2. • The diagnosis of latent syphilis is often made only on the basis of
positive serological reactions without any clinical data indicating a
specific infection
Latent syphilis is classified into:
• early
• late
• unspecified
3. Early latent syphilis
• corresponds to the period from primary seropositive syphilis to
secondary recurrent syphilis, inclusive, only without active clinical
manifestations (on average, up to 2 years from the moment of
infection).
• However, these patients at any time may experience active, infectious
manifestations of early syphilis. This forces to classify patients with
early latent syphilis as an epidemiologically dangerous group.
4. Diagnosis of early latent syphilis
• In the diagnosis of this form of syphilis, the following data can help:
• - anamnesis, which should be collected carefully, paying attention to
erosive and ulcerative rashes on the genitals, in the oral cavity in the past
(within 1-2 years), various skin rashes, taking antibiotics (for "sore throat",
"flu condition" ), treatment of gonorrhea (without examining the source of
infection), if preventive treatment has not been carried out, etc.;
• - the results of the examination of a person who has had sexual contact
with the patient, and the identification of an early form of syphilis in him;
• - detection of a scar or induration at the site of the primary syphiloma,
enlarged (usually inguinal) lymph nodes, clinically consistent with regional
scleradenitis;
5. • sharply positive results of all serological reactions;
• fever at the beginning of penicillin therapy;
• negative serological reactions by the end of the 1st and 2nd courses
of treatment;
• a sharply positive RIF result, although RIPT in some patients may still
be negative;
• the age of patients is more often up to 40 years;
• with latent syphilitic meningitis, there is a rapid sanitation of the
cerebrospinal fluid in the process of anti-syphilitic treatment.
6. Latent late syphilis/syphilis latens tarda
• is epidemiologically less dangerous than early forms, since when the
process is activated, it manifests itself either by damage to the
internal organs and the nervous system, or by the appearance of low-
infectious tertiary syphilides - tubercles and gummas.
• Positive serological blood tests are not always manifestations of
syphilis, whereas they can be false positive, i.e. caused by past
malaria, rheumatism, chronic diseases of the liver, lungs, chronic
purulent processes, age-related changes in metabolism.
• Diagnosis of latent late syphilis is considered the most difficult and
responsible and cannot be made without confirmation of RIF, RIPT
and RPHA.
• All patients with late syphilis are consulted by a neuropathologist, a
therapist to exclude specific damage to the central nervous system
and internal organs.
7. Diagnosis of late latent syphilis
• anamnesis data (if the patient indicates that he could have become infected from
some source more than 2 years ago);
• weakly positive serological reactions (VDRL) with positive RIF, RIPT and RPHA;
• negative serological reactions by the middle or the end of specific treatment, or
the absence of negative despite vigorous anti-syphilitic treatment with the use of
nonspecific agents;
• no exacerbation at the beginning of penicillin therapy
• pathology in the cerebrospinal fluid (latent syphilitic meningitis), observed in
these patients more often than in early latent syphilis, and its very slow
sanitation. In addition, late latent syphilis is also found in sexual partners or
(much more often) they do not have any manifestations of syphilis (they are
practically healthy, and they should not be given preventive treatment as sexual
intercourse in patients with early latent syphilis). The main goal of specific
treatment of patients with late latent syphilis is to prevent the development of
late forms of visceral syphilis and syphilis of the nervous system in them.
8. Latent (unknown, unspecified) syphilis
• diagnosed when the time and circumstances of infection are
unknown.
• The establishment of such a diagnosis in the absence of clinical and
anamnestic data on syphilis, only on the basis of serological tests,
confirms the possibility from the very beginning of an asymptomatic
latent course of syphilis.
10. • Congenital syphilis occurs as a result of entering of treponema
pallidum to the fetus through the placenta from a mother with
syphilis.
• Fetal infection can occur both in the case of the mother's illness
before conception, and later, at different stages of fetal development.
• Pale treponemes enter the fetus through the umbilical vein or
through the lymph gaps of the umbilical vessels.
• Despite the early penetration of pale treponemes into the fetus,
pathological changes in its organs and tissues develop only at the 5-
6th month of gestation, therefore, active anti-syphilitic treatment in
the early stages of pregnancy can ensure the birth of healthy
offspring
11. • Pregnancy in a woman with syphilis may end in late miscarriage,
premature birth, the birth of a sick child with early or late
manifestations of the disease, or with a latent infection.
