រោគស្វាយ ឬ ជំងឺស្វាយ (Syphilis) គឺជាជំងឺឆ្លងតាមការរួមភេទ (ឆ្លងតាមផ្លូវភេទ) ឬជំងឺកាមរោគ ឬរោគសង្គម (sexually transmitted infection) អាចហៅកាត់ថា STI ឬ STD ប៉ុន្តែពាក្យកាត់ STD លែងមានការពេញនិយមហើយព្រោះពាក្យ STI មានន័យទូលំទូលាយជាងពាក្យ STD ដែលបង្កប់អត្ថន័យថា ជំងឺ ។ រោគស្វាយឆ្លងដោយបាក់តេរីដែលមានសណ្ឋានដូចរឺស័រ (spirochete bacterium) ម្យ៉ាងឈ្មោះថា ត្រេផឺនីម៉ា ផាល់លីដឹម (Treponema pallidum) ប្រភេទ palludum ។ ផ្លូវចម្លងសំខាន់ជាងគេគឺការប៉ះពាល់ខាងផ្លូវភេទ (sexual contact) ។ ប៉ុន្តែរោគស្វាយក៏អាចឆ្លងពីម្តាយទៅទារកក្នុងពេលមានគភ៌ ឬ នៅពេលឆ្លងទន្លេ បង្កទៅជារោគស្វាយពីកំណើត (congenital syphilis) ។ ជំងឺផ្សេងទៀតរបស់មនុស្ស ដែលបង្កឡើងដោយប្រភេទផ្សេងទៀតនៃពួកបាក់តេរី Treponema pallidum ដូចជាជំងឺ yaws ដែលបង្កឡើងដោយបាក់តេរីប្រភេទ pertenue, ជំងឺ pinta ដែលបង្កឡើងដោយបាក់តេរីប្រភេទ carateum និង ជំងឺ bejel ដែលបង្កឡើងដោយបាក់តេរីប្រភេទ endemicum ។
រោគសញ្ញា (signs) និង សញ្ញាតំអូញ (symptoms) នៃរោគស្វាយប្រែប្រួលទៅតាមដំណាក់កាលនីមួយៗនៃដំណាក់កាលទាំង ៤ ដែលរោគស្វាយ (ពោលគឺតំណាក់កាលទី ១, ទី ២, ពួនសង្ងំ និង តំណាក់កាលទី ៣) ។ ដំណាក់កាលទី ១ រោគសញ្ញាកើតមានជាទូទៅគឺដំបៅរលួយតែមួយកន្លែង (chancre) ដែលជាដំបៅស្បែករលួយ (ulceration) មានលក្ខណៈហាប់ មិនឈឺ មិនរមាស់ ។ តំណាក់កាលទី ២ នៃរោគស្វាយឃើញមានចេញរោគសញ្ញានៃការកើតកន្ទួលរមាស់ (diffuse rash) សព្វបាទដៃ (palm) និង បាតជើង (sole of the feet) ។ ដំណាក់កាលពួនសម្ងំនៃរោគស្វាយមានបង្ហាញរោគសញ្ញាបន្តិចបន្តួចឬគ្មានរោគសញ្ញាសោះក៏មាន ។ ដំណាក់កាលទី ៣ នៃរោគស្វាយឃើញមានចេញដុំពកទន់ៗ (gumma) លេចឡើងនៅតាមទីតាំងផ្សេងៗដូចជានៅក្នុងថ្លើម (liver) (gumma hepatis), នៅក្នុងខួក្បាល (brain), នៅក្នុងបេះដូង (heart), នៅលើស្បែក (skin) ឧទាហរណ៍ស្បែកមុខ ស្បែកកន្សោមពងស្វាស, នៅក្នុងឆ្អឹង (bone), នៅក្នុងពងស្វាស (testis), និងនៅក្នុងជាលិកាដទៃទៀត (other tissues), ដែលបង្កឲ្យកើតជាបញ្ហាច្រើនយ៉ាងទៀតរួមទាំងបញ្ហាសរសៃប្រសាទ (neurological disorders) ឬបញ្ហាសន្ទះបេះដូង (heart valve disease) ។ រោគស្វាយនៅដំណាក់កាលទី ៣ នេះត្រូវបានគេហៅថាជារោគពូកែត្រាប់ជំងឺផ្សេងៗ (the great