Symptoms and signs of syphilis

　　1. Acquired syphilis

　　(1) Primary syphilis

　　The average incubation period is 3-4 weeks. Typical lesions are Hard Chancre and Ulcus. Durum) begins to appear as a small red papule or induration at the site where the spirochete invades, which later manifests as erosion and forms a shallow ulcer. It is hard, painless, garden-shaped or oval-shaped, with clear boundaries, neat edges, and dike-like bulges around the edges. It is surrounded by dark red infiltration, has characteristic cartilage-like hardness, has a flat base, no pus, and a fibrin-like film on the surface, which is difficult to remove. If squeezed a little, there may be a small amount of serous exudate, which contains a large number of Treponema pallidum, which is an important source of infection. Most hard chancres are single, but 2-3 can also be seen. The above is a typical hard chancre. However, if it occurs in the area of ​​original erosion, laceration, or eroded herpes or balanitis, the chancre will appear in the same shape as the original damage. In this case, a Treponema pallidum test should be performed. Chancre is caused by sexual intercourse infection, so the damage mostly occurs on the vulva and sexual contact parts. male They are mostly found near the glans, coronal sulcus and frenulum, the inner lobe of the foreskin, the penis, the root of the penis, the urethral opening or the urethra. The latter can easily be misdiagnosed. Chancre is often associated with foreskin edema. Some patients may develop lymphangitis on the back of the penis, which appears as a hard linear lesion. female Hard chancre is more common in the labia majora, clitoris, urethral meatus, and mons pubis, especially in the cervix, and is easily missed. External hard chancre of the vulva is more common in the lips, tongue, tonsils, fingers (medical staff can also be infected and develop finger chancre), breasts, eyelids, and external ears. In recent years, hard chancre in the anus and rectum is not uncommon. This kind of hard chancre is often accompanied by severe pain, difficulty in defecation, and easy bleeding. Those occurring in the rectum are easily misdiagnosed as rectal cancer. Hard chancre occurring outside the vulva is often atypical, and Treponema pallidum examination and genetic diagnostic testing should be performed. Chancre has the following characteristics: ① The injury is often single ； ②cartilage-like hardness ； ③no pain ； ④Clean damaged surfaces.

　　One week after the appearance of hard chancre, nearby lymph nodes swell, which is characterized by painlessness, no redness and swelling of the skin surface, no adhesion to surrounding tissues, and no ulceration, which is called painless transverse chancre (painless lymphadenitis). If chancre is not treated, it will heal on its own in 3-4 weeks. After effective treatment, it can heal quickly, leaving shallow atrophic scars. 2-3 weeks after the onset of chancre, the syphilis serum reaction begins to be positive. In addition to hard chancre in primary syphilis, a few patients may also develop hard and tough edema in the labia majora, foreskin or scrotum. Like elephant skin, it is called Edema Induratum. If the patient is also infected with chancre caused by Haemophilus ducreyi, or by sexually transmitted diseases Collapse ulcers caused by lymphogranuloma are called mixed chancre.

　　Diagnostic basis for primary syphilis: ① History of unclean sexual intercourse, incubation period of 3 weeks； ②Typical symptoms, such as a single painless chancre, usually occur in the external genitalia ； ③Laboratory examination: PCR test for positive Treponema pallidum gene or dark field microscopy, and Treponema pallidum was found in the chancre. ； Serum test for syphilis was positive. Only one of these three tests is positive.

　　(2) Secondary syphilis

　　This is the widespread stage of syphilis. The period from the disappearance of the chancre to the appearance of the secondary syphilis rash is called the second incubation period. Secondary syphilis rash usually occurs 3-4 weeks after the chancre subsides, which is equivalent to 9-12 weeks after infection. Secondary syphilis is when Treponema pallidum enters the bloodstream through lymph nodes and causes widespread damage throughout the body. except cause skin In addition to causing damage, it can also invade internal organs and nerve system.

　　Secondary syphilis may have influenza-like syndrome (headache, low-grade fever, soreness in the limbs) before the rash occurs. These prodrome lasts for about 3-5 days and subsides after the rash appears.

　　The skin lesions of secondary syphilis can be divided into macules, papules and pustules, with the latter being rare.

