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Primary syphiloma (hard chancre)

Clinical manifestations of primary syphilis are characterized by the presence of solid chancre (primary syphiloma) and damage to the lymph nodes and blood vessels.

At the end of the incubation period, the first symptom and the main manifestation of the primary period of syphilis - primary syphiloma - are synonymous in place of the pale treponema; Sometimes cases of syphilis begin to occur after 3–3.5 months immediately from a rash of the secondary period. This is the so-called "decapitated syphilis".

The chancre (ulcus durum) is an erosion or ulcer formed at the site of the introduction of pale treponemas into the skin or mucous membranes. Erosive chancre is observed in 80-90% of patients; the occurrence of ulcers contribute to the violation of the general condition of the patient due to chronic diseases; in toxicity; elderly or early childhood, as well as non-compliance with the rules of personal hygiene or self-treatment of solid chancre by external irritants.

Hard chancre is not a true primary morphological element of syphilis, since its appearance is preceded by the development of the so-called “primary sclerosis”, which is asymptomatic and, as a rule, is not noticed by either the patient or the doctor. These changes begin with the appearance of a small red spot, which in 2–3 days turns into a slightly hemispheric, painless, slightly peeling papula, slightly elevated above the skin level. After a few days, this pa pool is compacted and enlarged by peripheral growth. A crust appears on its surface, upon rejection of which an erosion or superficial ulcer (“hard chancre”) is formed. A hard chancre has an oval or rounded shape, often geometrically regular, its borders are even, clear, the bottom lies flush with the surrounding skin or rises upwards (saucer-like erosion). Uncomplicated hard chancre is never undercut or sheer edges, which is of great diagnostic value.

The surface of the primary syphiloma is smooth, smooth, has a bright red color (the color of "raw meat") or is covered with a dense patina of dull greyish yellow color. Sometimes this raid is located only in the central part of the chancre. Between him and the healthy skin remains a bezel of red color. In some cases, on a red or grayish-yellow background of erosion, especially in its central part, small dot hemorrhages are visible ("petechial" chancre). On the surface of a hard chancre there is a clear or opalescent discharge, giving it a peculiar mirror or lacquer gloss. If the bottom of the chancre is irritated, the gray discharge becomes abundant, it contains a large number of pale treponemas, which is used for diagnosis. When localized in open areas of the skin, the chancre is usually covered with a dense brownish peel.

At the base of the primary syphiloma there is always a seal of the underlying tissues, which was the reason to call the primary syphilous chancre. This compaction is clearly circumscribed from surrounding tissues and extends several millimeters beyond the limits of erosion or ulceration. The consistency of the seal is dense, with palpation it resembles the cartilage of the auricle. In shape, it can be nodular, lamellar and listoid.

Nodular seal has a hemispherical shape, clear boundaries, penetrates deep into the surrounding tissue. It is most often observed with the localization of solid chancre on the inner surface of the foreskin and coronary sulcus. At the same time, the seal can be seen with the eye (a symptom of a “visor” and “tarsal cartilage”). When placed in the region of the foreskin, the tissues subject to hard chancre can be sclerosed so strongly that their mobility is disturbed up to the development of phimosis.

The plate seal resembles the coin laid under the chancre base. It is most often observed with the localization of chancre on the outer surface of the preputial sac, in the trunk of the penis, the small and large labia. The sheet-like seal is presented in the form of a sheet of thick paper, most often it can be observed when a hard chancre is localized on the head of the penis.

Subjective sensations in the area of ​​primary syphiloma, as a rule, are absent, although sometimes it can be quite painful.

The dimensions of a solid chancre are usually small, and its diameter is on average 10–20 mm. There are also very small (dwarf), with a diameter of 1-3 mm or large (giant) chancre (up to 40-50 mm). Dwarf chancre usually occur in areas of the skin with a well-developed follicular apparatus as the infection spreads deep into the follicle. Dwarf chancres are especially dangerous from an epidemiological point of view, since they are difficult to detect and can be a source of infection. Giant chancres are most often observed on the skin of the pubis, lower abdomen, inner thighs, forearms, and face. Having reached a certain size, hard scaler has no tendency to peripheral growth.

Solid chancre are single and multiple. Multiple chancre arise simultaneously or sequentially. For the simultaneous development of multiple solid chancres, the patient must have several defects of the skin or mucous membrane, contributing to the penetration of pale treponema (the presence of associated diseases with itching and scratching, maceration, skin trauma, etc.). Multiple hard chancres occur consistently with multiple, multiple, non-simultaneous sexual intercourse with the infectious form of syphilis. These chancre vary in size and degree of compaction.

Primary syphilomas that occur in a patient at the same time on two parts of the body that are far apart (for example, on the genitals and the mammary gland, the red border of the lips, etc.) are called bipolar chancres. When bipolar chancroids occur, the normal course of syphilis changes; the induction and primary periods are reduced, serological reactions in the blood become positive before.

