Syphilitic osteomyelitis. Chronic surgical infection. Tuberculosis of bones and joints. Tuberculous spondylitis, coxitis, drives. Principles of general and local treatment. Syphilis of bones and joints. Actinomycosis X-ray picture of a syphilitic pore
Bones in syphilis are often affected.
Bone lesions are observed most often in tertiary syphilis, when the deepest lesions are observed, with significant destructive changes in them.
Tertiary syphilides, as mentioned earlier, can affect the bone, initially coming from the skin or mucous membranes. But in some cases, the bones themselves can be affected primarily and from them the process passes to nearby tissues.
In the tertiary period, both the bones and the periosteum (osteoperiostitis gummosa) are affected. Patients at the same time indicate pain in the bones, which develop in the evening, intensifying at night, subsiding in the morning (dolores osteocopi nocturni).
Examination of such bones reveals a thickening on them.
The swelling in this case is round or oblong in shape, dense in consistency, soldered to the bone.
Deposited among the normal elements of the periosteum, the gummy infiltrate sometimes quickly changes and destroys tissues, resulting in ulceration and scarring. In some cases, from the inner surface of the periosteum, the infiltrate passes to the bone. Then the bone, in turn, is rarefied and depressions are formed at this place, which are well felt by the finger.
In the future, resorption of the infiltrate may occur, but the defect in the affected tissues already remains.
In other cases, the destruction extends to the surface, to the skin. And eventually a large ulcer develops with elevated edges and a bottom covered with thick decay.
When probing the bottom, a corroded sparse bone is found.
With the process coming from the depths of the bone, in many cases it is impossible to detect changes from the outside, although there are characteristic nocturnal pains.
When tapping on a diseased bone, a sharp pain is also felt.
As in the previous case, the gummy infiltrate can resolve. But it can also progress, leading to deep destruction and disintegration.
As a result of all these extensive deep lesions, the patient can not only be disfigured, but also crippled.
Why these forms are called mutilating syphilis.
With gummy lesions of the bones of the skull, extremely sharp headaches are often observed at the same time, aggravated by night.
With timely treatment, the developed nodes - gummas, infiltrates - resolve. Otherwise, softening, perforation, bone sequesters are formed. In the future, healing occurs either through the formation of a fibrous scar, or with the formation of a depressed scar attached to the bones.
With the localization of gummas on the sternum or collarbone, either a spontaneous fracture of the latter can occur, or, with the localization of the gumma on the sternum, its opening into the mediastinum.
It is necessary to differentiate syphilitic lesions of the bones most often from tuberculous ones.
With them, predominantly young age is affected, and soft tissues are involved in the inflammatory process. At the same time, there is no intensive development of the bone roller, characteristic of the syphilitic process.
Specific changes in the bones can be accompanied by both congenital and acquired syphilis.
congenital syphilis
Congenital syphilis, in turn, is divided into two groups: early - lues hereditaria praecox and late - lues hereditaria tarda.
Early congenital syphilis
Early congenital syphilis appears within the first three to six months after birth, rarely later. The defeat of the skeleton manifests itself in three forms: syphilitic osteochondritis, ossifying periostitis and gummy osteitis. With osteochondritis, spirochetes accumulate in the epiphyseal cartilages and the process of endochondral ossification is sharply disrupted; due to reduced resistance, intrametaphyseal fractures often occur, leading to complete immobility in the joint [pseudoparalysis Parrot (Parrot)] or pathological separation of the epiphysis - epiphysiolysis.
Osteochondritis is most often accompanied by significant osteoperiosteal layers, which can also form on other parts of the skeleton. In the diaphyseal regions, the bone marrow is predominantly affected, in which several gummas usually appear with a sclerotic reaction inside the bone and significant osteoperiosteal layers.
In contrast to tuberculous lesions, these layers have an uneven appearance.
Late hereditary syphilis
Late hereditary syphilis appears after 7, more often after 10-12 years and until the end of puberty. It is characterized by some general changes, often infantilism and the presence of the well-known Gutchinson triad - changes in teeth, eyes and, or N. A. Velyaminov's triad - changes in teeth, eyes (keratitis) and skeleton, which is more true.