　　Maculatus, also known as roseola (roseola), is the most common. It accounts for about 70%-80% of secondary syphilis. Early-onset roseola resembles typhoid fever. It is a light red, circular or oval-shaped erythema of varying sizes, with a diameter of about 0.5-1.0cm, and a clear boundary. The fading caused by pressure is independent and does not merge with each other. They occur symmetrically. They usually occur on the trunk first, then gradually extend to the limbs, and can spread all over the body within a few days (generally less common on the neck and face). The subjective symptoms are not obvious, so they are often ignored (it is not easy to see in a warm environment, but it is obvious when the room temperature is low). If it occurs on the palms and soles, it may appear as psoriasis-like scales with a flesh-red base that does not fade when pressed, which is characteristic. Over a few days or 2-3 weeks, the color of the rash gradually changes from light red to brown, brownish-yellow, and finally subsides. Pigmentation may remain after healing. It can resolve quickly after treatment with anti-syphilitic drugs. Recurrent macules usually occur 2-4 months after infection, but may occur later than 6 months or 1-2 years. The skin lesions appear early and are large, about the size of a fingernail or various coins. They are small in number, arranged in localized clusters, and have obvious boundaries. They are mostly found on the extremities, such as the lower limbs, shoulder blades, forearms, and perianal areas. This type lasts for a long time. If left untreated, it may recur after subsidence. During the process, it may subside in the center and develop at the edges, forming a ring (annular roseola).

　　The serum reaction for syphilis in this period was strongly positive. The PCR test for Treponema pallidum DNA was positive.

　　Papular and maculopapular rash, clinical It is also common, accounting for about 40% of secondary syphilis. The onset time is slightly later than that of macules. According to its symptoms and clinical course, it can be divided into large papules and small papules.

　　Large papules: about 0.5-1cm in diameter, hemispherical infiltrated papules, smooth surface, dark brown to copper red, the center of the rash is absorbed, sunken or desquamated over time, commonly occurs on both sides of the trunk, abdomen, flexors of limbs, scrotum, labia majora, anus, groin, etc. There may be scales, called papulosquamous syphilis or psoriasiform syphilis (Psoriasiform) syphilid), with larger scaly patches, the scales are white or hard-to-pee scabs, there is superficial erosion under the scabs, and a red halo around the edges, like psoriasis. It usually occurs on the trunk, limbs, etc.

　　Small papules, also known as syphilitic moss milia, are mostly the same size as hair follicles, cone-shaped, solid, pointed, brown-red, clustered or mossy-like. It occurs later, within 1-2 years after infection, and lasts for a long time. It does not subside within 2-3 months without treatment. Some papules are arranged in a ring or arc shape, which is called annular syphilis. It usually occurs in the scrotum and neck, Treponema pallidum can be found, and the syphilis serum reaction is strongly positive.

　　Impetigo: now rare. It can be seen in malnutrition, physical weakness, alcoholism and drug abuse. Large rashes include impetigo-like, deep impetigo-like, and oyster shell-like forms. Small ones have acne-like appearance and Acne In similar forms, patients are often accompanied by fever and general malaise. Most of the skin lesions have copper-red infiltration. Based on the medical history, Treponema pallidum examination and syphilis serum reaction, it can be easily distinguished from acne vulgaris and impetigo. Among them, oyster shell sores have specific oyster shell-like skin lesions and are easy to identify.

　　Mucosal damage from secondary syphilis can occur alone or in combination with other syphilis eruptions. Easily ignored when occurring alone. People who smoke, drink alcohol, frequently consume hot and spicy foods, and those with poor dental hygiene are prone to the disease or its recurrence. Common damage is mucous membrane leukoplakia (Leukoplasia, Mocus patch). It usually occurs in the oral cavity, genital mucosa, and anal mucosa. If it occurs on the anal mucosa, it will be painful during defecation, and there may even be bleeding. The lesions are round or oval, with clear boundaries, surface erosion, gray-white or milky-white patches slightly higher than the mucosal surface, surrounded by dark red infiltrates, the size of a fingernail or slightly larger, and the number varies. Can enlarge or merge into each other to form a wreath or irregular shape. It can also develop into ulcers. The base of the ulcer is often a black film that is difficult to peel off. After peeling off, the base is uneven and prone to bleeding. There is no self-consciousness, but those who have formed ulcers will feel pain. There are a large number of Treponema pallidum on the surface of mucous membrane leukoplakia, which is an important source of infection.

　　Syphilis hair loss : About 10% of patients with secondary syphilis develop. This is caused by syphilitic infiltration of hair follicles, blockage of fine blood vessels in the hair area, and poor blood supply. It manifests as syphilitic alopecia areata or diffuse alopecia. The former is a bald spot of about 0.5cm, which is moth-eaten in shape. Diffuse hair loss, large area, sparse hair, uneven hair length. Commonly seen in the temporal, top and occipital areas, eyebrows, eyelashes, beards and pubic hair are also lost. Treponema pallidum is present locally in alopecia of secondary syphilis. Moreover, the location of Treponema pallidum is basically the same as the site of cell infiltration, so it is believed that syphilitic alopecia may be related to the invasion site of Treponema pallidum. Treponema pallidum does not invade the dermal papilla but invades the upper part of the hair follicle, so syphilitic alopecia is dominated by incomplete bald patches. However, syphilitic alopecia is not permanent hair loss. If treated promptly, hair can regenerate within 6 to 8 weeks, even without treatment.