Primary syphiloma can be localized anywhere on the skin and mucous membranes, where conditions for infection are created. Genital, perigenital, and extragenital localization of the chancre are distinguished. In more than 90% of patients, hard chancre is localized on the genitals. In men, chancre is most often observed in the coronary sulcus, on the inner and on the outer leaflet of the foreskin, head, less often on the trunk or on the base of the penis, especially when using condoms. An intraurethral arrangement of a hard chancre is possible, which is localized in the region of the scaphoid fossa or near the external opening of the urethra, passing to the mucous membrane of the urethra. It is characterized by limited compaction in the distal part of the urethra, scanty sero-bloody discharge, painful urination, and a specific increase in regional lymph nodes. The healing of the chancre can lead to a narrowing of the urethra.
Intraurethral hard ulcer must be differentiated from urethritis of various etiologies, with which (especially with chronic gonorrhea) it is often confused.

In women, primary syphiloma is localized on the large and small labia, in the posterior commissure, the clitoris, on the cervix, very rarely on the walls of the vagina. It is believed that cervical hardness of the cervix is ​​observed in 8–12% of cases; however, it appears to be much more common than diagnosed.

Chancres in the vaginal region of the cervix is ​​usually localized on the upper lip and around the external opening of the cervical canal; It is a sharply limited roundish erosion with a smooth, shiny, bright red or grayish coated surface, which separates the serous or serous purulent exudate. Inflammation around erosion is absent. In the area of ​​the external opening of the cervical canal, the chancre has a ring-shaped or semi-lunar shape and a significant seal.

Cases of inductive edema and the location of a hard chancre on the cervical mucosa are described.

Hard chancre can be observed in the anus in both women and men, especially homosexuals. These chancre are located in the area of ​​the anal folds, the external sphincter, the anal canal, and rarely on the rectal mucosa. They may have the appearance of a typical syphilitic erosion, or take an atypical form. In the depths of the posterior folds, the primary syphiloma has a rocket-like or lymphoid shape, in the region of the internal sphincter it is oval. The slit-like chancre in the depth of the anal warehouse is very similar to a banal crack, from which it differs by a dense base and incomplete closure of the edges. Primary syphiloma in the anus is painful, regardless of the act of defecation, but the latter may bleed. It can occur with symptoms of proctitis and sometimes requires differential diagnosis with ulcerated hemorrhoids, polyps, and even rectal cancer. Regional lymphadenitis in chancre of the anal region is not observed in all patients. Hard chancre in the rectal area is detected only with the help of a rectal speculum or rectoscope.

Extragenital chancres can occur anywhere on the skin and mucous membranes and are found in 1.5-10% or more of syphilis patients. They are single and multiple, in contrast to genital chancres, more quickly take the form of infiltrated ulcers, are marked by greater pain, duration of the course and are accompanied by a significant increase in regional lymph nodes. Extragenital primary syphiloma is most often localized on the red border of the lips, mammary gland, fingers, in the region of the axillary hollows, navel, eyelid.

Breast chancre is an erosion or ulcer of a normal or fractured shape, located in the nipple or areola area. It has a plate seal at the base, often covered with a crust, it can be single or multiple, localized on one or both mammary glands.

Localization of hard chancre on fingers, most often observed during professional infection of health workers (surgeons, obstetricians gynecologists, dentists, pathologists), as well as manual contacts (petting), deserves attention. Sometimes there is a combination of this chancre with primary syphiloma of the genital organs (bipolar chancre). Hard chancre is most often located on the distal loins of the fingers, especially II, may be typical or in the form of chancre felon.

Chancre panaritium is usually considered as an atypical form of primary syphiloma, since its clinical picture is extremely reminiscent of a common patient. Chancre felon starts with the formation of erosion or ulcers on the dorsum of the finger and simultaneous compaction of the underlying tissues of the phalanx. The ulcer differs in depth, its edges are sinuous, sometimes overhanging. The bottom is covered with purulent necrotic masses, patches of dead tissue are often visible. Soft tissues become not only dense, but as if welded together into one whole (from the skin to the periosteum). Infiltrate has no clear boundaries and extends to the entire fang, which is characteristic of other dactylites. The affected phalanx becomes edematous, club-shaped, swollen, the skin over it becomes dark or purplish-red. Similarity to panariticus increases spontaneous, shooting or throbbing pains, increasing with the slightest movement. Soon the elbow and axillary lymph nodes increase, the palpation of which is painful. For chancre felon long (not divided, months). The cause of atypical course of primary syphiloma on the fingers, apparently, is due to the combination of a secondary infection.

Diagnosis of chancre felon is very difficult and often the diagnosis is established with the appearance of secondary syphilides. In the presence of chancre felon in patients may develop malaise, fever, symptoms of general intoxication.

There are two more forms of primary syphilitic lesions of the fingers and hands - dactylitis luetica and paronychia luetica. They are distinguished by insignificant morbidity with marked inflammatory phenomena. Suppuration may be absent. Chronic. Enlarged regional lymph nodes in both of these forms, unlike chancre felon, are painless.

