum is only one, but there are sometimes multiple ulcers, especially the skin folds ("kissing chancre"). Healing in the middle of the week, leaving a faintly visible scar, the lower jaw is often accompanied by local lymphadenopathy, one or both sides are indeterminate, the local lymph nodes can move, the separation is as good as rubber, but it occurs in the lower jaw of the cervix and rectum, and is locally affected. The axillary lymph nodes failed to reach.
Any sputum that can be inoculated by direct contact can occur, but most of it occurs in the anal genital area. A few are found in the pharynx, tongue, lips, fingers, nipples and other parts. The shape of the lower jaw depends on the location, and It is also related to the host immune response. In the past, the affected person's jaw may be small and remain papular, and the lower jaw may smash more and may have severe pain.
The differential diagnosis of genital ulcers should include genital herpes. Usually herpes ulcers should be multiple, painful, superficial, and vesicles can be seen early, but atypical lesions may be indistinguishable from syphilis, genital herpes More common than syphilis, it has become the most common cause of "atypical diarrhea" in North America, but unlike syphilitic ulcers, the Tzanck test should be positive in herpes ulcers, ie, multinucleated giant cells in the base of the ulcer, chancroid Ulcers often have pain, and often multiple, exudate without hardening, lymphogranuloma venereum can have small papular lesions, and may be associated with local lymphadenopathy, other needs to be identified Inguinal granuloma (granuloma inguinale), drug eruption, cancer, superficial fungal infection, traumatic damage, lichen planus, etc., most cases are ultimately identified by dark-field examination, positive results are only found in syphilis.
(2) Secondary syphilis: After 4 to 8 weeks of squatting in the first stage, there is usually secondary syphilis damage. Patients can complain of fever, headache, disobedience, sore throat and other systemic symptoms. Most patients have There are systemic lymphadenopathy, including lymph nodes on the trochlear, and about 30% of patients can still see signs of sacral healing, but many patients (including gay men and women) have no history of acne.
About 80% of patients with secondary syphilis have skin damage or damage to the mucous membrane of the skin at some time during the course of the disease. Clinically, rash is often thought of by rash, but the symptoms of rash are often very mild. Many patients with advanced syphilis can't think of it. After the first and second stages of damage, the rash performance varies greatly, but there are some typical characteristics, they are generally extensive, symmetric distribution, often reddish, bronze or dark red (especially the earliest plaque damage) Generally, there is no itching (but there are some exceptions). Adults never appear in the form of blisters and bullae. In addition to very early rash lesions, they are hard, and the surface often has scaly (pimple scaly damage). It is pleomorphic, round, and remains pigmented or lost when healed. Skin damage can be extremely light and difficult to see, especially those with dark skin.
The initial reddish plaque lesions are common on the costal margin or the body side, and later spread to it, but except for the mouth, the face generally does not occur, and the subsequent papular lesions are generally systemic, palm and sputum are extremely significant, rash Frequent superficial scaly, and pigmentation, can occur in the face, it can be pustular, like acne vulgaris, sometimes large scale and similar to psoriasis (psoriasis), deep nodular damage may Misunderstanding, sometimes due to ulceration, similar to acne (ecchyma), malnutrition and debilitating patients, extensive destructive damage to the upper ecchymosis, forming a so-called rupial lesion, Damage around the hair follicle can form alopecia areata in the sac area or scalp.
Ring damage may also occur, especially around the face, especially blacks, damage in the corners and nose, and linear erosion in the center ("split papule").
Hot and humid parts such as perineum, gray and flat large pimples can be merged into condyloma latum, such damage can also be seen in the armpit, occasionally systemic, highly contagious, be careful not to be confused with common sexually transmitted diseases (condyloma acuminata) The latter is small, often multiple, and it is sharper than flat wetness.
Other mucosal lesions are also common, and inflammation can be seen in the phlegm and pharynx. About 30% of patients with secondary syphilis have a so-called mucous patch, which is a slightly elevated oval area, covered with an off-white membrane, and the base is reddish after removal. No bleeding, visible in the genitals, mouth and tongue, similar to flat wet warts, highly contagious.
Other secondary syphilis syndrome also has hepatitis. In some cases, it can be reported as up to 10%. Astragalus is rare, but alkaline phosphatase is often increased. Liver biopsy shows focal necrosis, mononuclear infiltration or portal vein. Vasculitis, silver staining can often find spirochetes, periostitis and extensive osteolytic lesions are also occasionally reported, bone scan for early syphilitic osteitis seems to be sensitive, immune complex kidney disease and transient nephrotic syndrome, there are also A small number of cases can also occur, iritis and anterior uveitis, 10% to 30% of cases of cerebrospinal fluid (CSF) cells increased, but less than 1% of meningitis symptoms, symptomatic gastritis may occur.