　　Syphilitic white spots are more common in female patients. It usually occurs 4-5 months or 1 year after infection. It usually occurs on both sides of the neck. It can also be found on the chest, back, breasts, limbs, armpits, vulva, perianal and other parts. The affected area is completely depigmented, and the surrounding pigment is increased, similar to Vitiligo . Various sizes. They can fuse with each other into large pieces, with a mesh-like shape in the middle, and the pigment in the mesh is lost. Syphilitic leukoplakia often accompanies syphilitic alopecia. It exists for a long time and is stubborn and difficult to disappear. It can last for 7-8 years and can be extended to tertiary syphilis. It is often accompanied by nervous system syphilis or appears before neurosyphilis occurs. There are abnormal changes in the cerebrospinal fluid. Syphilis serology was positive. Based on the medical history, symptoms of syphilis in other parts of the body, and positive syphilis serum reaction, it can be distinguished from vitiligo.

　　Secondary syphilis can also affect the nails, causing Paronychia , onychomycosis and other abnormal changes, similar to other non-syphilitic nail diseases. There may be dark red infiltration around syphilitic paronychia. Secondary syphilis can also cause osteitis, periostitis, arthritis, iridocyclitis, and retinitis, and can involve the nervous system, but there are no clinical symptoms. It is called secondary asymptomatic neurosyphilis. Syphilitic meningitis, cerebrovascular and meningeal vascular syphilis, headaches and corresponding neurological symptoms may also occur.

　　The serological reaction of manifest secondary syphilis is often strongly positive. Secondary syphilis lesions generally have no symptoms, and occasionally include slight itching. If periostitis or osteitis occurs, you will feel pain. This pain is worse at night and lighter or not painful during the day. It can disappear after 1-2 months without treatment, and it will disappear quickly after anti-plumbo treatment.

　　Early-onset rash and recurrent rash of secondary syphilis. The first to appear is the early-onset rash of secondary syphilis. It is characterized by a large number of skin lesions, small shape, mostly symmetrical and scattered, and is more likely to occur on the trunk and extended limbs. Those that relapse after subsidence are secondary recurrent syphilis, which are characterized by a small number of skin lesions, large shapes, mostly arranged in clusters on one side, often in annular, hemispherical, irregular shapes, etc., and tend to occur on the extremities, such as the head, face, perianal, vulva, palms and soles or the flexors of the limbs. Differentiating early-onset rash from recurrent rash has certain significance for treatment and prognosis. Generally, early-onset syphilis has a short course, is easy to cure, and has a good prognosis, while recurrent syphilis has a longer course, and its efficacy and prognosis are not as good as early-onset syphilis.

　　Diagnostic basis for secondary syphilis: ① History of unclean sexual intercourse and chancre； ②A variety of rashes such as roseola, maculopapular rash, mucosal damage, moth-eaten alopecia, general malaise, and swollen lymph nodes ； ③Laboratory examination: Take samples from the mucosal lesions and find Treponema pallidum under a dark field microscope ； Positive serological test for syphilis ； The PCR test was positive for Treponema pallidum DNA.

　　(3) Tertiary syphilis (late syphilis)

　　The onset time is usually 2 years after the onset of disease, but it can also take longer than 3-5 years. It usually occurs between the ages of 40 and 50. Mainly due to lack of anti-syphilis treatment or insufficient treatment time and insufficient drug dosage. Imbalance of the internal and external environment of the body also has a certain relationship. Patients with excessive drinking, inhalation, physical weakness and patients with chronic diseases such as tuberculosis have a poor prognosis.

　　The characteristics of tertiary syphilis are as follows: ① It occurs late (2-15 years after infection) and has a long course. If left untreated, it can last as long as 10-20-30 years or even for life.； ②Symptoms are complex and can affect any tissue and organ, including skin, mucous membranes, bones, joints, and various internal organs. It is more likely to invade the nervous system, is easily confused with other diseases, and is difficult to diagnose. ； ③There are few Treponema pallidum in the body and skin lesions, and its infectivity is weak, but its ability to destroy tissue is strong, often causing tissue defects and organ damage, which can cause disability and even endanger life. ； ④Although anti-tuberculosis treatment is effective, it cannot repair damaged tissues and organs. ⑤Syphilis serum reaction is unstable, the negative rate can reach more than 30%, and cerebrospinal fluid often changes.

