Osteomyelitis and syphilis are common in the tests. Syphilis: signs, manifestations of all stages, diagnosis, how to treat. How syphilis damages the skeletal system

Syphilis is a chronic infectious disease caused by Treponema pallidum. It has a peculiar course: the incubation period, the period of primary syphiloma (chancre), the secondary period, the latent period (latent syphilis), depends on the general reactivity of the body and the quality of treatment. If the patient is not treated, then the latent period changes with subsequent exacerbations and passes into the tertiary period. The apparatus of support and movement can be affected in both congenital and acquired syphilis.

Classification of syphilis of bones and joints

It is advisable to adhere to a simple classification of syphilitic bone lesions according to S. A. Reinberg:

1) periostitis (gummy and diffuse);

2) osteitis (gummy and diffuse);

With bone syphilis, two types of process are observed:

1) proliferative-exudative, having a productive-hyperplastic nature (with secondary recurrent syphilis) and is characterized by the appearance of layers on the surface of the bone (hyperplastic periostitis)

2) proliferative-alterative in the form of gummous destruction (with tertiary syphilis).

First, an infiltrate is formed in the osteogenic layer of the periosteum with caseous necrosis in the center, bone destruction and reactive osteosclerosis around it.

Clinical symptoms

Clinically, periostitis can manifest itself as limited or widespread bone hardening, which is very painful when pressed. A characteristic symptom is night pain, which decreases during the day with movement (unlike tuberculosis). The skin in this area is swollen and tense, and when pressed with a finger, a dimple is formed. Local temperatures remain normal.

On radiographs, diffuse appears as a wide ossified band along the bone, which runs parallel and does not merge with it, and sometimes has the appearance of spherical layers - the appearance of an onion in a section. Limited periostitis in the form of a ridge also occurs due to transverse stripes.

Gummy periostitis is characterized by single or multiple rubbers that connect to the cortical bone or even to the cancellous substance. It has a round shape with central osteonecrosis and sclerosis around, creating a mosaic pattern - “speckled” periostitis.

Syphilitic osteitis and osteoperiostitis occur in tertiary and late congenital syphilis. The classic manifestation is saber-shaped shins. Due to chronic inflammation, the entire tibia is hardened, elongated, and distorted by body weight during growth. X-ray shows diffuse osteosclerosis.

Gummy osteitis, as a rule, is associated with a subperiosteal specific process and appears on radiographs in the form of a saucer - an oval, light, structureless defect. Gummy osteomyelitis, as a rule, manifests itself as multiple destructive foci in the bone marrow with a ridge of sclerosis.

The epiphyses, phalanges of the fingers, metacarpal bones and metatarsals are very rarely affected by syphilis.

Syphilitic joint damage occurs in all periods of the disease. Specific inflammation can be limited to the synovial membrane and joint capsule without affecting cartilage and bone (chronic synovitis, gummous synovitis, acute syphilitic polyarthritis).

Synovitis occurs primarily, has a torpid course without pronounced clinical signs of inflammation (no fever, pain and dysfunction of the joint). Slight pain at night and symptoms of fluid in the joint dominate.

Gummous occurs rarely and is accompanied by villous growths of the membrane. The diagnosis is confirmed by examining synovial fluid - the Wasserman reaction.

Syphilitic osteoarthritis manifested by destruction of subchondral areas and epiphyses of the bone. The articular cartilage is damaged again. Despite significant destructive changes, there is no pain in the joint, its function remains intact. The joint space is slightly widened. Unlike tuberculous and pyogenic arthritis, contractures and ankylosis do not occur with syphilitic arthritis.

This includes tubercular arthropathy, which occurs at a late stage of the disease. It is characterized by enlargement of the joint due to exudate and its deformation. Pain occurs when pressure is applied to the joint. Over time, the adjacent muscles atrophy, and the joint becomes so loose that the patient, despite the absence of pain, cannot use the limb. Clinically there are no signs of inflammation. Synovial fluid is turbid, with tissue fragments. Radiographs show very characteristic destruction of the articular ends of the bones with the separation of large sequesters and destruction of the joint. This can lead to subluxations and dislocations.

