Syphilis nephritis

　　The causative agent of this disease is the syphilis spirochete, which belongs to the genus Treponema of the family Spirochaetaceae. The causative agent of syphilis is named Leptospirosis because it is transparent in body fluids, smooth in surface, and has strong refractive power and is not easy to stain.

　　Leptospirosis is a slender spiral-shaped microorganism. Under oil immersion, it can be observed to move in the following ways: rotating forward by rotating around its long axis is the main way it invades the human body; waving its body in a wavy motion to the left and right is the most common way of movement; another way is to contract and extend its body in a spiral manner, changing the spiral distance to crawl forward. The spiral moves very fast and often presents a mixed movement of the above three methods. Leptospirosis can寄生 and grow, reproduce in the human body for a long time, has strong reproductive and pathogenic power, but after leaving the human body, its vitality and resistance are very weak, and it is very sensitive to dryness, temperature, humidity, and chemicals. It dies within 1 to 2 hours in a dry environment. It is sensitive to high temperature but has strong resistance to low temperature. It dies immediately at 100℃; it can survive for 3 to 5 minutes at 60℃; it dies quickly under sunlight; it can survive for 1 to 2 days at 0℃; it can survive for several years at -78℃. It dies immediately in soapy water; it dies within 15 minutes in a 0.1% phenol solution; it dies within 5 minutes in a 5% formaldehyde solution; it can be killed immediately with a 1:5000 mercuric oxide solution; 0.1% Nizoral solution and potassium permanganate solution have good killing effects.

　　1. Mucosal lesions are prone to develop into chronic interstitial glossitis, which is a precancerous lesion and should be strictly observed.

　　2. Cardiovascular lesions can occur in succession, such as simple aortitis, aortic valve insufficiency, myocardial infarction, aneurysm, or sudden death.

　　3. Neurosyphilis develops slowly and can cause meningitis, which can compress the spinal cord and lead to spastic paralysis.

　　The clinical manifestations of acquired syphilis renal damage are diverse, such as acute nephrotic syndrome, membranous glomerulonephritis, acute progressive glomerulonephritis, etc., the latter of which is not very common, but routine syphilis tests should be performed for patients with newly onset nephrotic syndrome to exclude the possibility of syphilis.

　　The clinical manifestations of syphilis-related nephritis mainly include large amounts of proteinuria, edema, and generally normal renal function and blood pressure. Generally speaking, the clinical symptoms and signs, as well as proteinuria, disappear within 6 months, and some patients may last for about 1 year. Syphilis-related nephrotic syndrome often resolves spontaneously, and syphilis nephritis often disappears completely after anti-syphilis treatment.

　　In recent years, there have been many reports on nephritis related to congenital syphilis, with clinical manifestations such as edema, hematuria, severe proteinuria, and mild renal insufficiency. Under both ordinary and electron microscopy, glomerular basement membrane proliferation, focal periglomerular hyperplastic glomerulonephritis, and widespread immune complex deposition between the basement membrane and epithelium can be seen. The earlier the diagnosis, the better the prognosis.

　　1. Active and thorough treatment. For patients who have been cured, regular follow-up examinations should be conducted, and retreatment should be carried out when necessary, in order to achieve a根治 cure. Preventive treatment for syphilis should be carried out when necessary.

　　2. Be faithful in sexual relations, avoid prostitution, avoid selling sex, avoid extramarital or premarital sexual activities, and have a fixed sexual partner. If the sexual partner has syphilis, sexual intercourse should only be resumed after recovery, and barrier contraception measures should be taken.

　　3. Pay attention to personal hygiene. Items contaminated by syphilis patients should be disinfected in a timely manner. The prevention and treatment of syphilis directly affect the prognosis of syphilis-related nephritis.

　　I. Laboratory examination of syphilis

　　1. Examination of苍白螺旋体:It is an important method for the etiological diagnosis of syphilis and a strong piece of evidence for laboratory diagnosis of syphilis. The examination methods are: (1) Dark field examination; (2) Smear staining examination; (3) Immunofluorescence examination; (4) Rabbit infection test (RIT); (5) Tissue section staining examination.

