梅毒 Syphilis

1. 梅毒Syphilis 昆明医学院皮肤性病学教研室 周晓鸿 教 授

2. 学习目的Learning Objectives • Learning Objectives • Upon completion of this content, the learner will be able to: • Describe the pathogenesis of T. pallidum. • Discuss the clinical manifestations of syphilis. • Identify common methods used in the diagnosis of syphilis. • treatment regimens for syphilis. • Summarize appropriate prevention counseling messages for patients with syphilis. • Describe public health measures for the prevention of syphilis.

3. 定义Definition： • 由梅毒螺旋体( treponema pallidum)主要通过性接触、血液传播或从母体通过胎盘感染，侵犯多系统多脏器的慢性传染性疾病。 • Syphilis Definition: a sexual transmitted disease caused by spirochetal bacterium Treponema pallidum , a motile anaerobic. • Disease progresses in stagesmay become chronic without treatment

4. 病因：梅毒螺旋体是一种螺旋状的，革兰氏阴性的，厌氧菌。人类是其唯一的天然宿主。 Etiologic agent: Treponema pallidum:Treponema pallidum subspecies pallidum is a spiral-shaped,Gram gegative, highly mobile bacterium, Humans are the only known natural reservoir for subspeciespallidum. It is unable to survive without a host for more than a few days.

5. etiology • 梅毒螺旋体是一种小而纤细的呈螺旋状的微生物，长度为5—20微米，直径约0.25微米。肉眼看不到，在光镜暗视野下，人们仅能看到梅毒螺旋体的折光性，其活动较强。 • 梅毒螺旋体离开人体后不易存活。 • The particular spirochete responsible for syphilis is Treponema pallidum. • T pallidum is a fragile spiral bacterium 5-20 micrometers long by 0.25 micrometers in diameter. Its small size makes it invisible on light microscopy; therefore, it must be identified by its distinctive undulating movements on darkfield microscopy. It can survive only briefly outside of the body; thus, transmission almost always requires direct contact with the infectiouslesion.

7. 传染途径 • 传染途径：性接触传播、胎盘传播、产道传播、非性接触传播、输血传播、间接接触传播。 Syphilis is transmissible by sexual contact with infectious lesions, from mother to fetus in utero, via blood product transfusion, and occasionally through breaks in the skin that come into contact with infectious lesions • Risk factors of syphilis include the following: • Unprotected sex, promiscuous sex, and intravenous drug use are the major risk factors. • Health care workers are at occupational risk.

8. 梅毒的分期：根据传染途径的不同可分为：获得性梅毒（后天）及胎传梅毒（先天）；根据病程长短可分为：早期梅毒及晚期梅毒。一期及二期梅毒为早期梅毒，三期梅毒为晚期梅毒。根据有无临床症状又分为显性梅毒及隐性梅毒。Syphilis can present in one of four different stages: primary, secondary, latent, and tertiary, and may also occur congenitally.

9. Syphilis stages

10. 一期梅毒临床表现 • 一期梅毒：是梅毒螺旋体侵入部位发生的不疼不痒的炎症性浅溃疡，无全身症状及发热。一期梅毒又称硬下疳 (Chancre) ，是一期梅毒的标志。 • The primary phase usually starts with a sore at the site of infection. The sore or lesion is called:a chancre.

11. 硬下疳有以下特点：潜伏期：1周—2月，平均2—4周。好发部位：好发部位为： 阴茎、龟头、冠状沟、包皮、尿道口；大小阴唇、阴蒂、宫颈;肛门、肛管等。也可见于唇、舌、乳房等处。形态： 圆形或椭圆形、边界清晰的溃疡，高出皮面，疮面较清洁。 常为单发，个别多发。约3—8周硬下疳可不治自愈。

12. Chancre’s features • Primary phase: Primary syphilis occurs within 2-4 weeks of contact with an infected individual. • It manifests mainly on the glans penis in males and on the vulva or cervix in females. • Ten percent of syphilitic lesions are found on the anus, fingers, oropharynx, tongue, nipples, fingers, or other extragenital sites. Regional nontender lymphadenopathy follows invasion. • Lesions (chancres) are usually solitary, raised, firm, red papules that can be several centimeters in diameter. The chancre erodes to create an ulcerative crater within the papule, with slightly elevated edges around the central ulcer. • Although genital chancres are frequently solitary, they may be multiple in some patients • It usually heals within 3-8 weeks, with or without therapy.