Special varieties of hard chancre also include:

1) burn (combusiform) hard chancre, is an erosive primary syphilis, prone to pronounced peripheral growth with weak (leafy) compaction in the base; as erosion increases, its boundaries lose their correct shape, the bottom becomes red and grainy;

2) Folmann's balanitis is a rare clinical variant of hard chancre; on the head of the penis in men or on the external genitals in women, there are multiple minor erosions without noticeable consolidation at the base; in women, this is facilitated by antibiotic treatment during the incubation period or their local application to the chancre in the first days of its appearance;

3) herpetiform hard chancre appears in the form of small erosions, grouped in a small area; compaction at the base of erosion is mild; The clinical picture is very similar to genital herpes.

Some variants of the flow of a typical solid chancre are noted depending on the localization of the process and the anatomical features of the lesions. At the head of the penis, the chancre is usually erosive, has a rounded shape with a slight lamellar seal; in the coronoid sulcus, ulcerative, of large size with a nodular seal; on the bridle of the penis - in the form of a cord with a seal at the base, it bleeds during erection. Chancres, localized in the region on the outer boundary of the foreskin, are usually multiple and often linear. When the primary syphiloma is located on the inner sheet of the foreskin, it is difficult to remove the head from under it, radial tears appear and the infiltrate at the base of the chancre rolls in the form of a plate (hinged chancre).
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Primary syphiloma (hard chancre)

  1. Chancre
    Formed after the end of the incubus. period and is located on the site of the introduction of pale treponema in the skin or mucus. obol. Localization: head floor. penis, anus, large and small labia, posterior commissure, region cervix. Chancre is a single erosion of a rounded shape, saucer-shaped with clear boundaries. The color of eroded meat is red. Discharge erosive serous, scanty. Characteristic
  2. Complications of hard chancre
    Various external influences (trauma, non-compliance of the patient with hygienic rules, irrational treatment, the addition of secondary pyogenic and opportunistic infections), as well as factors that reduce the overall reactivity of the body (elderly and early childhood, chronic common diseases of the body: diabetes, berculosis, anemia, etc .; chronic intoxications, especially
  3. Complications of hard chancre
    Balanitis, balanoposthitis, phimosis, paraphimosis, gangrenization, fagedenism. Balanitis and balonapostitis - a bacterial infection joins. Appears puffiness, bright erythema, epithelial maceration. Separated on the surface of the chancre becomes seroz. - purulent .. Phimosis is a narrowing of the cavity of the foreskin, which does not allow to open the head of the penis. Due to edema of the foreskin, the penis appears
  4. Atypical solid chancre
    Shankr-panaritium is a club-shaped swelling of the terminal phalanx with sharp pain. There is a lack of acute inflammatory erythema, the presence of dense infiltration and regional lymphadenitis. More often sick honey. staff. Inductive edema - located in the region. large labia, scrotum or foreskin, i.e. in places with a large number of lymphatic vessels. There is swelling of these
  5. Chancre lips
    An erosive hard lip can have typical clinical signs (erosion with correct round edges, red, shiny, as if lacquered or covered with a dipteroid bloom bottom, at the base of which a leaf-shaped or lamellar seal is determined). Relatively often erosion has a small size (dwarf hard chancre). Significant diagnostic difficulties
  6. Chancre language
    . The chancre of the tongue is solitary, appears mostly on the dorsal surface of the tongue and has several forms: 1) erosive; 2) ulcerative; such an ulcer that affects the mucous membrane, deepened in the form of a cup or spoon; 3) slit-like, appears when the chancre is localized along the cracks of the tongue, when it has the appearance of elongated or prolonged erosion; seal the bottom of these
    Allan R. Ronald, Francis A. Plummer (Allan R. Ronald, Francis A. Plummer). Definition. Chancroid (venereal ulcer) is an acute sexually transmitted infection characterized by painful ulceration of the genital organs, often associated with inflammatory adenopathy of the inguinal lymph nodes. The latter may progress to the development of suppuration. Диагноз устанавливается на
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    Мягкий шанкр вызывается стрептобациллой, которая была открыта Ферраром (1885), Петерсоном (1887), изученная Дюкреем (1889), Унна (1892). Возбудитель имеет вид палочек, которые располагаются параллельно цепочками. Основной путь заражения - половой, редко - внеполовой ( через предметы ). Инкубационный период у мужчин от 2 - 3 дней до 2 - 3 недель, у женщин от 2 - 3 недель до 3 - 5 месяцев. У
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    Выявляется по поступлению ликвора через иглу Туохи или по установленному катетеру. Возможные варианты действий в данной ситуации: 1. Переустановить катетер в другом межпозвонковом промежутке. В случае успешной попытки вводится тест-доза местного анестетика. Если после нескольких попыток катетеризации вновь происходит пункция твердой мозговой оболочки необходимо отказаться от проведения
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