In infants with congenital syphilis there is specific osteochondritis(growth zone), in which the reverse development of cartilage is delayed and the deposition of soda in the cartilage cells increases. As a result of osteochondritis, already in the first weeks of a child’s life the epiphysis can separate from the diaphysis; pseudoparalysis develops - Parrot disease. The affected arm hangs down, movements are painful (the child cries). There are no clinical neurological disorders, finger movements are preserved. The lower extremities are rarely affected. These symptoms are the only early sign of congenital syphilis.

At the age of 4 to 16 years, congenital syphilis manifests itself as periostitis and osteoperiostitis, gummous osteomyelitis, classic saber-shaped deformities of the legs and forearms. Chronic hydroarthrosis occurs. Diagnosis is facilitated by the presence of Hutchinson's triad and a positive Wasserman reaction.

Treatment of patients with syphilis of bones and joints is based on the general principles of venereology. The use of large doses of antibiotics and specific therapy leads to complete recovery and prevention of relapses.

This is damage to bones and joints due to syphilitic infection.

Symptoms

Bone diseases in late syphilis have been known for a long time. There are the following main forms of bone lesions in syphilis: periostitis and osteitis (damage to the outer part of the bone), osteomyelitis (inflammatory infectious lesion of the entire thickness of the bone and bone marrow). Syphilitic widespread periostitis is powerful, looking like a ridge or lace. In this case, destruction and sclerosis of bone tissue occurs in the bones. A dense, clearly limited swelling is detected on the bone, sometimes protruding significantly above the surface of the bone. Patients are bothered by pain that gets worse at night. Such changes most often develop on the bones of the cranial vault and the anterior surface of the tibia. With syphilitic osteomyelitis, the bone thickens, becomes denser, becomes deformed, and its edges become uneven.

Such lesions radiographically resemble other chronic inflammatory processes in the bone. Very rarely, short bones (vertebrae, tarsal bones, wrists) can be affected. Joint diseases with syphilis are observed much less frequently than bone diseases. The membranes, bags, bones and cartilages of the joint are affected. Joint diseases are manifested by pain, spherical swelling of the joint, and slight impairment of their function. The most commonly affected joints are the knee, shoulder, elbow and ankle joints, which gradually become deformed, but movement in the affected joint is preserved and the pain is insignificant; the general condition of the patients changes little.

Complications. The formation of deep ulcers is possible, at the bottom of which there is necrotic bone tissue; destruction and deformation of the affected bones occurs.

Syphilis of the bones can already very early after infection (after about 6 weeks) cause very severe periosteal pain (skull, ribs, sternum, tibia). Severe night pain in the tibia is almost pathognomonic and can be compared in nature and distribution only with pain during Volyn fever.

Clinical and radiological data in the early stages they contribute little to establishing a diagnosis; Of decisive importance is the Wasserman reaction and the rapid effect of antisyphilitic treatment.

Syphilis of the bones tertiary period and congenital syphilis with saber-shaped shins and radiologically established destruction of the bone structure and involvement of the periosteum are now rare (Wassermann reaction!)

Fungal infections- actinomycosis, blastomycosis, coccidioidomycosis (in the USA) - are localized in the bones with increasing frequency, but in the clinical picture pulmonary and skin manifestations almost always come to the fore.

Occupational bone necrosis observed in those working with compressed air and in caisson work. In the former, fractures play a major role, in the latter, air embolisms, which lead to circulatory disorders.

Overload fractures occur when there is excessive (often unusual) load on the skeletal system.
Most Fractures of the metatarsal bones in soldiers are known (so-called marching fractures).

Multiple bone lesions.

With multiple bone lesions and diffuse changes in bones (osteoporosis, osteosclerosis) in adults, one should always remember that often we are not talking about a local bone disease itself, but about secondary changes in bones due to some general disease.