Late congenital syphilis manifests itself on the bones mainly in the form of osteoperiostitis that occurs around small gummas nesting in the cambial layer of the periosteum.
These periostites have a greater tendency to ossify and are either delimited or diffuse. Diffuse periostitis is most often observed on the tibia, causing significant growth and thickening of its anterior surface, which appears convex and uneven (see figure below).
Sometimes, depending on the irritation of the growth cartilage, there is an increased growth of the affected tibia (with normal growth of the fibula), which leads to a saber-shaped, arcuate curvature of the lower leg forward with deviation of the foot outward. Osteoperiosteal changes can also be seen in other bones.
In some cases, more or less deep destruction occurs, going from the surface to the depth (see the figure below), as well as decay in the soft tissues and ulceration; the latter, under the influence of specific treatment, relatively quickly undergo regression and scarring, but often re-ulcerate or new foci are found.
Therefore, one of the signs of syphilitic lesions are multiple star-shaped scars on the skin and tuberous thickenings on the bone, in particular, on the crest of the tibia. There are no leaky abscesses.
A peculiar feature of such lesions, mostly a little painful, are the so-called night pains (dolores osteocopi nocturni), apparently associated with changes in temperature, with warming in bed. The Wasserman reaction, which is so valuable in determining acquired syphilis, is relatively rarely positive in congenital late bone forms; it is often detected after a preliminary specific treatment.
Of decisive diagnostic importance is the success of specific treatment, especially potassium iodide, which is given to patients in large doses (up to 10 g per day).
"Osteoarticular tuberculosis", P.G. Kornev
2210
The skeletal system can be affected at all periods acquired syphilis and in congenital syphilis e.
About the structure bone tissue written . Bone damage in congenital syphilis has been described.
Bone disease in acquired syphilis is much less common than in congenital syphilis.
A syphilitic lesion of the musculoskeletal system can be either an independent isolated manifestation of a syphilitic infection or combined with lesions of other organs.
Depending on the localization (in the periosteum, cortical layer, spongy substance, bone marrow), the pathological syphilitic process develops periostitis, osteitis or osteomyelitis. With acquired syphilis, a combination of periostitis with osteitis is mainly observed - osteoperiostitis .
In long tubular bones, the diaphysis is predominantly affected.
The inflammatory process in bone syphilis in the secondary period of the disease is exudative-proliferative without pronounced foci of destruction, and in the later periods - gummy, destructive with more or less significant destruction of the bone.
An infiltrative-exudative inflammatory process leads to the formation of ossifying syphilitic periostitis and osteitis, in which specific vascular damage occurs and the formation of a perivascular and diffuse infiltrate consisting of lymphocytes and plasma cells. There is no necrosis. With syphilis, sclerosis of the vascular walls occurs with persistent narrowing of the lumen of the vessels. In the initial stage of syphilis, infiltrate and exudate occur in the cambial (inner) layer of the periosteum, so nerve endings are involved in the process. This causes severe soreness of the bones affected by syphilis, especially with pressure.
Ultimately, the infiltrate either resolves, or, more often, sclerosed, that is, it organizes and turns into bone tissue. In the periosteum, at the site of the inflammatory infiltrate, new layers of ossified tissue are formed.
Similar changes in syphilis occur in the spongy spaces and in the haversian canals of the bone. The formation of new bone substance also occurs, which leads to bone sclerosis.
Diffuse and perivascular infiltrative-exudative process caused by syphilitic infection can also be localized in the bone marrow. In these cases, ossification occurs throughout the entire bone mass.
When bones are damaged in the tertiary period of syphilis, destructive-proliferative (gummous) processes occur. Hummous infiltration may be diffuse or limited. Limited gummas of tertiary syphilis are solitary (subperiosteal, central, bone marrow) and multiple. Hummous infiltrate causes two parallel processes in the bone: osteoporosis (destruction and atrophy of bone tissue in the area of the infiltrate) and osteosclerosis (formation of new bone tissue around the infiltrate).
With gummy syphilitic periostitis, the infiltrate appears on the inner leaf of the periosteum. Usually, this infiltrate quickly spreads to the bone tissue, so osteoperiostitis occurs.