　　Skin and mucosal lesions of tertiary syphilis account for 28.4% of the incidence of late benign syphilis, and most occur within 3 to 10 years after infection. Clinically, it can be divided into nodular syphilitic rash, gumma, and juxtaarticular nodules. Skin damage has the following characteristics: ； ①Small in number, isolated or clustered rather than symmetrical, often occurring in areas susceptible to trauma ； ②The systemic symptoms are mild. If the skin lesions are not conscious, if the periosteum and bones are invaded, pain will be felt, especially at night. ； ③There is gumma, infiltration and induration. The ulcer formed after rupture still has hard infiltration at the bottom, which subsides very slowly, often lasting more than several months. ； ④Ulcers have a distinctive kidney or horseshoe shape ； ⑤Ulcers may heal in the center but often continue to expand at the edges ； ⑥There are few Treponema pallidum on the surface of the lesion and are difficult to detect under dark field microscopy, but vaccination can be positive. ； ⑦It is very powerful in destroying tissue and can form scars during healing.

　　Nodular syphilid rash (nodular Syphilid): It usually occurs within 3-4 years after infection, and the lesions tend to occur on the head, shoulders, back and extensor sides of the limbs. It is a group of infiltrative nodules with a diameter of about 0.3-1.0cm, copper-red in color, with a smooth surface or thin scales attached, and a hard texture. The patient has no subjective symptoms. The evolution of the nodules may have two outcomes. One is that the nodules are flattened and absorbed, leaving small atrophic spots and dark brown pigmentation for a long time. Another outcome is central necrosis, the formation of small abscesses, ulcers after ulceration, and nodular ulcerative syphilitic rash, leaving shallow scars after recovery. There is pigmentation around the scar, the atrophic area is smooth and thin, and new damage may appear at the edge. This is a characteristic of this disease. Old and new rashes appear one after another, and new ones occur, which can last for several years.

　　Gumma is common in tertiary syphilis, accounting for about 61% of tertiary syphilis. It is hardened deep under the skin. The initial appearance is as big as a pea, and gradually increases to the size of a broad bean or even a plum or larger. It is hard and can move when touched. The number is uncertain. The initial color is normal skin color, and as the nodules increase, the color gradually changes to light red, dark red or even purple. The nodules are prone to necrosis, can gradually soften, rupture, and ooze gum-like secretions, and can form specific garden-shaped, oval-shaped, or horseshoe-shaped ulcers with clear boundaries, neatly raised edges like dikes, and brown-red or dark red infiltration around them, which feels hard to the touch. Often one end heals, while the other end still spreads like a snake. The subjective symptoms are mild. If it invades the bone and periosteum, you will feel pain, especially at night. It can appear anywhere on the body, but is more common on the head, face and lower legs. The course of the disease is long, ranging from months to years or more. After healing, scars are formed, and the scars are surrounded by pigmentation bands. Gum swelling can invade bone and cartilage. Bone damage is more common in long tube osteitis, and bone and periostitis can occur. Those that occur on the head often destroy the skull. Those that occur on the palate and nose can destroy the hard palate and nasal bones, forming a connection between the nose and the palate. Those that occur near large blood vessels can erode the large blood vessels and cause massive bleeding. Gumma can be absorbed without leaving scars after anti-plumbo treatment. There are also those who form obvious superficial infiltrates without rupture.

　　Tertiary syphilis may also cause localized or diffuse alopecia and paronychia. The clinical manifestations are the same as those of secondary syphilis.

　　Tertiary syphilis can also involve mucous membranes, mainly in the mouth, tongue, etc. Nodular rash or gum swelling may occur. Those that occur on the tongue can present with a localized single gum swelling or diffuse gum infiltration. The latter can easily develop into chronic interstitial glossitis, with a grooved tongue of varying depths. It is a precancerous lesion and should be closely observed and given adequate anti-plumbing treatment. Sometimes the lesions are superficial, the tongue papilla disappears, and the lesions are red and smooth. There are no symptoms of tongue damage, but you may feel pain after eating hot or acidic foods.

　　Juxtaarticular nodules, hard and painless nodules may appear near the extension sides of large joints such as hips, elbows, knees, and sacrum. The surface skin has no inflammation and is normal or darker in color. It passes slowly and does not break. Treponema pallidum can be found in the nodules, often combined with other signs of syphilis, and the syphilis serum test is positive, and it is easy to resolve with anti-syphilis treatment. Some people think that this kind of nodule is the connective tissue of the skin, which is caused by Treponema pallidum with a special affinity for connective tissue. Tertiary syphilis can cause eye damage, such as iridocyclitis, retinitis, keratitis, etc. When the cardiovascular system is involved, simple aortitis, aortic valve insufficiency, aortic aneurysm, and coronary heart disease may occur. It can also invade the digestive, respiratory and urinary systems, but there are no specific symptoms. Corresponding examinations can be done based on the medical history. Tertiary syphilis easily invades the nervous system. In addition to asymptomatic neurosyphilis with no clinical changes and abnormal changes in cerebrospinal fluid examination, meningeal vascular syphilis and cerebral parenchymal syphilis can also occur.