The differential diagnosis of secondary syphilis involves many diseases. The rash may resemble pityriasis rosea, but the latter appears along the dermatofid line and often has a precursor patch (herald patch) visible, as well as a drug rash. , acute rash fever, psoriasis, lichen planus, hemorrhoids, etc., sometimes also need to consider, mucosal plaque looks very similar to oral candidiasis (thrush), sore throat of infectious mononucleosis, systemic lymphadenopathy , hepatitis and systemic rash, etc., can also resemble secondary syphilis, infectious hepatitis can also cause misunderstanding, some patients must be highly alert to make a diagnosis of syphilis, unfortunately, even today, even the general, pigment Severe, papular scaly damage, typical signs of damage to the palms and soles of the feet, diagnosis errors are not uncommon, but fortunately, if you want to do serological tests, the positive rate should be 99%, flat wet sputum and mucosal plaque contain a large number of Treponema It can be detected by the dark field method, and the lymphatic puncture may also detect the activity of the Helicobacter pylori.
Recurrent syphilis
After the first and second stage syphilis skin damage disappears, 20% to 30% of patients will have recurrent skin damage, the number of recurrent damage may be less, or harder than the initial damage, but like the typical one, the second stage syphilis, Sex partners are also contagious.
(3) recessive syphilis: latent syphilis (latent syphilis) refers to no clinical signs of syphilis, CSF is also normal syphilis, after the second stage of syphilis, you can enter the recessive period, and can continue this life, but by Reactive serological tests, often can detect syphilis, must show more than one reaction, can be identified, in order to rule out technical errors, some diseases are known to sometimes cause false positives in syphilis non-dirospiral test, such as systemic Lupus erythematosus, etc., must be excluded, but also to exclude congenital syphilis, in order to diagnose recessive syphilis, patients have not necessarily had a history of syphilis, if any, for the diagnosis of hidden syphilis is certainly very helpful.
Recessive syphilis can be divided into early and late stages. The signs suggest that infectious recurrence is mostly in the first year. Epidemiological data prove that most of the spread of syphilis occurs in the first year after infection, so the United States has hidden Early syphilis is defined as the first year after the disappearance of the second or second stage of damage, or the asymptomatic patient with negative syphilis serological test in the previous year. The new positive reaction, late late syphilis is usually not contagious, except for pregnant women, many years later The fetus can still be infected.
(4) Late syphilis: Tertiary syphilis is the stage of disease destruction, which can cause disease and waste. Late syphilis comorbidity is still an important clinical problem, but since the Second World War, newly discovered syphilis cases have been The incidence of late-stage syphilis is still unknown, but the prevalence of various types of advanced syphilis is already a rough figure.
Late syphilis progression is often very slow, but due to arterial endocarditis and thrombotic changes in the CNS, some neurological syndromes may suddenly start, late syphilis is not contagious, internal organs can be affected, but can be divided into three The main types: late benign (dendritic), cardiovascular, neurosyphilis.
1 Late benign syphilis: According to the study of untreated cases in Oslo (1891 ~ 1951), late benign syphilis, gumm, is the most common complication of advanced syphilis. In the era of penicillin, gum swelling is rare, generally It occurs 1 to 10 years after the initial infection, and can be found in any part of the body. Although it may be extremely destructive, it will be effective after treatment, so it is still relatively benign damage. Histologically, the gum-like swelling is granuloma, but Histological manifestations are not specific, may be associated with central necrosis, epithelial and fibroblasts, giant cells are occasionally seen, sometimes vasculitis, can not be found in silver staining, but sometimes can still be Rabbits were inoculated and detected.
The gums are single or multiple, usually asymmetrical, but often clustered, starting with a superficial nodule, or a deeper lesion, and rupturing to form punched-out ulcers. Generally, it is not painful, the progress is slow, the touch is hard, the center is often healed and there is atrophy, the external pigmentation ring, the skin gum may be similar to other chronic granulomatous ulcerative damage, such as tuberculosis, sarcoidosis, leprosy and In the case of deep fungal infections, it may not be possible to make a definitive histological diagnosis, but only syphilis can swollen rapidly under the treatment of penicillin, and another type of gum is a psoriasis-like lesion of psoriasis.
Gum swelling can also affect the deep organ system. The most common are the respiratory tract, digestive tract and bone. It is hundreds of years old. The nose and eucalyptus gum often cause septal perforation and the facial image is damaged. The gum can also affect the throat and the throat. Lung parenchyma, gastric gum can be similar to gastric cancer and lymphoma, liver gum has been the most common visceral syphilis, often with hepatosplenomegaly and anemia, occasional fever and jaundice, bone gum mainly occurs in long bones, skull and collarbone Especially for nighttime pain, if there is a radiation sign, it is often periostitis and osteolytic or sclerosing destructive osteitis.
2 cardiovascular syphilis: the main cardiovascular complications of syphilis are aortic regurgitation and aortic aneurysm (often in the ascending aorta), sometimes involving other aorta, coronary sinus is also involved and the blood supply is insufficient, all these The complication is caused by occlusive endarteritis of the vasorum, which damages the intima and media of the large blood vessels. As the ascending aorta expands, the annulus is enlarged and closed. The leaflets are still normal, and the patient may eventually die from congestive heart failure. Some cases of syphilitic aortic regurgitation have a certain effect after being placed into the artificial heart valve. The aneurysm can sometimes pulsate the anterior chest wall. The syphilitic aortitis may also involve the descending aorta, but all are in the proximal end of the renal artery, so it is different from the arteriosclerotic aneurysm, which is often below the renal artery.