imitator) ព្រោះវាបង្ហាញរោគសញ្ញាច្រើនយ៉ាងដែលមិនមែនជារោគសញ្ញានៃរោគស្វាយ ។ ដើម្បីវិនិច្ឆ័យថាអ្នកជំងឺម្នាក់កើតរោគស្វាយ វេជ្ជបណ្ឌិតនឹងបូមឈាមយកទៅធ្វើតេស្តដើម្បីរកមើលវត្តមានបាក់តេរី (blood tests) ទោះជាយ៉ាងណាក៏ដោយ វេជ្ជបណ្ឌិតក៏អាចប្រើវិធីផ្សេងទៀតដើម្បីរកមើលវត្តមានបាក់តេរី ពោលគឺការប្រើ dark field microscopy ។ វេជ្ជបណ្ឌិតអាចព្យាបាលរោគស្វាយឲ្យជាស្រឡះដោយការប្រើថ្នាំពេទ្យប្រភេទអង់ទីប៊ីយ៉ូទិច (antibiotics) ជាពិសេសវេជ្ជបណ្ឌិតចូលចិត្តប្រើថ្នាំនៅក្នុងក្រុម penicillin G សម្រាប់ចាក់ក្នុងសាច់ដុំ (intramuscular) ប៉ុន្តែសម្រាប់ការព្យាបាលរោគស្វាយដែលចេញសញ្ញានៅក្នុងប្រព័ន្ធសរសៃប្រសាទ (neurosyphilis) វេជ្ជបណ្ឌិតនឹងប្រើ penicillin G ដើម្បីចាក់បញ្ចូលតាមសរសៃឈាមខ្មៅ (intravenously) ហើយសម្រាប់ក្រុមអ្នកជំងឺដែលមានប្រតិកម្មទាស់ជាមួយនឹង penicillin វេជ្ជបណ្ឌិតនឹងឲ្យអ្នកជំងឺលេបថ្នាំ ceftriaxone ឬ doxycycline ឬ azithromycin ។
កាលពីឆ្នាំ ១៩៩៩ មានរបាយការណ៍បញ្ជាក់ថា មនុស្សចំនួន ១២ លាននាក់បន្ថែមទៀតនៅលើពិភពលោក បានកើតរោគស្វាយ ដែលក្នុងនោះលើសពី ៩០% នៃអ្នកជំងឺដែលកើតរោគស្វាយ រស់នៅក្នុងប្រទេសកំពុងអភិវឌ្ឍន៍ (developing world) ។ ដោយសារការប្រើថ្នាំ penicillin ជាទូទៅសម្រាប់ព្យាបាលអ្នកជំងឺស្វាយនៅទសវត្សរ៍ឆ្នាំ ១៩៤០ ចំនួនអ្នកកើតរោគស្វាយបានថយចុះគួរឲ្យកត់សម្គាល់ ក៏ប៉ុន្តែចំនួនអ្នកកើតរោគស្វាយនៅក្នុងប្រទេសជាច្រើនចាប់ផ្តើមកើនឡើងយ៉ាងរហ័សនៅក្នុងសហវត្សថ្មី ជាពិសេសដោយសារអ្នកកើតរោគស្វាយក៏មានប្រព័ន្ធភាពស៊ាំថយចុះដោយសារពួកគេមានមេរោគអេដស៍ (human immunodeficiency virus) ឬ HIV នៅក្នុងចរន្តឈាមផងដែរ ។ បញ្ហានេះត្រូវបានរកឃើញថា កត្តាចូលរួមមួយក្នុងចំណោមកត្តាចូលរួមជាច្រើន គឺ ការរួមភេទគ្មានសុវត្ថភាព ដូចជាមនុស្សប្រុសរួមភេទជាមួយមនុស្សប្រុស, ការរួមភេទជាមួយដៃគូច្រើន, ពេស្យាចារ និង ការថយចុះនៃចំនួនអ្នកប្រើស្រោមអនាម័យ (condoms) ។ 
រោគសញ្ញា និង សញ្ញាតំអូញ[កែប្រែ]
Syphilis can present in one of four different stages: primary, secondary, latent, and tertiary, and may also occur congenitally. It was referred to as "the great imitator" by Sir William Osler due to its varied presentations.