　　Diagnostic basis for tertiary syphilis: ①Have unclean sexual intercourse and a history of early syphilis； ②Typical symptoms include nodular syphilis, gumma, aortitis, aortic insufficiency, aortic aneurysm, tuberculosis, and paralytic dementia. ； ③Laboratory tests: syphilis serological test, non-spiral antigen serological test about 66% positive ； Treponema antigen serum test was positive. Cerebrospinal fluid examination showed an increase in white blood cells and protein, and a positive Venereal Disease Research Laboratory test (VDRL).

　　Regarding the diagnosis of neurosyphilis, no single test can confirm the diagnosis of all neurosyphilis. It can be based on the following conditions, such as positive syphilis serological test, abnormal cell count and protein in cerebrospinal fluid, or positive cerebrospinal fluid VDRL (cerebrospinal fluid RPR test is not performed) and clinical symptoms are optional. Cerebrospinal fluid VDRL is the standard serological method in cerebrospinal fluid. When serum contamination is excluded, if VDRL is positive in cerebrospinal fluid, neurosyphilis should be considered. However, cerebrospinal fluid VDRL may also be negative in patients with neurosyphilis.

　　Latent syphilis: Latent syphilis refers to patients who have been diagnosed with syphilis. At a certain period, there are no abnormal findings in the skin, mucous membranes, any organ system and cerebrospinal fluid examination. Physical examination and chest X-ray lack clinical manifestations of syphilis. cerebrospinal fluid examination is normal, but only syphilis serology is positive, or there is a clear history of syphilis infection and no clinical manifestations have ever occurred. Called latent syphilis. The diagnosis of latent syphilis also depends on the history of primary and secondary syphilis, the history of contact with syphilis, and the history of delivering a baby with congenital syphilis. Previous negative syphilis serological test results and history of disease or exposure can help determine the duration of latent syphilis. Early latent syphilis occurs when the infection lasts for less than 2 years, late latent syphilis occurs when the infection lasts for more than 2 years, and latent syphilis has an unclear disease stage. Latent syphilis does not cause symptoms because the body's own immunity is strong, or the spirochetes are temporarily suppressed due to treatment. During the period of latent syphilis, spirochetes still appear intermittently in the blood. Pregnant women with latent syphilis can infect their fetuses in the womb. Infections can also be transmitted to blood recipients from donated blood.

　　Early latent syphilis can be judged based on the following conditions: ① Continuous syphilis serological test changes, that is, whether the non-treponemal test increases by 4 times or more； ②Is there a history of symptoms of primary or secondary syphilis? ； ③Whether the sexual partner has primary, secondary or latent syphilis with a course of disease within 2 years ； ④The diagnosis can only be confirmed if the genetic test is positive for Treponema pallidum DNA. Except for early latent syphilis, almost all others are syphilis with unknown disease stage. This type of syphilis should be treated as late latent syphilis. For children with latent syphilis diagnosed after the neonatal period, the mother's medical history and the child's birth circumstances should be carefully analyzed to determine whether the patient has congenital or acquired syphilis. All patients with latent syphilis should be examined for signs of tertiary syphilis, such as aortitis, neurosyphilis, gumma, and iritis.

　　Syphilis in pregnancy: Syphilis and pregnancy can affect each other. Syphilis in pregnancy can infect the fetus through the placenta. Due to placental blood vessel obstruction caused by syphilis in pregnancy, fetal nutrition is affected, and miscarriage, premature birth or stillbirth are prone to occur. Although full-term delivery is possible, about 64.5% of fetuses have been infected with syphilis and congenital syphilis occurs, of which 15% to 20% are early-onset congenital syphilis. Syphilis also has a great impact on pregnancy. Although women with syphilis can become pregnant, the pregnancy rate is significantly reduced. The infertility rate of active syphilis is 23% to 40%, which is 1 to 5 times higher than normal. Pregnancy syphilis has a great impact on the health of pregnant women. It can cause weight loss, fatigue, nutritional depletion, and reduced resistance to diseases. If it is early stage syphilis, the impact on health is more serious. In addition to the above symptoms, fever, night sweats, anemia, easy involvement of bones and joints, bone decalcification, and joint pain may occur. Due to blood vessel infarction in the placenta, early placental detachment is prone to occur, leading to miscarriage, premature birth, and stillbirth.

　　In addition to the above-mentioned vascular changes, the placenta of syphilis often increases in weight, the maternal surface is swollen and pale in color, the number of villi is greatly reduced due to vascular infarction, the density of interstitial cells increases, and Treponema pallidum can be detected in the placenta.