Syphilitic gumma in the periosteum in the initial stage is an inflammatory node, containing a small amount of light thick gelatinous mass in the center. Over time, the central part of syphilitic gums undergoes caseous decay and necrosis, tissue destruction occurs. In the peripheral part, a powerful infiltrate develops, consisting of lymphoid plasma and scattered epithelioid and giant cells. The infiltrate is located mainly along the existing and newly formed vessels. The infiltrate and granulation tissue destroy the normal structure of the bone, forming foci of destruction. Osteosclerosis develops around the syphilitic gummous focus due to abundant vascularization as a result of a reactive productive (condensing) process.
In the cortical and spongy bone in syphilis, there are mainly single gummas growing both inward and outward. The gummous process can also spread to these parts of the bone from the periosteum. Hummous infiltrate from the periosteum penetrates through the vascular channels into the cortical and spongy layer of the bone. As a result, in the spongy substance, the bone tissue around the vascular channels is destroyed, and the spongy tissue surrounding them is rarefied. On the periphery of syphilitic foci, on the contrary, sclerosis occurs.
In gummous tertiary syphilis, extensive necrosis with bone sequestration and fistula formation usually does not occur. In the process of reverse development, the foci of destruction are filled with bone masses of endosteal origin.
It should be noted that with the localization of the gummous process of tertiary syphilis in the cancellous bone, destructive changes are extensive, while reactive changes are insignificant. With gumma in the compact substance of the bone, tissue destruction is insignificant, and reactive changes are quite pronounced.
With diffuse gummous osteoperiostitis, the changes are similar to those with limited syphilitic gums, but more common, spilled.
Gummas with syphilis of the bone marrow, as well as gummas of spongy bone, are characterized by a slight tendency to cheesy necrosis.
The bone canal in tertiary syphilis can be completely filled with newly formed bone substance (bone eburnation).
In clinical terms, it should be noted that already at the end of the primary period of syphilis, patients may complain of pain in various bones. The pains are constant and strictly localized (more often in the bones of the skull, sternum, long bones of the limbs) or intermittent, changing localization, "wandering", "flying" pains. These pains especially disturb patients at night. The examination does not reveal any objective changes.
Syphilitic periostitis of the secondary period is characterized by the appearance on the surface of the bone of a small dense painful spindle-shaped or hemispherical tumor, the skin over which is not changed. A characteristic feature of syphilitic periostitis is the nocturnal exacerbation of pain. Usually, syphilitic periostitis of the secondary period of syphilis disappears without a trace, less often lime salts are deposited at the site of the lesion, which leads to the development of persistent hyperostoses and exostoses.
In rare cases, the inflammatory process in syphilis proceeds rapidly, which, apparently, is associated with the addition of a secondary purulent infection. An abscess develops, which opens with the formation of a deep ulcer. At the bottom, the bone tissue is clearly defined by the probe. The ulcer gradually granulates and heals with a retracted scar soldered to the bone.
Ostitis of secondary syphilis is less common than specific periostitis. Ostitis begins with severe pain that is localized deep in the bone. Pain is due to the fact that at first a specific cellular infiltrate is deposited in a limited area of \u200b\u200bthe endosteum. Then it penetrates the canals of the spongy substance, stretches them and causes severe pain. During this period of syphilis, no objective symptoms are detected. Later, when the pathological process reaches the outer surface of the bone, its outer plate protrudes and a very painful, especially with pressure, hard swelling appears on the bone. In the future, after the thinning of the outer bone plate, the consistency of the swelling becomes elastic. At this stage of syphilis, the inflammatory process passes to the periosteum, osteoperiostitis occurs.
Ultimately, the syphilitic infiltrate with osteitis in some cases resolves, in others, osteosclerosis occurs, i.e. the infiltrate is impregnated with lime salts, turning into bone mass. For the patient, the second outcome is preferable, since in the first case, osteoporosis remains in place of the infiltrate, caused by the death of part of the bone plates; the bone becomes brittle, with syphilis spontaneous fractures are possible.
The third way of development of syphilitic secondary osteitis - the transition of inflammation to suppuration with the corresponding evolution - is rarely observed. In these cases, the pus separates the periosteum from the bone, melts the periosteum, muscles and skin, and comes out. In the cortical layer, as a result of necrosis, a sequester can form with the passage of pieces of bone.