Primary chancre of syphilis at the site of infection on the penis
Primary syphilis is typically acquired by direct sexual contact with the infectious lesions of another person. Approximately 3 to 90 days after the initial exposure (average 21 days) a skin lesion, called a chancre, appears at the point of contact. This is classically (40% of the time) a single, firm, painless, non-itchy skin ulceration with a clean base and sharp borders between 0.3 and 3.0 cm in size. The lesion, however, may take on almost any form. In the classic form, it evolves from a macule to a papule and finally to an erosion or ulcer. Occasionally, multiple lesions may be present (~40%), with multiple lesions more common when coinfected with HIV. Lesions may be painful or tender (30%), and they may occur outside of the genitals (2–7%). The most common location in women is the cervix (44%), the penis in heterosexual men (99%), and anally and rectally relatively commonly in men who have sex with men (34%). Lymph node enlargement frequently (80%) occurs around the area of infection, occurring seven to 10 days after chancre formation. The lesion may persist for three to six weeks without treatment.
Typical presentation of secondary syphilis with a rash on the palms of the hands
Reddish papules and nodules over much of the body due to secondary syphilis Secondary syphilis occurs approximately four to ten weeks after the primary infection. While secondary disease is known for the many different ways it can manifest, symptoms most commonly involve the skin, mucous membranes, and lymph nodes. There may be a symmetrical, reddish-pink, non-itchy rash on the trunk and extremities, including the palms and soles. The rash may become maculopapular or pustular. It may form flat, broad, whitish, wart-like lesions known as condyloma latum on mucous membranes. All of these lesions harbor bacteria and are infectious. Other symptoms may include fever, sore throat, malaise, weight loss, hair loss, and headache. Rare manifestations include hepatitis, kidney disease, arthritis, periostitis, optic neuritis, uveitis, and interstitial keratitis. The acute symptoms usually resolve after three to six weeks; however, about 25% of people may present with a recurrence of secondary symptoms. Many people who present with secondary syphilis (40–85% of women, 20–65% of men) do not report previously having had the classic chancre of primary syphilis.
Latent syphilis is defined as having serologic proof of infection without symptoms of disease. It is further described as either early (less than 1 year after secondary syphilis) or late (more than 1 year after secondary syphilis) in the United States. The United Kingdom uses a cut-off of two years for early and late latent syphilis. Early latent syphilis may have a relapse of symptoms. Late latent syphilis is asymptomatic, and not as contagious as early latent syphilis.
Tertiary syphilis may occur approximately 3 to 15 years after the initial infection, and may be divided into three different forms: gummatous syphilis (15%), late neurosyphilis (6.5%), and cardiovascular syphilis (10%). Without treatment, a third of infected people develop tertiary disease. People with tertiary syphilis are not infectious.
Patient with tertiary (gummatous) syphilis. Bust in Musée de l'Homme, Paris. Gummatous syphilis or late benign syphilis usually occurs 1 to 46 years after the initial infection, with an average of 15 years. This stage is characterized by the formation of chronic gummas, which are soft, tumor-like balls of inflammation which may vary considerably in size. They typically affect the skin, bone, and liver, but can occur anywhere. Neurosyphilis refers to an infection involving the central nervous system. It may occur early, being either asymptomatic or in the form of syphilitic meningitis, or late as meningovascular syphilis, general paresis, or tabes dorsalis, which is associated with poor balance and lightning pains in the lower extremities. Late neurosyphilis typically occurs 4 to 25 years after the initial infection. Meningovascular syphilis typically presents with apathy and seizure, and general paresis with dementia and tabes dorsalis. Also, there may be Argyll Robertson pupils, which are bilateral small pupils that constrict when the person focuses on near objects, but do not constrict when exposed to bright light. Cardiovascular syphilis usually occurs 10–30 years after the initial infection. The most common complication is syphilitic aortitis, which may result in aneurysm formation.