　　Examination results: Positive in primary syphilis lesions; positive in skin, mucosal lesions, or blood in secondary syphilis, with a detection rate of 80% to 85%; in late syphilis, skin, mucosal lesions, or blood are mostly negative.

　　2. Syphilis serological test:Also known as syphilis serological reaction, it is the main method of syphilis immunological examination and an important indicator for laboratory diagnosis of syphilis. This test is also used in routine diagnosis and is suitable for screening examinations in large populations; or used to observe the efficacy; judge whether recurrence or reinfection occurs; used for early diagnosis (such as RPR test); used as a quantitative test to determine the strength of reagin in patients and exclude the phenomenon of pre-zone; differentiate early or late latent syphilis; differentiate congenital syphilis from passive reaginemia; if CSF is used for VDRL test, it also helps in the diagnosis of neurosyphilis, with the examination results being:

　　(1) Primary syphilis: Negative early on, positive later, with a positivity rate of 53% to 86%. Generally, within 4 weeks after infection, sometimes 5 to 6 weeks, the VDRL (USR) test is negative, and the positivity rate can reach 90% to 100% after 6 to 8 weeks, while the FTA-ABS test is positive as early as the second week.

　　(2) Secondary syphilis: The positivity rate reaches 95% to 100% for any test, and the positivity rate or titer is higher for untreated patients, reaching 100% with a high probability of positivity. If negative results appear, it indicates that the patient's resistance is low, without the ability to react, and the prognosis is poor. The positivity rate for recurrent secondary syphilis is 60% to 100%, and the titer is high (at least 1:60). The earlier the recurrence, the higher the positivity rate.

　　(3) Late syphilis: The positivity rate decreases, for untreated patients, the serum reagin test is 70% to 80%, and the specific antibody test is 93% to 100%. The positivity rate for cardiovascular syphilis is 80% to 96%, and the positivity rate for paresis can reach 100%. Generally speaking, the longer the infection time, the lower the positivity rate.

　　3. Cerebrospinal fluid examination:After苍白螺旋体invades the central nervous system, it can be detected through cerebrospinal fluid (CSF) cell count, protein determination, spirochete examination, spirochete DNA, reagin test, and specific antibody test. If conditions permit, the CSF-VDRL (CSF-VDRL) test, CSF-FTA-ABS test, or CSF-TPHA test can be performed. It is also possible to check for苍白螺旋体 DNA, apply immunoblotting tests, 19s-IgM-FTA-ABS tests, IgM-SPHA tests, IgM-Captia tests, and CSF monoclonal IgM antibody tests, all of which have very high specificity. The indications for examination include early syphilis after 1 year of treatment for syphilis; syphilis with unknown course or late syphilis; recurrent syphilis (whether clinical recurrence or serological recurrence); syphilis with a course lasting over 2 years and untreated; all latent syphilis patients.

　　2. Laboratory examination for kidney disease related to syphilis

　　Hematuria, severe proteinuria, and mild renal insufficiency can be observed.

　　In addition to the typical pathological changes of syphilis, the degree of glomerular lesions varies from mild to severe proliferative lesions. The main pathological changes are diffuse mesangial proliferation and subepithelial deposition of immune complexes. Some patients have interstitial mononuclear cell infiltration found in renal biopsy. Under immunofluorescence microscopy, IgG and C3 granular deposition can be seen under the glomerular epithelium. In addition to IgG and C3 granular deposition, there is also IgM deposition in the mesangial area.

　　Dietary therapy for syphilis kidney disease: eat more fruits, vegetables, red beans, and jujube. Avoid spicy and刺激性 food, soy products, and allergens. In addition, it is also necessary to avoid eating spicy and irritating foods.

　　1. Treatment

　　This disease mainly treats syphilis, and corresponding symptomatic treatment for kidney disease is carried out at the same time as the treatment of the primary disease.