In the tertiary period of syphilis, trauma contributes to bone damage. Bones that are poorly covered with muscles are most often affected: the bones of the legs, skull, sternum, collarbone, ulna and nose bones. Gummas or gummous diffuse infiltrates can occur both in the periosteum and in the bone. Usually these lesions in syphilis exist simultaneously.
With gummy syphilitic periostitis, a painful, elastic swelling of a flattened or fusiform shape is determined. The swelling is limited to the dense bone roller surrounding it.
In some cases, as a result of evolution, the gummy syphilitic infiltrate resolves and the swelling gradually disappears, the skin above it remains apparently unchanged.
On the bone, as a result of osteoporosis in syphilis, a defect remains in the form of a depression with a rough surface. Around this recess, as a result of peripheral osteosclerosis, a dense bone roller is felt.
In other cases, the syphilitic infiltrate purulently disintegrates. The skin turns red, a typical gummous ulcer is formed, which heals with a scar drawn in tightly soldered to the bone. A depression is felt in the bone, surrounded by a bone roller.
The only symptom of the onset of gummous osteitis with syphilis is a deep, aggravated at night, bone pain. Light percussion of the affected bone causes sharp pain. After the gummous infiltrate, spreading from the depths outward, reaches the outer plate of the bone, a very painful diffuse swelling of the bone appears, of a hard consistency, with blurry boundaries. Over time, the outer bone plate becomes thinner, the consistency of the swelling becomes elastic, the pathological process spreads to the periosteum - osteoperiostitis develops. One of the outcomes of gummous osteoperiostitis in syphilis is purulent fusion with the formation of a more or less large sequester. After separation along the demarcation line of the sequester, the ulcer cavity is filled with granulations and scarred. With a significant size of the lesion or localization on the bones of the face, the gummy osteoperiostitis, which has turned into sequestration, causes deformities.
With gummy syphilitic osteomyelitis, limited gummas are formed in the cancellous bone and bone marrow, which are either ossified, or a sequester is formed in their central part, and reactive osteosclerosis occurs in the peripheral part. In the latter case, gummas, destroying the cortical bone and periosteum, are opened through the skin. A sequester that does not separate for a long time and an associated purulent (pyococcal) infection support the purulent process.
With syphilis of bones in the secondary period, changes are rarely noted on radiographs. In these cases, muff-like osteoperiosteal layers surrounding the affected bone are visible; bone destruction is usually not observed.
The syphilitic gumma of the bone is characterized by the following x-ray picture: in the center - a light focus of destruction, and around it - an intense shadow of osteosclerosis. In the diffuse-hyperosteotic form of bone syphilis, when the central canal (enostosis) disappears as a result of ossification of continuous gummy infiltration, the bone is significantly thickened, the medullary canal is narrowed or absent, the cortical substance is thinned, the entire bone acquires a pattern of spongy bone tissue, against which one or more different intensity sharp shadows of osteosclerosis and enlightened areas of osteoporosis.
Sequesters with syphilis give an intense shadow in the form of plates of irregularly round or oval shape, located in saucer-shaped recesses and surrounded by a strip of enlightenment due to areas of sparse bone.
Differential diagnosis has to be made between gummous bone syphilis and osteomyelitis, bone tuberculosis, bone sarcoma, Paget's disease (osteitis deformans), lepromatous bone granuloma.
Positive blood serological tests for syphilis, a characteristic radiograph of bone lesions, extraosseous manifestations of syphilis (rashes on the skin and mucous membranes) facilitate the correct diagnosis. However, it should be borne in mind that serological reactions often do not help in differential diagnosis: they can be negative in syphilis and false positive in tuberculosis, leprosy, sarcoma, and chronic purulent diseases. Of greater, but not absolute, diagnostic value are the results of RIBT and RIF (reactions of immobilization of pale treponema and immunofluorescence).
At chronic osteomyelitis X-ray picture can simulate gummous osteoperiostitis in tertiary syphilis.