Congenital syphilis is that which is transmitted during pregnancy or during birth. Two-thirds of syphilitic infants are born without symptoms. Common symptoms that develop over the first couple years of life include: hepatosplenomegaly (70%), rash (70%), fever (40%), neurosyphilis (20%), and pneumonitis (20%). If untreated, late congenital syphilis may occur in 40%, including: saddle nose deformation, Higoumenakis sign, saber shin, or Clutton's joints among others.
Histopathology of Treponema pallidum spirochetes using a modified Steiner silver stain Main article: Treponema pallidum Treponema pallidum subspecies pallidum is a spiral-shaped, Gram-negative, highly mobile bacterium. Three other human diseases are caused by related Treponema pallidum, including yaws (subspecies pertenue), pinta (subspecies carateum) and bejel (subspecies endemicum). Unlike subtype pallidum, they do not cause neurological disease. Humans are the only known natural reservoir for subspecies pallidum. It is unable to survive without a host for more than a few days. This is due to its small genome (1.14 MDa) failing to encode the metabolic pathways necessary to make most of its macronutrients. It has a slow doubling time of greater than 30 hours.
Syphilis is transmitted primarily by sexual contact or during pregnancy from a mother to her fetus; the spirochaete is able to pass through intact mucous membranes or compromised skin. It is thus transmissible by kissing near a lesion, as well as oral, vaginal, and anal sex. Approximately 30 to 60% of those exposed to primary or secondary syphilis will get the disease. Its infectivity is exemplified by the fact that an individual inoculated with only 57 organisms has a 50% chance of being infected. Most (60%) of new cases in the United States occur in men who have sex with men. It can be transmitted via blood products. However, it is tested for in many countries and thus the risk is low. The risk of transmission from sharing needles appears limited. Syphilis cannot be contracted through toilet seats, daily activities, hot tubs, or sharing eating utensils or clothing.
Poster for testing of syphilis, showing a man and a woman bowing their heads in shame
This posters acknowledges the social stigma of syphilis, while urging those who possibly have the disease to be tested. (circa 1936)
Syphilis is difficult to diagnose clinically early in its presentation. Confirmation is either via blood tests or direct visual inspection using microscopy. Blood tests are more commonly used, as they are easier to perform. Diagnostic tests are, however, unable to distinguish between the stages of the disease.
Blood tests are divided into nontreponemal and treponemal tests. Nontreponemal tests are used initially, and include venereal disease research laboratory (VDRL) and rapid plasma reagin tests. However, as these tests are occasionally false positives, confirmation is required with a treponemal test, such as treponemal pallidum particle agglutination (TPHA) or fluorescent treponemal antibody absorption test (FTA-Abs). False positives on the nontreponemal tests can occur with some viral infections such as varicella and measles, as well as with lymphoma, tuberculosis, malaria, endocarditis, connective tissue disease, and pregnancy. Treponemal antibody tests usually become positive two to five weeks after the initial infection. Neurosyphilis is diagnosed by finding high numbers of leukocytes (predominately lymphocytes) and high protein levels in the cerebrospinal fluid in the setting of a known syphilis infection.
Dark ground microscopy of serous fluid from a chancre may be used to make an immediate diagnosis. However, hospitals do not always have equipment or experienced staff members, whereas testing must be done within 10 minutes of acquiring the sample. Sensitivity has been reported to be nearly 80%, thus can only be used to confirm a diagnosis but not rule one out. Two other tests can be carried out on a sample from the chancre: direct fluorescent antibody testing and nucleic acid amplification tests. Direct fluorescent testing uses antibodies tagged with fluorescein, which attach to specific syphilis proteins, while nucleic acid amplification uses techniques, such as the polymerase chain reaction, to detect the presence of specific syphilis genes. These tests are not as time-sensitive, as they do not require living bacteria to make the diagnosis.
As of 2010, there is no vaccine effective for prevention. Abstinence from intimate physical contact with an infected person is effective at reducing the transmission of syphilis, as is the proper use of a latex condom. Condom use, however, does not completely eliminate the risk. Thus, the Centers for Disease Control and Prevention recommends a long-term, mutually monogamous relationship with an uninfected partner and the avoidance of substances such as alcohol and other drugs that increase risky sexual behavior.