Congenital syphilis is divided into:
• syphilis of the fetus
• early congenital syphilis (from the moment of birth to 4 years of age)
• late congenital syphilis (in children over 4 years of age)
• latent congenital syphilis, which is observed in all age groups.
12. Specific change in the placenta
• Congenital syphilis of the fetus is preceded by a specific change in the placenta.
Pale treponemas, penetrating the placenta, cause severe anatomical and
morphological changes in the form of edema, connective tissue hyperplasia and
necrosis. Vascular lesions characteristic of syphilitic infection of the type of endo-,
meso-, perivasculitis are accompanied by severe sclerosis of the villi,
degeneration of the epithelium, cellular infiltration of the vessel walls with their
obliteration.
• An increase in the mass of the placenta is typical for syphilis. Normally, the ratio
of the mass of the placenta to the mass of the fetus is 1: 6, and with syphilitic
infection it is 1: 3. Excessive development of granulation tissue and abscesses in
the villous vessels is especially pronounced in the embryonic part of the placenta.
Confirmation of the diagnosis of syphilis is the detection of pale treponemas in
the umbilical cord of the fetus. In the placenta, pale treponemas are found less
often. The greatest number of pale treponemas is found in the internal organs of
the fetus - the liver, spleen, adrenal glands.
• With syphilis, late miscarriages and stillbirths occur in the 6-7th month of
pregnancy (macerated fetus).
13. Syphilis of the fetus
• In the first months of pregnancy, the fetus is not affected, since pale
treponemas enter its body only with the development of placental
circulation. Typical specific changes are detected no earlier than the 5th
month.
• Internal organs enlarge and thicken due to the development of diffuse
inflammatory infiltration and the subsequent proliferation of connective
tissue.
• Sometimes infiltrative clusters form miliary syphilomas, especially in the
liver and spleen.
• In the lungs, the phenomenon of "white pneumonia" is found due to
specific infiltration of interalveolar septa, hyperplasia and desquamation of
the alveolar epithelium. The affected part of the lung is compacted, has a
grayish-white color.
14. • The phenomena of osteochondritis and osteoperiostitis are noted.
• The skin of stillborn fetuses is macerated, the epidermis is loosened,
eroded in places, exfoliates in layers due to an autolytic enzymatic
process.
• Due to the underdevelopment of the subcutaneous fatty tissue, the
skin easily folds, wrinkled, especially on the face, which becomes
similar to the face of an old man.
• The most frequent and reliable sign of fetal syphilis is X-ray detection
at the 5-6th month of intrauterine development of a lesion of the
skeletal system in the form of a specific osteochondrosis, less often
osteoperiostitis.
16. Infantile syphilis
• Congenital syphilis of infancy can have a variety of manifestations,
since it affects a number of organs and systems. The manifestations of
the disease are detected either immediately after the birth of a child,
or during the first 2 months of life. Sometimes a baby is already born
with signs of syphilis. Skin, mucous membranes, internal organs,
nervous system, bones can be affected. The rash contains many
treponemas pallidus and is therefore very contagious.
17. • Syphilitic pemphigus is a reliable sign of
early severe congenital syphilis.
• Manifests with the formation of blisters
on the palms and soles, flexor surfaces of
the forearms and lower legs, face, less
often on the trunk. Sometimes the
elements can be located throughout the
skin.
• The content is often serous-purulent, but
it can also be hemorrhagic. There are
many pale treponemas in the contents of
the blisters, such patients extremely
contagious. After opening the bubbles,
weeping are formed, surrounded by the
remnants of the caps of the bubbles,
erosion.
• The diagnosis is established on the basis
of the detection of pale treponemas and
positive serological reactions.
• Syphilitic rhinitis may be the only and
very early manifestation of syphilis in
infants.
• Mucous membrane of the nose is
swollen, edematous, hyperemic,
sometimes eroded, with a significant
amount of mucus mixed with pus and
blood.
• The discharge shrinks into massive crusts,
sometimes completely covering the nasal
passages.
• When sucking, the baby periodically
breaks away from the breast with a cry to
take a deep breath through the mouth.
Nasal breathing becomes difficult, noisy,
wheezing or impossible, leading to
exhaustion of the child.
• Long-term runny nose can lead to
destructive changes in the osteochondral
part of the nose and its deformation
(saddle nose, lornet nose)
18. • Diffuse thickening of Gochsinger's skin is a reliable sign of congenital
syphilis.