It usually occurs within 5 to 10 years after the initial infection, and it takes 20 to 30 years to have obvious clinical syndromes. It is believed that there are more males than females in black blood syphilis, and blacks may be more than whites, but not after congenital infections. Cardiovascular syphilis will occur, and the Central Committee is not yet known.
Asymptomatic aortitis, it is best to see the ascending aortic wall calcification from the chest radiograph to make a diagnosis, the signs of syphilitic aortic regurgitation, the same as other etiological aortic regurgitation, aortic annulus The faint murmur caused by dilation due to dilatation is often the loudest at the right edge of the sternum. The syphilitic aortic aneurysm can be fusiform, but mostly cystic, and it is not easy to dissection the aortic wall (sandwich formation), 10 % to 25% of patients with cardiovascular syphilis are associated with neurosyphilis.
Nowadays, syphilis is the cause of aortic regurgitation, and the elderly are more than younger patients. This is because the incidence of advanced cardiovascular syphilis is decreasing.
3 neurosyphilis: neurosyphilis (neurosyphilis) can be divided into 4 categories: asymptomatic, meningeal vascular, spinal cord paralysis, paralysis dementia, classification is not absolute, coincident with each other is also very common, now in the neurosyphilis, as a classic syndrome The number of variant cases, more than in the past, may be the effect of antibacterials on other diseases.
Examine
Examination of syphilitic arthritis
Dark-field examination: The most accurate diagnosis is from the early acquired or congenital syphilis lesions, found typical vertebrate of morphology and activity, primary syphilis and moist mucosal damage of secondary and congenital syphilis, dark field examination (dark field Examination) can often obtain positive results, secondary syphilis lymphatic puncture, sometimes positive, but in the first stage of syphilis, the patient may also use soap or other toxic compounds in the damage, so that the test results in false negative results, so A negative result can not rule out syphilis. For cases with suspicious damage and negative dark-field examination, it is best not to clean the lesion, return every day, and check it twice, but in clinical practice, for high-risk subjects (drug users, Gay active men) After the serological examination, it is safer to treat their suspected lesions. There may also be spirochetes in the mouth, especially near the iliac crest. Morphologically, it is similar to Helicobacter pylori, usually by clinical manifestations. , medical history and serological tests to make a diagnosis.
Diagnosis
Diagnosis of syphilitic arthritis
diagnosis
Syphilitic arthritis is mainly determined by comprehensive analysis and judgment in the following aspects.
1. History of family history of syphilis, such as abortion, premature birth, and history of joint disease, the patient has a history of syphilis infection, or symptoms of syphilis infection, there are typical Hao Qin's three signs, but syphilitic arthritis patients sometimes There is no clear history of syphilis infection.
2. Joint performance syphilitic arthritis is most common in the knee joint, followed by the elbow joint, but much less than the knee joint. In the sterno-lock joint, the thoracic rib joint, the chance of syphilitic arthritis in the mandibular joint is more than other purulent There are many opportunities for inflammation. Chronic joint syphilis is lighter than joint tuberculosis, but nighttime pain is one of the characteristics. Compared with joint tuberculosis, joint syphilis has less joint dysfunction and joint activity, but due to soft tissue scar around the joint. It can also cause joint contracture.
3. X-ray image bone atrophy is rare, this is a feature of joint syphilis, if there is bone destruction, it is also a localized destruction.
4. Joint fluid is usually serous or serous fibrinous joint fluid, not purulent joint fluid.
5. Kanghua reaction Although the blood Kanghua reaction is negative, it is not uncommon, but the positive reaction rate of the joint fluid Kanghua is higher. If there is no fluid in the joint, the saline is injected into the joint. After 24 hours, the joint is extracted. The normal saline is injected into the Kanghua reaction of the joint fluid, and compared with the blood Kanghua reaction. The hyperthermia reaction titer in the joint extract is higher than the blood titer, and the joint is diagnosed as joint syphilis. However, when the blood Kanghua reaction is positive and the joint fluid is negative, the possibility of joint syphilis cannot be ruled out.
6. When the reaction of driving plum is carried out for the treatment of plum, there may be a temporary increase in local joint symptoms, and this reaction will soon disappear, and the joint symptoms will be relieved thereafter.
Differential diagnosis
Syphilitic joint pain needs to be differentiated from neuralgia and snoring. Syphilitic osteoarthritis needs to be differentiated from common osteoarthritis. White swollen joint syphilis is differentiated from tuberculous arthritis. Edema of edema joint often requires tuberculosis. Synovitis, joint effusion, chronic rheumatoid arthritis, joint effusion, or non-specific joint synovitis, identification of joint fluid.
