Article 154: Jarisch-Herxheimer Reaction and Precautions in Syphilis Treatment and Traditional Chinese Medicine Differentiation

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Treatment and recuperation of common diseases

How to avoid the Jahlil-Hydrösn reaction

This reaction occurs within hours to 24 hours (usually 3-12 hours) after the first dose. Flu-like symptoms appear, such as fever and malaise. Syphilitic lesions may temporarily worsen, and those with visceral and neurosyphilis may experience significant deterioration; for example, meningovascular syphilis can lead to cerebral thrombosis, cranial nerve palsy, and deafness. Cardiovascular syphilis can cause heart failure and aortic aneurysm rupture. Early congenital syphilis can cause high fever, difficulty breathing, cyanosis, seizures, and even death. Those with optic neuritis experience further vision loss. It is generally believed that this is due to the "toxins" produced when the initial large dose of the drug kills a large number of spirochetes. Therefore, prevention involves starting treatment with a small dose and gradually increasing to the normal dose.

Precautions for Western medicine treatment

1. Penicillin dosage should not be increased arbitrarily: High doses of penicillin will kill a large number of Treponema pallidum bacteria in a short period of time, releasing a large amount of foreign proteins, causing a Hessheimer's reaction, manifested as fever, general malaise, temporary aggravation of syphilis damage, worsening of visceral and nervous system syphilis symptoms, and even endangering life. To prevent this reaction, prednisone can be taken orally before treatment, 5 mg each time, 3 times a day for 3 consecutive days.

2. Precautions for the treatment of cardiovascular syphilis: Benzathine penicillin should not be used for cardiovascular syphilis. If heart failure is present, it should be treated first. Once cardiac function can be compensated, penicillin can be administered via intramuscular injection. However, care should be taken to start with a small dose to avoid Hesheimer's reaction.

Aqueous procaine penicillin G, 800,000 units daily, intramuscular injection, once daily for 15 consecutive days as one course of treatment, for a total of 2 courses (or more), with a 2-week break between courses.

Tetracycline or erythromycin, 2 grams daily, divided into 4 oral doses, for 30 consecutive days as one course of treatment.

3. Precautions for the treatment of syphilis in the central nervous system: Penicillin should be started at a low dose, as high doses may cause Hessheimer's reaction and worsen the condition.

800,000 units of aqueous procaine penicillin G, administered intramuscularly once daily for 14 days.

Tetracycline or erythromycin, 0.5g orally each time, 4 times a day, for a total of 30 days.

4. Use of other antibiotics: Chloramphenicol, cephalosporin V, cephalosporin II and doxycycline can all treat early syphilis, but only in special cases and cannot be used as routine treatment.

5. Strict adherence to cure criteria is essential: When determining the treatment criteria for a patient, the disappearance of skin and mucous membrane lesions should not be the sole basis. Monthly blood tests for reagin (anti-reagin test) should be conducted, and only after the reagin test becomes negative should changes in other symptoms be considered to determine whether a cure has been achieved. Furthermore, regular follow-up examinations are crucial. Generally, regular check-ups are recommended for three years after a cure. If a relapse occurs, anti-syphilis treatment should be initiated promptly.

What issues should be considered during syphilis treatment?

First, regardless of the type of syphilis, an early diagnosis and treatment are essential to achieve a complete cure.

When treating early syphilis, the dosage should be started with a small amount and gradually increased to avoid treatment shock.

When treating late-stage syphilis, a milder anti-syphilis medication should be used first as preparation to avoid causing complications in the treatment process.

Regardless of the stage of syphilis being treated, the medication dosage must be adequate. Before treatment, it is important to inquire about and observe the patient's history of drug allergies. After syphilis treatment is completed, patients must have regular follow-up examinations to monitor the treatment's effectiveness.

What is serum resistance?