　　When diagnosing syphilis in pregnancy, you must ask in detail whether you and your spouse have a history of syphilis, and whether you have a history of miscarriage and premature birth. Pregnant women with syphilis must undergo a syphilis serum test: ① Once in the first trimester and once in the second trimester (or late trimester) (do not do it a few days before or after delivery, as false positive reactions are prone to occur) ； ②If the husband has syphilis but he has no symptoms of syphilis and the serum reaction is negative, but the child develops symptoms of late syphilis before the age of 10, the mother of the child will be treated as latent syphilis. ； ③A small number of pregnant women may also experience biological false-positive reactions (mostly weak positive reactions). If neither the pregnant woman nor her spouse has a history of syphilis or symptoms of syphilis, nor has there been any suspicious history in the past, and one of the two serum tests is suspicious, and the follow-up test is weakly positive, observation should continue and anti-syphilis treatment will not be given temporarily. A serum reaction can be performed every 2-3 weeks, and a serum quantitative test can be performed at the same time to observe whether the titer has increased. A detailed physical examination should be performed on the person, and the umbilical cord and placenta should be checked for abnormalities during delivery. If there is any doubt, the umbilical cord vein wall and the fetal side of the placenta can be scraped for dark field microscopy to detect Treponema pallidum. ； ④Pregnancy syphilis is often complicated by stubborn proteinuria, which can often disappear with anti-syphilis treatment ； ⑤In addition to a comprehensive examination of the pregnant woman with syphilis in pregnancy, a detailed examination of her spouse should also be carried out.

　　For pregnant women with syphilis, if they are given adequate anti-syphilis treatment in the first trimester, the fetus will not be infected. If treated in the third trimester, fetal infection will not be prevented. Mothers with syphilis should follow up their newborn babies for at least six months after delivery. Pregnant women who take drugs can increase the risk of infection to their fetuses.

　　fetal syphilis； Treponema pallidum enters the fetus and can cause pathological changes in various organs. The severity of the damage is related to the mother's illness stage and the time the fetus was infected. The main lesions are:

　　①Skin: The infant's body is smaller and lighter than normal fetuses, with less subcutaneous fat. The skin is dry, dark gray, fragile, and easy to peel off to reveal erosion. The skin on the palms and soles is thickened and shiny, and often has bullae. If it is a stillbirth, the skin will be soaked and softened, and it will peel off easily and become eroded. Mucous membranes are prone to ulcers, nasal and oral congestion, and bloody secretions. Most fetuses with this condition are syphilis fetuses.

　　② Liver: easily invaded, enlarged and hardened, weighing 1/8-1/10 of the body weight (normal is 1/30). The appearance is distinctive brownish-yellow. Yellow miliary nodules are visible on the cut surface. Sometimes there may also be gum swelling and scars. Slice microscopy showed thickening of the portal vein and hepatic vein walls, thickening of the hepatic ducts, narrowing of the lumen, high-grade connective tissue hyperplasia and lymphoid cells around the liver lobules, plasma cell infiltration, and ascites.

　　③ The lungs can invade one lobe or all of them, causing specific lesions. The lung lobes become enlarged, solidified, and pale in color, which is called white pneumonia. Most of the alveoli are airless, so the lungs cannot float when placed in water. There is limited or diffuse lymphocyte, plasma cell and monocyte infiltration in the bronchial and alveolar walls.

　　④ The spleen became significantly enlarged and gained weight (about 2-3 times heavier than normal). Under the microscope, small cell infiltration and periarteriolar fibrosis could be seen in the blood vessel wall.

　　⑤ The kidneys are often invaded. In addition to small cell infiltration, renal tubular degeneration may occur. Hemorrhagic glomerulonephritis and interstitial nephritis changes.

　　⑥ The pancreas enlarges, showing diffuse fibroplasia and cell infiltration under the microscope, and then the main substance atrophies.

　　⑦ Bone, with specific osteochondritis. The epiphysis and diaphysis of long bones are unevenly jagged. Later, the bone and epiphysis may be loosely separated, forming pseudoparalysis.

　　2. Congenital syphilis

　　Congenital syphilis is transmitted to the fetus through the placenta through the blood of pregnant women with syphilis during the fetal period, so it is also called fetal-transmitted syphilis. Usually, placental infection occurs around four months into pregnancy, and the fetus may die or miscarry. If a pregnant woman has been infected with syphilis for more than five years, it is unlikely that the fetus will be infected in the womb. Early congenital syphilis occurs within 2 years of age, and late congenital syphilis occurs over 2 years of age. It is characterized by the absence of chancre. Early lesions are more severe than acquired syphilis, while late lesions are lighter. Cardiovascular involvement is less, and bone and sensory systems such as eyes and nose are more commonly affected.