• Usually appears not at the birth of a child, but at the 8-10th week of life.
Syphilis is usually localized on the palms, soles, buttocks, especially in the
lips and chin. The process begins with the onset of diffuse or focal
erythema. Then infiltration develops in these places, as a result of which
the skin folds are smoothed out, the skin becomes dense, inelastic. The lips
are thickened and swollen, yellowish-red in color, the mucous membrane
and the red border of the lips are tense.
• Usually, the surface of the lesion is macerated and wet, and a large number
of pale treponemas are determined on it. With a cry, mechanical trauma,
or a sufficiently intense tension of the lips, the child develops superficial
and deep cracks that extend to the red border. The cracks are usually
perpendicular to the lips, bleed and quickly crust over. After 2-3 months,
even without treatment, diffuse Gochzinger infiltration is gradually
resolved, but at the site of deep cracks, especially in the corners of the
mouth, radial scars (Robinson-Fournier scars) remain. These scars are a
pathognomonic symptom of the transferred early congenital syphilis
throughout life.
19. • Specific damage to the laryngeal mucosa is expressed by diffuse
infiltration and often ulcerative laryngitis with hoarseness. With the
transition of the process to cartilage, perichondritis and destruction
of cartilage can develop, followed by the formation of stenosis.
• There is a diffuse infiltration in the forehead, where the skin is tense,
dry, shiny, stagnant erythematous color with a copper tint. The spread
of the process to the brow ridges is accompanied by a thinning of the
eyebrows.
• On the scalp, hair thinns and falls out.
• Less commonly, the skin of the buttocks, back of the thighs, legs,
scrotum and labia is affected.
• Diffuse lesions of the skin of the fingers and toes are accompanied by
peculiar deformities of the nails. A roseolous rash on the skin of the
trunk is rare, sometimes it flakes and merges, which is unusual for a
roseolous rash of adults and children with acquired syphilis.
20. The defeat of the skeletal system is the most
frequent active manifestation of early congenital
syphilis in children.
• This is due to the intensive formation of fetal bone tissue at the 5-6th
month of intrauterine development with abundant blood supply to
the growth zones of long tubular bones. Osteochondritis is the most
typical form of bone pathology in congenital syphilis in infants.
• Long tubular bones, more often of the upper extremities, are
affected. The pathological process is localized in the metaphysis on
the border with the cartilage.
21. • Osteochondritis I degree is represented by an uneven expansion of
the preliminary ossification zone, which looks like a white
homogeneous strip as a result of excessive calcification of cartilage
cells. The strip of the pre-ossification zone has an extension of up to 2
mm and looks jagged. This is a pathognomonic sign, because a line
without notches is observed in healthy children or in sepsis and other
serious diseases.
• Osteochondritis II degree on the roentgenogram has the form of a
white stripe extended to 4 mm in the area of preliminary calcification,
also with jagged edges. Under this zone, towards the diaphysis, a
second stripe is found, but dark, narrow with a small number of bone
bars, which is a newly formed bone tissue. In some cases, the white
stripe may disappear and then only one dark stripe is revealed.
22. • Osteochondritis III degree - a dark stripe of rarefaction between the
pineal gland and the metaphysis up to 4 mm wide on the
roentgenogram, sharply delimited from healthy bone tissue. This strip
can be continuous or consist of separate foci of destruction. Later, as
a result of necrosis of the granulation tissue, the pineal gland may
separate from the diaphysis with a pathological fracture called Parro's
disease.
• The child stops moving the affected limb, and with passive
movements or careless touch, he makes a sharp cry. The upper limb
hangs like a whip, while the lower one remains bent at the hip and
knee joints. There are swelling in the knee and ankle joints.
23. • Periostitis and osteo-periostitis, which are observed in 70-80% of sick
children, are frequent bone damage in early congenital syphilis.
• Periostitis and osteoperiostitis of the skull bones can lead to various
changes in its shape. The buttock-like skull is the most typical: the
frontal and parietal tubercles are sharply enlarged and protruded,
separated by a longitudinal depression. Often, all sizes of the skull are
increased due to hydrocephalus.
• One of the forms of specific changes in bones in infants is dactylitis -
a lesion of the proximal, less often the middle phalanges of the
fingers, expressed in a cylindrical or fusiform thickening of the bone.