If a syphilis patient's antigen serological test does not turn negative within a certain period after anti-syphilis treatment, this is called serological resistance. Serological resistance in early syphilis is often related to insufficient or irregular treatment dosage leading to relapse, and may also be related to reinfection or the presence of neurosyphilis. Therefore, if a patient with early syphilis does not develop a negative serological reaction after 6 months of regular and adequate antibiotic treatment, a thorough examination should be conducted to check for reinfection or the presence of secondary neurosyphilis.

Doubling the treatment dose (double the total dose) often results in a negative serological test. Serological resistance in late-stage syphilis is generally seen in central nervous system syphilis or when treatment for other types of syphilis begins too late, such as when paralytic dementia has developed. In such cases, anti-syphilis treatment will not lower the serological titer. There is no significant difference in prognosis or infectivity between serologically resistant and non-resistant late-stage syphilis treated with adequate doses. Further or unlimited treatment will not lower the serological titer, and the level of the serological titer does not parallel clinical progression. Therefore, there is no need to be overly concerned about serological resistance in late-stage syphilis. After ruling out neurological, cardiovascular, and other visceral syphilis, treatment should be discontinued, and regular follow-up is necessary.

What is serum relapse?

In patients with positive serological reactions, the serological reaction may temporarily become negative after receiving anti-syphilis treatment, only to become positive again after a certain period of time; or the serological reaction may be negative before treatment but become positive after treatment. This phenomenon is called "serological relapse." Serological relapse is generally believed to be related to the following factors:

1. Received insufficient anti-syphilis treatment.

2. When the body's immune function is severely impaired, even with adequate penicillin treatment, relapse is still possible.

3. Some scholars believe that serum relapses after penicillin treatment may be due to Treponema pallidum developing resistance to penicillin, but there is currently insufficient evidence to support this.

Serological relapse should be treated as active syphilis and anti-syphilis treatment should be initiated. If there is severe immune dysfunction, immune enhancers should be administered at the same time.

How does Traditional Chinese Medicine differentiate syndromes and treat diseases?

1. Liver meridian damp-heat type: Symptoms include hard chancre on the external genitalia or anus, swollen inguinal lymph nodes, irritability, bitter taste in the mouth, scanty dark urine, dry stool, red tongue with yellow and greasy coating, and wiry and rapid pulse.

Treatment principle: Clear heat and promote diuresis, detoxify and expel syphilis.

Prescription: Gentian root 10g, Gardenia fruit 10g, Scutellaria root 10g, Bupleurum root 10g, Rehmannia root 12g, Plantago seed (wrapped) 15g, Alisma rhizome 10g, Akebia stem 6g, Smilax rhizome 30g, Honeysuckle flower 15g, Licorice root 6g.

2. Blood-heat and toxin accumulation type: Symptoms include ulceration of hard chancre, red sore surface with serous discharge, hard surrounding area, or swollen inguinal lymph nodes, bitter taste in mouth, dry throat, yellow urine, red tongue with yellow coating, and wiry and rapid pulse.

Treatment principle: Cool the blood and detoxify, resolve blood stasis and dissipate nodules.

Prescription: 15g Rehmannia glutinosa, 10g Paeonia suffruticosa, 10g Paeonia lactiflora, 15g Lithospermum erythrorhizon, 30g Smilax glabra, 15g Lonicera japonica, 10g Forsythia suspensa, 15g Isatis indigotica, 30g Taraxacum mongolicum, 6g Glycyrrhiza uralensis.

3. Toxic-blood stasis type: Symptoms include persistent hard chancre, dark red secondary syphilis rash, or swollen and hard inguinal lymph nodes, dark red tongue or ecchymosis, and choppy pulse.

Treatment principle: Detoxify, remove blood stasis, soften and dissipate nodules.

Prescription: Smilax glabra 30g, Lonicera japonica 15g, Scrophularia ningpoensis 15g, Angelica sinensis 10g, Ligusticum chuanxiong 10g, Paeonia lactiflora 10g, Angelica dahurica 10g, Atractylodes macrocephala 10g, Platycodon grandiflorus 10g, Gleditsia sinensis 10g, Glycyrrhiza uralensis 5g.