With appropriate changes in bones Therefore, a biochemical blood test should always be performed to determine the content of total protein, calcium, phosphorus and phosphatase. The results of these studies can be decisive for the diagnosis. Hyperglobulin m and I speaks in favor of myeloma, hypercalcemia (with a decrease in phosphates) is characteristic of primary hyperparathyroidism (Recklinghausen's osteitis fibrosa) or (with an increase in phosphates) - for secondary hyperparathyroidism. Elevated alkaline phosphatase levels are suggestive of osteomalacia, osteitis fibrosa, Paget's disease, or bone metastases.

Mostly multiple limited bony lesions in adults with more or less severe bone pain are observed with:
a) inflammatory lesions x: osteomyelitis, tuberculosis, syphilis, fungal lesions, sarcoidosis;
b) tumors: myeloma, primary bone marrow tumors;
c) bone metastases: lymphogranulomatosis, hemangioma;
d) storage diseases: Gaucher disease, Niemann-Pick disease, Hand-Schüller-Christian disease.

Possibly rare eosinophilic granuloma, first described by Fraser (1935), is only a particularly benign form of Schüller-Christian disease. Accordingly, eosinophilic granuloma should be considered as a partial manifestation of Schüller-Christian disease. Here, too, non-sharply defined bone defects in the ribs or other flat bones are pathognomonic. The lesions can be single or multiple. The disease develops mainly in adolescence (however, cases of the disease are described up to the 5th decade of life) and, as a rule, begins suddenly with bone pain and swelling, intensifying over the course of weeks.

Observed low-grade fever. There is slight eosinophilia in the blood (up to 10%), but in general the blood picture is not typical.
The diagnosis can only be accurately established after trial excision, although the clinical picture is quite typical. Further, rapid progression of the disease and good effect of radiation therapy are characteristic.

Bones are often affected by syphilis.

Bone lesions are observed most often in tertiary syphilis, when the deepest lesions are observed, with significant destructive changes in them.

Tertiary syphilides, as stated earlier, can affect the bone, initially originating from the skin or mucous membranes. But in some cases, the bones themselves may be affected primarily, and from there the process spreads to nearby tissues.

In the tertiary period, both bones and periosteum (osteoperiostitis gummosa) are affected. Patients indicate pain in the bones, which develops in the evening, intensifies at night, subsides in the morning (dolores osteocopi nocturni).

Examination of such bones reveals thickening on them.

The swelling can be round or oblong, of dense consistency, and fused to the bone.

Deposited among the normal elements of the periosteum, the gummous infiltrate sometimes quickly changes and destroys tissue, resulting in ulceration and scars. In some cases, from the inner surface of the periosteum, the infiltrate moves to the bone. Then the bone, in turn, is thinned out and depressions are formed in this place, which can be easily 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 spreads to the surface, to the skin. And ultimately, a large ulcer develops with raised edges and a bottom covered with thick decay.

When probing the bottom, an eroded, sparse bone is discovered.

When the process comes from the depths of the bone, in many cases no changes can be detected from the outside, although there are characteristic night pains.

When tapping on the sore bone, a sharp pain is also felt.

As in the previous case, the gummous infiltrate can resolve. But it can also progress, leading to deep destruction and decay.

As a result of all these extensive deep lesions, the patient can not only be disfigured, but also crippled.

This is why these forms are called crippling syphilis.

With gummous lesions of the skull bones, extremely sharp headaches, intensifying at night, are often observed at the same time.

With timely treatment, developed nodes - gummas, infiltrates - resolve. Otherwise, softening, perforation occurs, and bone sequestration is formed. Subsequent healing occurs either through the formation of a fibrous scar, or with the formation of a depressed scar adhered to the bones.

When the gumma is localized on the sternum or clavicle, either a spontaneous fracture of the latter can occur, or, when the gumma is localized on the sternum, its opening into the mediastinum.

It is most often necessary to differentiate syphilitic bone lesions from tuberculosis lesions.

They mainly affect young people, and soft tissues are involved in the inflammatory process. At the same time, there is no intensive development of the bone ridge, characteristic of the syphilitic process.

The content of the article

Etiologists and pathogenesis of syphilitic osteomyelitis

Clinic of syphilitic osteomyelitis

Treatment of syphilitic osteomyelitis