Osteomyelitis - purulent disease of the bones, proceeds with the formation of bone sequesters, which do not tend to resolve. In acute osteomyelitis, unlike syphilis, sclerotic phenomena are weakly expressed. Differential Diagnosis in chronic osteomyelitis and syphilis, it is difficult, since the sequestral cavities of osteomyelitis are very similar to the syphilitic gummous focus of destruction, and the pronounced sclerotic reaction in syphilis and osteomyelitis is very often exactly the same. characteristic feature chronic osteomyelitis, detected radiologically, is a fistulous tract extending from the sequestral cavity outward through the thickness of the bone and soft tissues.
Brodie's abscess - a kind of purulent osteomyelitis, located in the metaphysis (for syphilitic gumma, this is a rarer localization), it is recognized by its regular spherical shape. Radiologically, smooth, even edges of the focus are determined.
It is very difficult to recognize tertiary syphilis of the bone, complicated by purulent osteomyelitis.
Tuberculosis of the bones most commonly seen in children. The course of the disease is long; malaise, subfebrile temperature are noted. Damage to the bones is accompanied by severe pain, which limits the movement of the diseased limb, and therefore moderate atrophy of inactive muscles develops. There are no night pains characteristic of syphilis. Characteristic is the formation of long non-healing fistulas through which sequesters depart.
In tuberculosis of the bones, the epiphyses are predominantly affected. On the radiograph of a tuberculous focus in the bone, a characteristic picture is visible: the focus of destruction, as a rule, does not cause a sclerotic reaction around and passes without sharp boundaries to the adjacent part of the bone with a pore. Almost always there is a sequester and, as a rule, there is no periostitis.
The tuberculous process, located in the epiphysis or metaphysis, unlike syphilis, almost always destroys the articular cartilage line and spreads into the joint.
Bone sarcoma occurs in young people. The favorite localization of sarcoma is the proximal part of the metaphysis and epiphysis of the tibia. This tumor is solitary, characterized by progressive growth, involvement of all layers of the bone in the pathological process, accompanied by excruciating pain. On the roentgenogram there are no clear boundaries of the tumor, the phenomena of osteosclerosis are insignificant; in the destructive form of the disease, the destruction of all layers of the bone is visible; on the border with a healthy bone, a typical splitting of the periosteum is noted, which hangs over the tumor in the form of a visor. The epiphyseal articular cartilage remains unaffected by the pathological process.
Lepromatous granulomas are small in size (3-4 mm), their boundaries are fuzzy, there is no compacted roller. With them, neither hyperostosis nor sclerosis occurs; these phenomena are observed with syphilis. Night pains are absent.
Paget's disease - a systemic disease in which either the entire skeletal system or several bones are affected. Often the bones of the skull are involved in the process. The essence of the disease is the resorption of bone tissue and the formation of osteoid tissue instead. In parallel with the destruction of the affected bone, the process of formation of a new bone occurs. The bone marrow is replaced by fibrous connective tissue. When x-rays determine the combination of osteoporosis and osteosclerosis; the bone has a mesh structure, which is not observed in syphilis. The bones of the lower legs can curve forward in an arcuate manner, resembling the saber-shaped lower legs in congenital syphilis. However, with syphilis, only the anterior surface is curved due to massive bone layers, and with Paget's disease, the curvature is arcuate and occurs due to both the anterior and posterior surfaces. The curvature of the bones of the lower leg can also be in the form of the letter "O", as in rickets.
With syphilis, joint damage is observed much less frequently than bone damage. In the secondary period, there can be two forms of joint damage: arthralgia and hydrarthrosis. Syphilitic arthralgia proceeds without visible changes in the joints.
At syphilitic hydrarthrosis predominantly affects the knee, shoulder and wrist joints. Hydroarthrosis is accompanied high temperature, acute painful swelling of one or more joints, redness of the skin and the appearance of a serous effusion in the articular bag. In some cases, the disease is not so acute, with less severe symptoms.
Common to the proposed numerous classifications of tertiary syphilitic arthritis is the allocation of two main forms of the disease in them:
Primary synovial arthritis without previous lesions of the cartilage and bones of the joints
Primary bone arthritis, which occurs as a result of a specific lesion of the articular ends of the bone.
Synovitis in syphilis occurs acutely or chronically and is characterized by inflammation of the synovial membrane and joint bag, which is often accompanied by serous effusion (hydrarthrosis).
The group of syphilitic synovitis includes the following main clinical forms of arthritis.