Often several phalanges are affected and soft tissue is intact
24. • Congenital syphilis of infancy can be conditionally divided into two periods:
• from the moment of birth to 3-4 months and
• from 3-4 months to 1 year.
• In the first period, generalized processes on the skin and mucous
membranes prevail, diffuse infiltrations, syphilitic pemphigus, damage to
the skeletal system (in the form of osteochondritis, periostitis, dactylitis),
various changes in the internal organs (especially the liver and spleen) and
the nervous system occur.
• In the second period, the severity of syphilitic changes is significantly
reduced, is intermediate between congenital syphilis of infancy and
congenital syphilis of early childhood.
25. • Congenital syphilis of early childhood can be manifested by eye
disease - chorioretinitis and optic nerve atrophy. Sometimes this is
the only symptom of congenital syphilis. With chorioretinitis, lumps of
pigment and depigmentation zones appear along the periphery of the
fundus - a symptom of "salt and pepper". The defeat of the optic
nerve is manifested by the indistinctness of the contours of the optic
nerve head, followed by its atrophy and loss of vision.
• The defeat of the nervous system is formed in the form of meningitis,
meningo-encephalitis and hydrocephalus.
26. Early childhood syphilis
• is accompanied by limited changes in the skin and mucous
membranes in the form of a small amount of roseolous and papular
elements, as well as periostitis and osteoperiostitis. Skin eruptions
are less profuse than in infants. Large papules and wide warts
predominate, prone to grouping and localization in limited areas,
more often in the buttocks, large folds of the skin and genitals.
• Papules erode, become wet, hypertrophy and turn into wide warts.
Papular elements are often located on the mucous membranes of the
cheeks, tonsils, and tongue. In the corners of the mouth, papular
elements become wet, covered with purulent discharge and resemble
seizures with a pyogenic or yeast infection.
27. • Lesions of internal organs are less common and less pronounced. The
liver and spleen are most changed. They are enlarged, dense, painful
on palpation. Less commonly, kidney damage is detected. In urine,
protein, renal epithelium, casts, erythrocytes are found. The
phenomena of hypochromic anemia and leukocytosis are often noted
• The latent form of early congenital syphilis prevails over the manifest
one. The diagnosis is confirmed by strongly positive
• RIF and RIT.
28. Late congenital syphilis
• This form includes any congenital manifestations of syphilis that arose
in a child over 4-5 years old (more often at 14-15 years old, and
sometimes later).
• Many authors consider late congenital syphilis to be a recurrence of
syphilis, transferred in early childhood or infancy, as well as a
manifestation of a long and asymptomatic disease. The active
manifestations of late congenital syphilis are identical to those of
tertiary syphilis, but skin lesions are not as profuse as in early
congenital syphilis.
29. • Tuberculous-ulcerative syphilides and gummas are located mainly on
the skin of the trunk, limbs and face. The tubercles tend to cluster
without fusion. Gummy syphilides are often solitary and are observed
at a later age. Lumpy and gummy manifestations of late congenital
syphilis are prone to rapid decay, ulceration.
• In addition to the symptoms of late congenital syphilis, a number of
patients may have manifestations of syphilis transferred from early
childhood syphilis, - Robinson-Fournier scars, saddle nose, skull
deformities, residual osteoperiostitis.
30. • Late congenital syphilis is characterized by unconditional signs
(reliably indicating a congenital infection) and probable signs
(requiring additional confirmation).
• Dystrophies (stigmas) occur in many chronic infectious diseases and
are not pathogmonic for congenital syphilis.
31. Reliable (unconditional) signs of late congenital
syphilis include the Hutchinson triad - interstitial
(parenchymal) diffuse keratitis, syphilitic
labyrinthitis and Getchinson's teeth.
• Parenchymal keratitis is manifested by diffuse corneal opacity,
photophobia, lacrimation, and blepharospasm.
• Corneal opacity, more intense in the center, sometimes forms not
diffusely, but in separate areas. After infiltration, newly formed
vessels penetrate into the deep layers of the cornea. Usually one eye
gets sick first, after a while - the other. The process takes a long time,
the resolution is very slow. Often syphilitic keratitis is accompanied by
iritis, iridocyclitis and chorioretinitis.
32. • Syphilitic labyrinthitis, or labyrinthine deafness, which occurs
suddenly against the background of visible well-being, is manifested
by hearing loss (usually in both ears) and tinnitus. The process is
associated with infiltrative inflammation of the labyrinth and bilateral
degeneration of the auditory nerves. With labyrinthitis, before the
child develops speech, there may be difficulty in pronouncing sounds
or deaf-dumbness.