　　Early congenital syphilis, which occurs soon after birth, is mostly premature infants with malnutrition, low vitality, light weight, thin body, pale and loose skin, face like an old man, often accompanied by mild fever. The rash is similar to that of acquired secondary syphilis, including macules, maculopapular rashes, papules, pustules, etc. Macules and maculopapular rashes that occur on the buttocks often merge into dark red infiltrative plaques, and the surface may be flaked or slightly moist. Those around the mouth often show seborrheic symptoms, with a dark red halo around them. Those that occur on the anus, vulva, and flexors of the limbs often present with eczema papules and flat condyloma. Pustular rash is most common on the palms and soles. The pustules are as big as peas, with dark red or copper-red infiltrates at the base, and an erosive surface after ulceration. There are a large number of Treponema pallidum in wet papules, flat condyloma and the erosive surface of ruptured pustules. A few patients may also develop flaccid bullae, also known as syphilitic pemphigus. There are serous purulent secretions in the bullae and dark red infiltration at the base. Paronychia and onychomycosis may occur in the nails. Oyster shell sores or deep impetigo lesions may also be seen. The inferior turbinate is swollen with purulent secretions and crusts, which can block the nasal cavity and make it difficult for the patient to breathe and suck milk. This is one of the characteristics of congenital syphilis in infants. If it continues to progress, the nasal bones and hard palate may be destroyed, resulting in saddle nose and hard palate perforation. If the larynx and vocal cords are violated, hoarseness may occur.

　　May be accompanied by systemic lymphadenitis. The skin lesions of slightly longer syphilis in young children are similar to those of recurrent syphilis the day after tomorrow. The skin lesions are large and numerous, often in clusters, and flat condyloma are common. The mucosa may also be involved, and gumma may occur in a few sick children. Bone damage and bone damage are most common in early congenital syphilis, and syphilitic dactylitis causes diffuse spindle swelling, involving one or several fingers, sometimes accompanied by ulcers. Osteomyelitis is common, mostly in long bones. Others include osteochondritis, periostitis, pain, inability to move the limbs, and paralysis of the limbs, so it is called syphilitic pseudoplegia.

　　Visceral damage may include hepatosplenomegaly, and kidney invasion may cause proteinuria, casts, hematuria, edema, etc. In addition, orchitis and epididymitis can still be seen, often combined with scrotal edema. Eye damage includes syphilitic choroiditis, iridocyclitis, retinitis, optic neuritis, etc. The nervous system can also be involved, and encephalomalacia, cerebral edema, and epileptic seizures can occur, and pathological changes can occur in the cerebrospinal fluid.

　　Late congenital syphilis usually begins to show symptoms between the ages of 5 and 8, with multiple symptoms appearing one after another between the ages of 13 and 14. Late-onset symptoms may not occur until around the age of 20. Late congenital syphilis mainly affects the skin, bones, teeth, eyes and nerves. ①Skin and mucous membrane damage: Gum swelling may occur, which may cause perforation of the palate, nasal septum, and saddle nose (the nose is deeply collapsed, and the tip of the nose is enlarged and raised like a saddle). Patients with saddle nose can also see a widening of the distance between their eyes and everted nostrils. Saddle nose usually appears at the age of 7-8 years and becomes more obvious at the age of 15-16 years. ； ②Bones: periostitis, osteitis, bone pain, especially at night. Periostitis often involves the lumen, and is often limited to this area. It can cause the front of the bone to become hypertrophic and bulge in an arched shape, so it is called saber shin (the middle part of the tibia is thick and bulges forward). Joint effusion, usually joint effusion of both knees, is mildly stiff and painless, which is characteristic. ①Forehead convexity ； The characteristics of half-moon incisors (Hutchinson's teeth from Hao Qin) are that the two central incisors of the permanent teeth have narrow free edges, a half-moon defect in the center, the affected teeth are short, the front-to-back diameter is increased, the tooth angles are blunt, and the dentition is irregular. The first molar is small in shape, with the tooth tips concentrated in the middle of the biting surface, shaped like a mulberry, and is called a mulberry tooth. If the above three characteristics of parenchymal keratitis, syphilitic labyrinthitis and half-moon incisors appear at the same time, it is called Hao Qinsheng's triad. ②Substantial keratitis: This disease occurs in 50% of late congenital syphilis. About 95% of parenchymal keratitis of the eye is syphilitic. The disease is mostly bilateral, and may occur on one side first and then on the other side. The course is slow, the course is long, and the disease is resistant to anti-syphilis therapy. It is difficult to control the progress of anti-syphilis therapy, and the prognosis is difficult to determine. The children are younger and in good health. Those with adequate treatment have a better prognosis, otherwise they may cause blindness. ； ③Nervous deafness: Labyrinthitis caused by invasion of the labyrinth. It is more common in patients under the age of 15. It usually affects both ears. The onset is sudden, sometimes mild and sometimes severe, and may be accompanied by dizziness and tinnitus. It is resistant to antiplumb therapy and often fails to inhibit its development, eventually leading to deafness. It is difficult to differentiate between syphilitic labyrinthitis and non-syphilitic labyrinthitis.