Synovitis with syphilis, arising as a reaction to the gummous process in the bone, located in close proximity to the joint (most often in the metaphysis). They run sharp. Clinically, this synovitis with syphilis is characterized by painful swelling and dysfunction of the joint, the development of hydrarthrosis. Radiological changes in the joint are not detected. Under the influence of specific antisyphilitic treatment, reactive synovitis quickly disappears.
Chronic synovitis of Kleton considered as allergic arthritis to syphilis. These synovitis occur without acute inflammatory response, without high temperature, without sharp pain and without a pronounced dysfunction of the joint. They are usually bilateral. Radiological changes in the joint are not detected.
Synovitis of Kleton is very resistant to antisyphilitic therapy.
Syphilitic acute polyarthritis the tertiary period, as well as that of the secondary period, is considered by some authors as arthritis of an allergic nature. According to the clinical picture, it is similar to rheumatic polyarthritis.
Primary gummy synovitis very rare in syphilis. They begin with moderate pains, aggravated at the exact time. Mobility in the joint is almost painless, slightly limited. Note the symptoms of subacute dropsy of the joint. The skin over the joint is not changed. Later, subjective sensations and swelling of the joint increase; due to the growth of the synovial membrane and villi during movement in the joint, friction noise is determined - crepitus. Fistulas are not formed. Without treatment, ankylosis develops.
Secondary gummy syphilitic arthritis is a consequence of the spread of gummy infiltrate of the epiphysis of the bone into the joint. In rare cases, gumma with syphilis can (primarily located in the articular ligaments, in the fiber surrounding the capsule joint) of the patella, etc.
Secondary gummous arthritis in syphilis, which is essentially primary bone arthritis, begins painlessly with the development of dropsy of the joint
As the gummous infiltrate of the affected joint with syphilis spreads, the clinical picture becomes more and more similar to primary gummous arthritis.
Diagnosis of gummous arthritis in syphilis is difficult. They are in many ways similar to tuberculous arthritis. When recognizing syphilitic arthritis, it should be borne in mind that with tuberculosis, pain and functional disorders are more intense than with syphilis. Syphilis is characterized by nocturnal bone pain. In cases of tuberculosis, palpation of the affected joint determines limited, severely painful points.
Tuberculous arthritis causes an increase in temperature, with syphilis this does not happen. Tertiary syphilis of the joints differs from tuberculosis of the joints in the characteristic x-ray picture of the expansion of the joint space and the presence of areas of osteosclerosis. Antisyphilitic treatment in cases of syphilitic arthritis gives a good rapid therapeutic effect.
It should be borne in mind that hybrid forms of osteoarthritis in syphilis are possible: syphilis and tuberculosis, syphilis and purulent infection.
There are two forms of joint damage - synovial and gummy. When synovial, the synovial membrane is affected and the process rarely passes to other parts of the joint, especially to the bones. With the gummous form of joint damage, gumma, located in the tissues of the joint itself, the epiphyses of the bones and ligaments in close proximity to the joint, also spreads to the joint.
Joint damage is not uncommon. Slonim (Tashkent) writes that among the hundreds of cases of arthritis that passed through his clinic, he recognized syphilis in 12%. Vasiliev (Leningrad), analyzing similar material, found only 3%. Ge (Kazan) in patients suffering from gummous syphilis, found joint lesions among men in 5%, among women - in 3%.
With tertiary syphilis, the knee, ankle, and elbow joints are more often affected. The clinical picture can be very diverse, pain - of varying strength. Night pains, their reduction during the day and during movement, improvement as a result of specific therapy are signs characteristic of syphilitic arthritis.
Lesions can sometimes proceed as acute polyarthritis and be accompanied by high fever. These acute polyarthritis do not improve with salicylates and quickly regress after specific therapy. More often, however, syphilitic arthritis occurs chronically. In chronic cases
the process sometimes does not cause significant tissue changes with effusion into the joint with little pain and minor dysfunction. With prolonged existence, productive changes can be observed, namely, the growth of the villi of the synovial membrane (crunching during movements), the development of sclerotic cords and discs, perisynovitis (Meshchersky). Specific treatment gives quick success only in the first stages: later it is impossible to eliminate a number of defects resulting from scarring.