Congenital syphilis in the newborn can be prevented by screening mothers during early pregnancy and treating those who are infected. The United States Preventive Services Task Force (USPSTF) strongly recommends universal screening of all pregnant women, while the World Health Organization recommends all women be tested at their first antenatal visit and again in the third trimester. If they are positive, they recommend their partners also be treated. Congenital syphilis is, however, still common in the developing world, as many women do not receive antenatal care at all, and the antenatal care others do receive does not include screening, and it still occasionally occurs in the developed world, as those most likely to acquire syphilis (through drug use, etc.) are least likely to receive care during pregnancy. A number of measures to increase access to testing appear effective at reducing rates of congenital syphilis in low- to middle-income countries.
Syphilis is a notifiable disease in many countries, including Canada the European Union, and the United States. This means health care providers are required to notify public health authorities, which will then ideally provide partner notification to the person's partners. Physicians may also encourage patients to send their partners to seek care. The CDC recommends sexually active men who have sex with men are tested at least yearly.
The first-choice treatment for uncomplicated syphilis remains a single dose of intramuscular penicillin G or a single dose of oral azithromycin. Doxycycline and tetracycline are alternative choices; however, due to the risk of birth defects these are not recommended for pregnant women. Antibiotic resistance has developed to a number of agents, including macrolides, clindamycin, and rifampin. Ceftriaxone, a third-generation cephalosporin antibiotic, may be as effective as penicillin-based treatment.
For neurosyphilis, due to the poor penetration of penicillin G into the central nervous system, those affected are recommended to be given large doses of intravenous penicillin for a minimum of 10 days. If a person is allergic, ceftriaxone may be used or penicillin desensitization attempted. Other late presentations may be treated with once-weekly intramuscular penicillin G for three weeks. If allergic, as in the case of early disease, doxycycline or tetracycline may be used, albeit for a longer duration. Treatment at this stage limits further progression, but has only slight effect on damage which has already occurred.
One of the potential side effects of treatment is the Jarisch-Herxheimer reaction. It frequently starts within one hour and lasts for 24 hours, with symptoms of fever, muscles pains, headache, and tachycardia. It is caused by cytokines released by the immune system in response to lipoproteins released from rupturing syphilis bacteria.
Main article: Epidemiology of syphilis
Age-standardized death from syphilis per 100,000 inhabitants in 2004
<35 35-70 70-105 105-140 140-175 175-210 210-245 245-280 280-315 315-350 350-500 >500
Syphilis is believed to have infected 12 million additional people in 1999, with greater than 90% of cases in the developing world. It affects between 700,000 and 1.6 million pregnancies a year, resulting in spontaneous abortions, stillbirths, and congenital syphilis. During 2010 it caused about 113,000 deaths down from 202,000 in 1990. In sub-Saharan Africa, syphilis contributes to approximately 20% of perinatal deaths. Rates are proportionally higher among intravenous drug users, those who are infected with HIV, and men who have sex with men. In the United States, rates of syphilis as of 2007 were six times greater in men than women, while they were nearly equal in 1997. African Americans accounted for almost half of all cases in 2010. Syphilis was very common in Europe during the 18th and 19th centuries. In the developed world during the early 20th century, infections declined rapidly with the widespread use of antibiotics, until the 1980s and 1990s. Since the year 2000, rates of syphilis have been increasing in the USA, Canada, the UK, Australia and Europe, primarily among men who have sex with men. Rates of syphilis among American women have, however, remained stable during this time, and rates among UK women have increased, but at a rate less than that of men. Increased rates among heterosexuals have occurred in China and Russia since the 1990s. This has been attributed to unsafe sexual practices, such as sexual promiscuity, prostitution, and decreasing use of barrier protection.
Untreated, it has a mortality of 8% to 58%, with a greater death rate in males. The symptoms of syphilis have become less severe over the 19th and 20th centuries, in part due to widespread availability of effective treatment and partly due to decreasing virulence of the spirochaete. With early treatment, few complications result. Syphilis increases the risk of HIV transmission by two to five times, and coinfection is common (30–60% in a number of urban centers).