　　Congenital latent syphilis: No clinical symptoms and positive syphilis serology are congenital latent syphilis.

　　Diagnosis basis of congenital syphilis: ① Family history: mother has syphilis； ②Typical lesions and signs ； ③Laboratory testing to detect Treponema pallidum from lesions, nasal secretions, or placental and umbilical cord samples ； ④Positive serological test for syphilis ； ⑤The genetic test was positive for Treponema pallidum DNA.

　　Syphilis combined with HIV infection: In recent years, there have been many cases of syphilis patients combined with HIV infection, which has changed the clinical course of syphilis. Because genital ulcers in patients with syphilis are an important risk factor for acquiring and transmitting HIV infection ； HIV can cause meningeal lesions, allowing Treponema pallidum to easily cross the blood-brain barrier and cause neurosyphilis.

　　Due to HIV infection and impaired immunity, early syphilis does not cause skin lesions, arthritis, hepatitis and osteitis. Patients may appear to be harmless due to lack of immune response, but in fact they may be in the active syphilis stage. Syphilis develops rapidly due to immunodeficiency and can rapidly develop into tertiary syphilis. There are even outbreaks, such as of the aggressive form of malignant syphilis (Lues Malighna). HIV infection can also accelerate the development of syphilis into early neurosyphilis. In cases of syphilis with neurological involvement, penicillin is not effective. In the 1960s and 1970s, cases of neurosyphilis after regular treatment with penicillin were rare. However, in recent years, a large number of syphilis patients with HIV infection have developed acute meningitis, cranial nerve abnormalities and cerebrovascular accidents.

　　The diagnosis of syphilis should be very careful because it has similarities with many other diseases. The manifestations are diverse, complex, and the course of the disease is long. It remains in a latent state for a long time. The diagnosis must be based on medical history, physical examination and laboratory results for comprehensive analysis and judgment. If necessary, auxiliary methods such as follow-up, family surveys, and experimental treatments are also required.

　　1. Medical history:

　　(1) History of unclean sexual intercourse: Try to ask the patient about his or her history of whoring or other unclean sexual intercourse to determine the source of infection. If there is a hard chancre in the anus, you should ask whether there is a history of anal intercourse. Asking clearly about the time of unclean sexual intercourse is very necessary to determine the incubation period of syphilis.

　　(2) History of current illness: whether there is a history of genital ulceration, skin erythema, papules, and condyloma, and whether there is a history of chancre, secondary or tertiary syphilis. Syphilis serological test detection status.

　　(3) Marital history: whether there has been a foreign-related marriage, the number of marriages, whether the spouse has any clinical manifestations of sexually transmitted diseases or suspected sexually transmitted diseases, etc.

　　(4) Childbirth history: Whether there is a history of threatened abortion, premature delivery, miscarriage and stillbirth, and whether there is a history of childbirth with fetal-transmitted syphilis in the past.

　　(5) If congenital syphilis is suspected, you should ask whether your parents have suffered from syphilis, the infection status of your brothers and sisters, and whether you have symptoms and signs of early and late syphilis.

　　(6) If latent syphilis is suspected, inquire about the history of infection and the presence of diseases that may cause biologically false positives in serum tests.

　　(7) Treatment history: whether you have had any treatment to dispel plum blossoms, whether the dosage and duration of treatment are regular, whether there is any history of drug allergy, etc.

　　2. Physical examination

　　(1) General examination: Whether the growth and development status is good, mental status；

　　(2) Skin and mucous membranes: Carefully examine the skin, mucous membranes, lymph nodes, hair, reproductive organs, anus, mouth, etc. of the whole body according to the skin damage characteristics of early and late syphilis.

　　(3) Special examination: in-depth examination of the eyes, skeletal system, heart and nervous system or specialist examination.

　　3. Laboratory examination:

　　(1) Dark-field microscopic examination of Treponema pallidum should be performed for early syphilis.

　　(2) Syphilis serum reagin test (such as VDRL, USR or RPR test), and if necessary, treponemal antigen test (such as FTA-ABS or TPHA test).

　　(3) Cerebrospinal fluid examination to rule out neurosyphilis, especially asymptomatic neurosyphilis. Early syphilis can cause nerve damage. In secondary syphilis, 35% of patients have abnormal cerebrospinal fluid, so the cerebrospinal fluid must be checked.

　　(4) Genetic diagnostic testing.