• Bone conduction is impaired. Since pale treponemas cannot be
detected with these manifestations of syphilis, it is believed that
parenchymal keratitis and syphilitic labyrinthitis are caused by an
allergic reaction of an infectious genesis.
33. • Dental pathology (Hutchinson's teeth) in the form of dystrophy of
the upper central permanent incisors and hypoplasia of their chewing
surface. On the cutting edge of the teeth, semilunar crescent-shaped
notches are formed, as a result of which the cutting surface of the
incisors narrows somewhat, and the neck of the teeth becomes
wider, the teeth acquire a barrel-shaped shape or the shape of a
screwdriver.
• The difference in the width of the neck and the cutting surface must
be at least 2 mm, otherwise this symptom cannot be considered
reliable. The enamel on the cutting edge is often absent. A semilunar
notch along the incisal edge of the upper central incisors can be
detected in early childhood by radiography. Treatment of a mother in
the last months of pregnancy or a child in the first 3 months of life
can prevent the formation of dental dystrophies.
34. • Some authors include a group of reliable signs specific gonitis
• Specific gonitis is a chronic synovitis of the knee joints without
affecting the cartilage and epiphyses of the bones, proceeds
chronically, without disrupting the function of the joint, without
increasing body temperature and pain. The joint is enlarged in
volume, slightly swollen, mobility is not limited. The process can be
symmetrical. The ankle and elbow joints are more often affected.
35. • One of the most frequent manifestations of late congenital syphilis is
damage to the skeletal system, especially symmetrical changes in the
tibia of the legs - saber legs. Distinguish between true and false saber
shin. A true saber shin is considered as a consequence of
osteochondritis suffered in infancy. The falciform bend of the tibia is
directed anteriorly. A false saber shin is also observed with acquired
syphilis. On the anterior surface of the tibia there are massive
osteoperiosteal layers as a result of repeatedly recurrent
osteoperiostitis
• The saber legs, as well as the "saber" forearm, are not considered
unconditional signs of late congenital syphilis, since they can be
observed in some orthopedic diseases, especially in Paget's disease.
36. • Robinson-Fournier scars can begin on the red border of the lips,
sometimes in the Klein zone, and go to the skin adjacent to the red
border. On the red border, the scars appear as thin, discolored linear
stripes that stand out clearly against the background of the pale pink
red border of the lips.
• In addition to the Robinson-Fournier scars, the buttock-like skull is a
"stamp" of early congenital syphilis that persists throughout
subsequent life. It is formed as a result of diffuse ossifying infiltrate in
the frontal and parietal bones. This is facilitated by syphilitic
hydrocephalus.
37. Stigma of late congenital syphilis
• a symptom of the Ausitidian is a thickening of the sternal end of the clavicle due
to diffuse hyperostosis. The right clavicle is most often affected. X-ray confirms
the clinical diagnosis;
• high ("lancet" or "gothic") hard palate;
• an infantile little finger (Dubois-Hissard symptom), shortening of the little finger
(Dubois symptom), and the little finger itself is somewhat curved and turned
inward (Hissar's symptom);
• axiphoidia - the absence of the xiphoid process of the sternum (but the xiphoid
process can be turned inward, and then the impression of its absence is created);
38. • Carabelli tubercle - the 5th accessory tubercle on the chewing
surface of the first molar of the upper jaw;
• Diastema Gachet - widely spaced upper incisors;
• Hypertrichosis in boys and girls, as well as low hair growth on the
forehead (almost to the eyebrows);
• Dystrophies of the bones of the skull - protruding frontal and parietal
tubercles, but without a dividing strip.
39. Diagnostics
• At least one reliable symptom has diagnostic value.
• Probable signs and dystrophies (stigma) are taken into account in
combination with at least one true sign or in combination with
serological examination data and anamnestic confirmation of
infection in children and their parents.
• In late congenital syphilis, the diagnosis is confirmed by the data of
serological reactions of RIF, RIBT and RPHA.
40. Prognosis
• depends on the quality and timeliness of treatment for the mother
and the severity of the child's illness. Full treatment, rational regimen
and care, breastfeeding ensure a complete cure for children. In late
congenital syphilis, early treatment is effective enough, but RIBT and
RIF can remain positive for a long time.