13. These photographs depict the characteristic chancre observed in primary syphilis

14. 二期梅毒 • 一期梅毒未经治疗或治疗不彻底，螺旋体由淋巴循环进入血液循环形成螺旋体菌血症，引起皮肤、粘膜、骨骼、内脏、心血管及神经损害，称为二期梅毒。 • Secondary syphilis usually presents with a cutaneous eruption within 2-10 weeks after the chancre heals and is most florid 3-4 months after infection, once the bacteria have spread through the body. • Mild constitutional symptoms of malaise, headache, anorexia, nausea, aching pains in the bones, and fatigue often are present, as well as fever and neck stiffness. • Other less-common manifestations include GI involvement, hepatitis, nephropathy,proctitis, arthritis, and optic neuritis.

15. 梅毒疹 • 梅毒疹(玫瑰疹)：多为红色、棕色斑疹、斑丘疹， 好发于躯干、四肢、手掌及足底等，无瘙痒。可表现有丘疹、丘疹鳞屑性、环状斑块、脓疱等损害，故梅毒被称为“伟大的模仿者”。

16. Rashes of secondary syphilis • The rash in secondary syphilis is usually reddish-brown in color, not itchy and widespread. However, the appearance of the rash's individual lesions can vary dramatically: They may be flat or raised; they may or may not be scaly; and there may or may not be pustules present. It is partially do to the variability of this rash that led to syphilis being called "the great imitator," because it can resemble many other conditions. The rash can last for a few weeks or months.

17. This photographs show the disseminated rash observed in secondary syphilis

18. This photographs show the disseminated rash observed in secondary syphilis

19. This picture show palm rash of secondary syphilis

20. This image show raised scaly papula and plagues

21. 二期梅毒皮损特点: 1.广泛对称，好发手掌、足底；2）.一般无自觉症状；3）.破坏性弱传染性强，可自愈。 The skin lesions are bilaterally symmetrical，not itchy ，typically predispose occuring in palm and sole, less destructiveness ,strong infectivinity, can self-healing.

22. 2.扁平湿疣是特殊的丘疹性梅毒疹，好发于肛周、生殖器、腋窝、腹股沟等皱折多汗的部位。condylomata lata:Moist papules occur most frequently in the ano-genital region (condylomata lata) and the mouth, but they may be seen on any body surface where moisture can accumulate between intertriginous surfaces (e.g., axillae or toe webs).

23. condylomata lata

24. 3.梅毒性虫蚀状秃发由于梅毒螺旋体侵入毛囊漏斗下部至峡部稍上方的外毛根鞘处，不侵入毛乳头，因此呈不完全脱发。弥漫性脱发呈虫蚀状，面积较大，头发稀疏，长短不齐，非永久性脱发。"Moth-eaten" scalp alopecia: beginning in the occipital hair is characteristic. Loss of the eyelashes and the lateral third of the eyebrows may occur.

26. 4.粘膜损害多见于口腔、舌、咽、喉或生殖器粘膜，表现为粘膜炎及粘膜斑。mucous patches: Lesions of the mouth, throat, and cervix (mucous patches) frequently occur in secondary syphilis.

27. 1）.梅毒性咽炎。pharyngitis2）.梅毒性舌炎。glottitis3）.粘膜斑。Mucous patch4）.红斑糜烂性梅毒疹.erythemous and erosive patch

28. 5.二期梅毒的骨关节损害osteoarthropathy 1）.骨膜炎。periostitis2）.关节炎。arthritis3）.骨炎、骨髓炎、腱鞘炎、滑膜炎。Ostitis,osteomyelitis, tenosynovitis,synovitis

29. 6.二期梅毒的眼损害 ocular involvement虹膜炎，虹膜睫状体炎，脉络膜炎，视神经炎，视网膜炎，角膜炎，间质性角膜炎及葡萄膜炎，可造成视力损害。Iritis ,iridocyclitis,choroiditis,optic neuritis,retinitis,keratitis, uveitis,etc, can lead loss of vision.

30. 7.二期梅毒的神经损害 主要表现为无症状神经梅毒、梅毒性脑膜炎、脑血管梅毒。Neurologic involvement: asymptomatic neurosyphlis, meningitis, cerebrovascula syphilis.

31. 8.二期梅毒的多发性硬化性淋巴结炎全身无痛性淋巴结肿大变硬。Multiple sclerolymphadenitis syphilitica

32. 9.二期内脏梅毒肝炎、胆管周围炎、肾病、胃肠道疾病。Hepatitis, pericholangitis,nephropathy,gastrointestinal disease.