Main article: History of syphilis
Portrait of Gerard de Lairesse by Rembrandt van Rijn, circa 1665–67, oil on canvas - De Lairesse, himself a painter and art theorist, had congenital syphilis that deformed his face and eventually blinded him.
The exact origin of syphilis is disputed. Syphilis was indisputably present in the Americas before European contact. The dispute is over whether or not syphilis was also present elsewhere in the world at that time. One of the two primary hypotheses proposes that syphilis was carried from the Americas to Europe by the returning crewmen from Christopher Columbus's voyage to the Americas. The other hypothesis says that syphilis existed in Europe previously, but went unrecognized until shortly after Columbus' return. These are referred to as the Columbian and pre-Columbian hypotheses, respectively. The Columbian hypothesis is best supported by the available evidence. The first written records of an outbreak of syphilis in Europe occurred in 1494 or 1495 in Naples, Italy, during a French invasion (Italian War of 1494–98). Due to its being spread by returning French troops, it was initially known as the "French disease." In 1530, the name "syphilis" was first used by the Italian physician and poet Girolamo Fracastoro as the title of his Latin poem in dactylic hexameter describing the ravages of the disease in Italy. It was also known historically as the "Great Pox".
The causative organism, Treponema pallidum, was first identified by Fritz Schaudinn and Erich Hoffmann in 1905. The first effective treatment (Salvarsan) was developed in 1910 by Paul Ehrlich, which was followed by trials of penicillin and confirmation of its effectiveness in 1943. Before the advent of effective treatment, mercury and isolation were commonly used, with treatments often worse than the disease. Many famous historical figures, including Franz Schubert, Arthur Schopenhauer, and Édouard Manet, are believed to have had the disease.
Society and culture[កែប្រែ]
Arts and literature[កែប្រែ]
See also: Notable cases of syphilis
The earliest known medical illustration of people with syphilis, Vienna, 1498 The earliest known depiction of an individual with syphilis is Albrecht Dürer's Syphilitic Man, a woodcut believed to represent a Landsknecht, a Northern European mercenary. The myth of the femme fatale or "poison women" of the 19th century is believed to be partly derived from the devastation of syphilis, with classic examples in literature including John Keats' La Belle Dame sans Merci.
The artist Jan van der Straet painted a scene of a wealthy man receiving treatment for syphilis with the tropical wood guaiacum sometime around 1580. The title of the work is "Preparation and Use of Guayaco for Treating Syphilis". That the artist chose to include this image in a series of works celebrating the New World indicates how important a treatment, however ineffective, for syphilis was to the European elite at that time. The richly colored and detailed work depicts four servants preparing the concoction while a physician looks on, hiding something behind his back while the hapless patient drinks.
Tuskegee and Guatemala studies[កែប្រែ]
See also: Tuskegee syphilis experiment and Syphilis experiments in Guatemala One of the most infamous United States cases of questionable medical ethics in the 20th century was the Tuskegee syphilis study. The study took place in Tuskegee, Alabama, and was supported by the U.S. Public Health Service (PHS) in partnership with the Tuskegee Institute. The study began in 1932, when syphilis was a widespread problem and there was no safe and effective treatment. The study was designed to measure the progression of untreated syphilis. By 1947, penicillin had been validated as an effective cure for syphilis and was becoming widely used to treat the disease. Study directors, however, continued the study and did not offer the participants treatment with penicillin. This is debated, and some have found that penicillin was given to many of the subjects. The study did not end until 1972.
Syphilis experiments were also carried out in Guatemala from 1946 to 1948. They were United States-sponsored human experiments, conducted during the government of Juan José Arévalo with the cooperation of some Guatemalan health ministries and officials. Doctors infected soldiers, prisoners, and mental patients with syphilis and other sexually transmitted diseases, without the informed consent of the subjects, and then treated them with antibiotics. In October 2010, the U.S. formally apologized to Guatemala for conducting these experiments.
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UCSF HIV InSite Knowledge Base Chapter: Syphilis and HIV