　　1. Early syphilis includes:Primary, secondary syphilis, and latent syphilis with a disease duration of 2 years or less. Effective antispirillum drugs should be chosen to eliminate the living spirochetes in the body, so that the lesions lose their infectivity in the shortest time possible, to prevent transmission to others; and to promote the early repair of tissue damage, and accelerate the healing of the lesions. Early syphilis can be completely cured if treated in time, and can prevent the further development and deterioration of lesions and clinical symptoms, protecting important organs from damage.

　　(1) Penicillin class: benzathine penicillin is the first choice. If this drug is not available, aqueous penicillin G can be used as an alternative. The common dose is 2.4 million units of benzathine penicillin, injected intramuscularly in both gluteal muscles, once a week, for 2 to 3 times; APPG 800,000 units per day, injected intramuscularly, for 10 to 15 consecutive days, with a total dose of 8 million to 12 million units; aqueous penicillin G 1.2 million units per time, injected intramuscularly, 3 times a day, for 20 consecutive days, with a total dose of 36 million to 72 million units.

　　(2) For those allergic to penicillin, the following drugs can be used: 0.5g of tetracycline hydrochloride, taken orally, 4 times a day, for 15 consecutive days (not suitable for those with impaired liver or kidney function); erythromycin, the method of use is the same as tetracycline; doxycycline (doxycycline) 0.1g, taken orally, 2 times a day, for 15 consecutive days.

　　2. Late syphilis includes:Late stage skin, mucosal, and bone joint syphilis, or latent syphilis with a disease duration of over 2 years or an undetermined disease duration. Late syphilis has a significant destructive effect on various tissues and organs of the body. It is necessary to cure the lesions, promote tissue repair, prevent the progression and loss of function of important organs, and restore health.

　　Late syphilis can cause some injuries that cannot be completely repaired, such as defects in the throat and nose, skeletal deformities, etc. Orthopedic surgery can correct some deformities and disabilities, restoring partial or all functions.

　　(1) Penicillin class: benzathine penicillin is the first choice, or Penicillin G suspension for injection can be used as an alternative. Benzathine penicillin 2.4 million units, intramuscular injection, once a week, for a total of 3 times. APPG 800,000 units per day, intramuscular injection, for a course of 20 days, with a total dose of 16 million units. The second course can also be considered, with a total dose of 32 million units. Drug-free period of 2 weeks between courses. Penicillin G suspension for injection 1.2 million units, intramuscular injection, 3 times a day, for a course of 20 days, with a total dose of 72 million units. The second course can also be considered, with a total dose of 144 million units. Drug-free period of 2 weeks between courses.

　　(2) For those allergic to penicillin, the following drugs can be chosen: 0.5g of doxycycline hydrochloride taken orally, 4 times a day, for a course of 30 days, with a total dose of 60.0g. Erythromycin, the usage is the same as doxycycline. Doxycycline (Doryx) 0.1g taken orally, 2 times a day, for a course of 30 days.

　　3. Benzathine penicillin is contraindicated in the treatment of cardiovascular syphilis:If there is heart failure or arrhythmia, drugs should be used for correction, and desensitization treatment should be performed after the heart function can compensate and the rhythm returns to normal. It should start with a low dose and gradually increase the dose to avoid J-H reaction, causing the condition to worsen or the patient to die.

　　Commonly used Penicillin G suspension for injection, 100,000 units on the first day, once intramuscular injection; 100,000 units on the second day, intramuscular injection, 2 times a day; 200,000 units on the third day, intramuscular injection, 2 times a day; from the fourth day on, the following treatment plan is applied: APPG 800,000 units per day, intramuscular injection, for a course of 15 days, with a total dose of 12 million units, for a total of 2 or more courses. Drug-free period of 2 weeks between courses.