33. 三期梅毒（晚期梅毒） 早期梅毒未经治疗或者治疗不充分，经过一定的潜伏期，一般为3—4年，最长可达20年,多无症状，三期梅毒一般没有传染性。 三期梅毒一般进展缓慢，最终可累及多脏器： 精神状态异常， 部分神经异常， 痴呆， 心血管系统及神经系统受累

34. Tertiary (late) syphilis The latent stage of syphilis, which occurs after the symptoms of secondary syphilis have disappeared, can last from a 3-4 years to up to 20 years! There are no symptoms in this stage, and after about two years, an infected man may cease to be contagious • Tertiary (late) syphilis is slowly progressive and may affect any organ. The disease is generally not thought to be infectious at this stage. Manifestations may include the following: • Altered mental status • Focal neurologic findings, including sensorineural hearing and vision loss • Dementia • Symptoms related to the cardiovascular system or the central nervous system (CNS)

35. 树胶肿又称梅毒性树胶肿：是三期梅毒的标志，深在的皮下结节—暗红色浸润性斑块—中央软化—穿凿性溃疡。溃疡边缘锐利，基底暗红，有粘稠树胶样脓汁流出，故名树胶肿。树胶肿又称梅毒性树胶肿：是三期梅毒的标志，深在的皮下结节—暗红色浸润性斑块—中央软化—穿凿性溃疡。溃疡边缘锐利，基底暗红，有粘稠树胶样脓汁流出，故名树胶肿。

36. 潜伏梅毒 Latent syphilis • 凡有梅毒感染史，无临床症状或临床症状已消失，除梅毒血清阳性外，无任何阳性体征，并且脑脊液检查正常者。可分为早期潜伏梅毒及晚期潜伏梅毒。 • Latent syphilis • They are asymptomatic during the latent phase, and the disease is detected only by serologic tests. • Latent syphilis is divided into early latent and late latent. The distinction is important because treatment for each is different. The early latent period is the first year after the resolution of primary or secondary syphilis. Asymptomatic patients who have a newly active serologic test after having a serologically negative test result within 1 year are also considered to be in the early latent period. Late latency syphilis is not infectious; however, women in this stage can spread the disease in utero.

37. 树胶肿Gumma • The typical lesion is a gumma, and patient complaints usually are secondary to bone pain, which is described as a deep boring pain characteristically worse at night. Trauma may predispose a specific site to gumma involvement.

38. 梅毒螺实验室检查 • 暗视野显微镜检查：直接查梅毒螺旋体，用于一期梅毒及二期梅毒皮损。 • Dark-field microscopy is essential in evaluating moist cutaneous lesions, such as the chancre of primary syphilis or the condyloma lata of secondary syphilis

39. 非梅毒螺旋体抗原血清试验 • 1.性病研究实验室试验VDRL。2.不加热血清反应素试验USR。3.快速血浆反应素环状卡片试验RPR。 • nontreponemal serology screening test  • Venereal Disease Research Laboratory (VDRL), USR,rapid plasma reagin (RPR)

40. 梅毒螺旋体血清试验treponemal test • 荧光螺旋体抗体吸收试验FTA-ABS • 梅毒螺旋体血凝试验TPHA • 梅毒螺旋体微粒凝集试验TPPA • the fluorescent treponemal antibody-absorption (FTA-ABS), quantitative VDRL/RPR, • T pallidum hemagglutination (TPHA), • T pallidum particle agglutination (TPPA) tests.

41. 血清抗体的临床意义

42. 治疗 • 一期梅毒、二期梅毒及早潜伏期梅毒(病程<1年，早期梅毒)： • 首选方案：成人．苄星青霉索G 240万u，单次肌内注射共3次。 • 儿童，苄星青霉素G 5万U／kg(最大剂量240万u)，单次肌内注射。对青霉素过敏者，四环素500mg口服，每日4次，共14d；或强力霉素100mg口服，每日2次，共14d。替换方案：红霉素500mg口服，每日4次，共14d。

43. 治疗 treatment • Penicillin is the treatment of choice for treating syphilis., patients with known penicillin allergies should undergo penicillin allergy skin testing and penicillin desensitization, if necessary • Recommended Regimen for Adults: Benzathine penicillin G 2.4 million units IM in 3 doses. • Recommended Regimen for Infants and Children:Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose • Clinical and serologic conversions are the endpoints of medical treatment for syphilis. Follow-up Venereal Disease Research Laboratory (VDRL) test levels should be obtained to document treatment efficacy.

44. 治疗后监测 • 第1年内3月随诊一次，第2、3年每半年随诊一次，如果复发，应进行治疗。 • 复发：主要表现为临床症状复发及血清复发，也就是血清抗体滴度由阴转阳或滴度升高四倍。

45. 治疗后监测 monitor after treatment • Clinical and serologic evaluation should be performed 3 months in the first year after treatment; then every 6 months in the next 2 years. more frequent evaluation might be prudent if follow-up is uncertain. • Patients who have signs or symptoms that persist or recur or who have a sustained fourfold increase in nontreponemal test titer (i.e., compared with the maximum or baseline titer at the time of treatment) probably failed treatment or were reinfected. These patients should be retreated.