A lesion is rarely observed, which Meshchersky, by analogy with tuberculosis of the joints, called pseudo-tumor albus, and others call osteo-chondro-arthropathia. The lesion is located in the epiphysis and, progressing, captures the cartilage, causes effusion, hypertrophy of synovial villi and joint deformity. Subsequently, decay, suppuration, fistulas may occur. During treatment, especially in advanced cases, persistent changes always remain.
Chronic arthritis of syphilitic etiology can occur both as deforming arthritis and as arthritis simulating a picture of chronic articular rheumatism.
The easiest cases for diagnosis are those cases when gumma, located in one of the articular ends of the bones, destroys them, irradiates to the joint. In addition to the picture of progressive joint disease (pain, effusion, crunching, increase in volume, increasing dysfunction, etc.), gummous bone lesions can be determined on an x-ray, which ensures the correct diagnosis.
In the diagnosis of syphilitic arthritis, one has to emphasize their slow development, often slight pain.
Slonim draws attention to the local focal reaction in specific treatment. Slonim considers such a focal exacerbation reaction at the beginning of treatment (even with iodine) a sign of syphilis. In addition, he points to a frequent combination of joint damage with viscerosyphilis (hepatitis, aortitis). The pains are aggravated at night, at rest, decrease with movement. The diagnosis is difficult, and sometimes only a trial treatment solves the problem;
The Wasserman reaction in the blood can often be negative. A positive Wassermann test with effusive fluid is especially convincing with a negative result with blood serum. A positive Wassermann test in blood and effusion is less convincing.
X-ray examination in the case of gummy arthritis can significantly help the diagnosis.
Syphilis is a chronic disease that results from a contact infection. The infection can also be transmitted by transfusion.
Primary syphilis (hard chancre) appears 3 weeks after infection. At the site of infection, a rounded plate-like thickening of the skin is formed, which is slightly raised and sharply limited from the surrounding tissues. In case of violation of the epithelial cover, a wet surface appears, in which, when taking a smear, you can see the pathogen. 1-2 weeks after the appearance of the primary focus, regional lymph nodes become hard and enlarged, however, retain good mobility and remain painless.
The predominant localization of the primary focus is the external genitalia. It can be on the cheeks, lips, chin, on the border of the forehead with hair, on the anterior third of the tongue, on the soft palate and tonsils, in the gluteal folds, armpit, anus, rectum, on the nipples of the mammary glands, as well as on the fingers of the hands. The reason for this atypical localization is the possibility of transmitting the pathogen through hands, infected shaving, drinking and eating devices, sometimes infection occurs with kisses and some types of sexual intercourse.
Secondary stage. It starts already 6-12 weeks after infection and lasts 2-4 years. At this stage, the process is generalized. The skin and mucous membranes are especially affected, on which there are moist papules, ulcerations and infiltrates.
Tertiary syphilis (late) follows secondary after many years, sometimes decades. Mostly internal organs are affected. Bone damage is of the greatest surgical importance. A typical manifestation of late syphilis is gumma (syphiloma), which is a granular tumor up to the size of a man's fist. Despite the fact that the gumma is sufficiently supplied with vessels, its center is easily necrotic. The proliferation of connective tissue around gummous nodes causes cicatricial encapsulation of the focus.
This late stage of syphilis is of considerable surgical interest, since almost all organs are affected in it. In addition, late syphilis may distort clinical picture any disease.
All parts of the bone can be affected. Depending on the localization of the process, there are periostitis, osteitis, osteomyelitis. As a rule, the process develops in the periosteum, passes to the bone and may be infiltrative-exudative or gummy-destructive.
The exudative-infiltrative form of syphilis manifests itself in the form of ossifying osteoperiostitis. The process ends with a sharp thickening of the bone - osteosclerosis, leading in some cases to a significant deformation of the bone. Hummous osteoperiostitis is more often localized in the diaphysis of the tibia, in the bones upper limbs, collarbone, ribs, as well as in the bones of the skull and face. With the localization of the gummous process in the facial bones, destruction of the nose and eye sockets can occur. With syphilitic bone gums complicated by a secondary infection, extensive necrosis with bone sequestration is observed. X-ray determined osteoperiostitis with signs of bone destruction. With suppuration of the gummous infiltrate, the skin is involved in the process, on which round ulcers are formed, bordered by dense, sclerotic edges. Syphilis of the bones is characterized by excruciating night pains in the bones.