　　For those allergic to penicillin, the following drugs can be chosen: 0.5g of doxycycline hydrochloride taken orally, 4 times a day, for a course of 30 days, with a total dose of 60g; erythromycin, the usage is the same as doxycycline. Doxycycline (Doryx) 0.1g taken orally, 2 times a day, for a course of 30 days.

　　4. Treatment of Neurosyphilis:

　　(1) 2 to 4 million units of Penicillin G suspension for injection, intravenous infusion, once every 4 hours, for a course of 10 days. Then, benzathine penicillin 2.4 million units per week, intramuscular injection, for a total of 3 weeks.

　　(2) 2.4 million units of APPG per day, intramuscular injection, simultaneously taking 0.5g of probenecid orally, 4 times a day, for a course of 10 to 14 days. Then, benzathine penicillin 2.4 million units per week, intramuscular injection, for a total of 3 weeks.

　　(3) For those allergic to penicillin, 0.5g of doxycycline hydrochloride can be taken orally, 4 times a day, for a course of 30 days, with a total dose of 60g.

　　5. Treatment of Syphilis during Pregnancy:In addition to treating syphilis in pregnant women at an early or late stage, it is also necessary to prevent congenital syphilis; once congenital syphilis occurs, the fetus should be cured before birth.

　　(1) 800,000 units of APPG per day, intramuscular injection, for a course of 10 days, with a total dose of 8 million units. A course of treatment is administered within the first 3 months of pregnancy and another within the last 3 months of pregnancy.

　　(2) 1.2 million units of Penicillin G suspension for injection, intramuscular injection, 3 times a day, for a course of 20 days, with a total dose of 72 million units. A course of treatment is administered within the first 3 months of pregnancy and another within the last 3 months of pregnancy.

　　(3) For those allergic to penicillin, erythromycin can be used for treatment, and tetracycline is contraindicated. The dosage and method of use are the same as for non-pregnant patients, but the infants born to them should be treated with penicillin.

　　(4) For those with a clear record of having received sufficient treatment in the past, without recurrence or reinfection, treatment may not be necessary.

　　6. Treatment of Congenital Syphilis

　　(1) Early congenital syphilis:

　　①For those with abnormal cerebrospinal fluid: APPG 50,000U/(kg·d), given by intramuscular injection for 10-14 days; or aqueous penicillin G 50,000U/(kg·d), given intravenously in two divided doses for 10-14 days.

　　②For those with normal cerebrospinal fluid: benzathine penicillin 50,000U/kg, given as a single intramuscular injection. It is not used for those with neurosyphilis damage.

　　③For those without the condition to examine cerebrospinal fluid: treatment can be given as for those with abnormal cerebrospinal fluid.

　　④For those allergic to penicillin: erythromycin can be used for treatment, with a dose of 7.5-12.5mg/(kg·d), taken orally in four divided doses, for a total of 15 days. Tetracycline is contraindicated.

　　(2) Late congenital syphilis:

　　①APPG 50,000U/(kg·d), intramuscular injection, for a course of 10 days. The dose of penicillin for older children should not exceed the treatment dose for adult patients at the same time.

　　②For those allergic to penicillin, erythromycin or tetracycline can be used for treatment, with a dose of 7.5-12.5mg/(kg·d), taken orally in four divided doses, for a total of 30 days. Tetracycline is contraindicated in children under 8 years old.

　　7. Treatment of Syphilitic Nephritis:Refer to the treatment of glomerulonephritis in other nephrotic syndromes.

　　II. Prognosis

　　In the early stage of syphilis, active, standardized, and reasonable treatment can completely block the progression of the disease, cure the patient, and prevent further development and deterioration of lesions and clinical symptoms, protecting important organs from damage. If delayed to the advanced stage, syphilis damage has deeply penetrated into internal organs and the nervous system, some injuries that cannot be completely repaired by medication may occur, and even regular treatment cannot cure the disease, leaving disabilities or scars, causing organ dysfunction. Therefore, early syphilis can be cured, but late syphilis cannot be cured. The prognosis of syphilitic nephritis is consistent with the outcome of the primary disease.