Syphilis of the joints- affects large joints and manifests itself in the form of pain, aggravated by movement, and may be accompanied by effusion in the joint. It manifests itself in the form of gummy synovitis or osteoarthritis. Synovitis occurs either as a result of a reaction to a gummous process localized in the metaphysis near the joint, or as a result of a syphilitic lesion of the epiphyses. With gummous osteoarthritis, all elements of the joint are affected.
Treatment- specific (drugs of mercury, bismuth, iodine, antibiotics). With dangling joints, deformities, ankylosis, orthopedic treatment is used. In arthritis complicated by a secondary infection - arthrotomy.
51. Actinomycosis. Pathogenesis. main localizations. Clinical manifestations, diagnosis, treatment.
Chronic illness person. It affects all tissues and organs, is characterized by the formation of a dense infiltrate and proceeds almost without pain. The causative agent is a radiant fungus, (actinomycete), first discovered by Langenbeck in 1845. Among various pathogenic actinomycetes, anaerobes and aerobes have been identified. Of these, Wolf-Israel's anaerobes and Bostrom's aerobe are of particular importance. The first type of actinomycete is the most pathogenic for humans, while the second is pathogenic or weakly pathogenic.
Infection occurs endogenously. The oral cavity, gastrointestinal tract and respiratory tract are the main places where the introduction of the radiant fungus into the human body occurs. Temperature-sensitive anaerobic form of actinomycetes is a permanent inhabitant of the upper respiratory tract and gastrointestinal tract.
It has been established that actinomycetes are constantly present in oral cavity person. Drusen are found in carious teeth, tonsils and gums. Anaerobically growing actinomycete manifests its pathogenic properties in humans only when it enters ischemic tissues during inflammation or damage. Ulcers of the oral mucosa, diseased tonsils, wound surfaces in gastrointestinal tract or respiratory tract, as well as inflammation of the walls of the bronchi after an influenza infection or hypothermia.
As a result of the introduction of actinomycetes into tissues, chronic inflammation develops. A dense woody infiltrate appears, consisting of inflammatory granulomas, in the center of which there are characteristic colonies of the radiant fungus. The construction of fungal colonies (the so-called drusen) occurs as follows. In the center is a widely branched filamentous network. A single drusen of the fungus reaches the size of a pinhead and is visible as a nodule of pale yellow color. The infiltrate has a tendency to constantly and stubbornly spread to neighboring tissues, capturing and destroying located muscles, bones, joints along the way, breaking through into serous cavities and even into blood vessels. In the latter case, the transfer of metastases to various organs through the blood stream is possible. The incubation period ranges from several weeks to several years. The disease is observed mainly among middle-aged men. Children get sick relatively rarely.
A characteristic sign of actinomycosis is the appearance of a dense, woody, progressive infiltrate. Another sign is the lack of reaction from the regional lymph nodes, since this infection does not spread through the lymphatic pathways. If there is an increase in the lymph nodes, then this indicates a secondary infection, which plays an important role in the development of the pathological process.
Localization:
internal organs (gastrointestinal tract, lungs, bladder)
When actinomycosis spreads to the portal vein, liver metastases develop.
Cervical-facial and temporal-facial actinomycosis.
Treatment of actinomycosis. Regardless of the localization of the process - combined: immunotherapy, iodine therapy, X-ray therapy, the use of antibiotics and surgical intervention. Iodine preparations (up to 3 grams of potassium iodide per day) have proven themselves therapeutically well. Positive results are explained by softening and resorption of infiltrates. Iodine therapy is usually combined with radiotherapy. The use of antibiotics in high doses with sulfanilamide preparations is based on the elimination of a mixed infection and a change in the environment.
Immunotherapy is carried out by introducing actinolysates at a dose of 0.5 to 2 grams 2 times a week intramuscularly. The course of treatment is 20-25 injections. Along with conservative treatment, surgical treatment is also indicated, which consists in opening fistulous passages, in scraping granulations. In some cases, it is possible to excise the infiltrate.
52. Leprosy. Pathogens. Clinical manifestations, surgical manual.
