Congenital syphilis

Background

Epidemiology

• Rare, with about 20 per 100,000 live births in the US
• Greatest risk to child is with untreated primary maternal syphilis

Pathophysiology

• Transplacental transmission while bacteremic
• Can be transmitted during delivery, as well

Clinical Presentation

• Mothers typically have had no prenatal care
• To the fetus, can cause spontaneous abortion (40% in untreated primary syphilis), preterm delivery, polyhydramnios, intra-uterine growth restriction, hydrops fetalis, or intra-uterine fetal demise
• At birth, two thirds of affected neonates are asymptomatic, with disease developing over the following 6 weeks
• Early disease, within the first two years, includes:
  • Rhinitis (called snuffles, often bloody and copious), desquamating rash, hepatosplenomegaly, lymphadenopathy, and skeletal abnormalities
  • Also: condyloma lata, vesicular rash or bullous rash, periostitis, hydrops, thrombocytopenia, hepatitis, jaundice, or glomerulonephritis
  • About 20% involve the CNS
• Late disease, after the first two years, includes:
  • Sensorineural hearing loss, intellectual impairment, saddle nose deformity, frontal bossing, jaw, dental, and palatal abnormalities including Hutchison teeth, saber tibia, short stature, and keratitis

Diagnosis

• Darkfield microscopy and/or PCR on body fluids, including nasal discharge or CSF
• Serology
  • RPR on infant blood (not cord blood), paired with maternal RPR
  • May need CSF analysis
• Also check HIV serology, skeletal survey, chest x-ray, ophthalmology, audiology, and cranial ultrasound

Management

• Treat syphilis in pregnancy with high-dose penicillin to prevent congenital syphilis
• Treat affected infant with penicillin G 50,000 U/kg/day IV q12h for the first 7 days of life, followed by q8h to complete a total of 10 days
• Can treat lower-risk infants with benzathine penicillin G 50,000 U/kg IM once

Canadian guidelines

• Treat infants at birth if:
  • Symptomatic
  • Infant's RPR at least four-fold higher than mother's
  • Maternal treatment inadequate, did not contain penicillin, is unknown or occurred in the last month of pregnancy, or if the maternal serologic response is inadequate
  • Adequate follow-up cannt be ensured

Maternal treatment			Neonatal assessment	Recommendations
Type	Timing	Outcome		Monthly exam for 3 months	Serology	CBC/CSF/x-rays	Treatment
any	before pregnancy	adequate, with no RPR rise and no risk factors for reinfection	normal exam	no	no	no	none
primary, secondary, or early latent	>4 weeks before delivery	adequate	normal exam, RPR < 4-fold maternal	yes	0, 3, 6, and 18 months	no	none
primary, secondary, or early latent	≤4 weeks before delivery		normal exam, RPR < 4-fold maternal	yes	0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months	yes	usually
primary, secondary, or early latent		not penicillin	normal exam, RPR < 4-fold maternal	yes	0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months	yes	usually
primary, secondary, or early latent	before or during pregnancy	RPR not decline as expected	normal exam, RPR < 4-fold maternal	yes	0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months	yes	usually
primary, secondary, or early latent	before pregnancy	inadequate, or reinfection	normal exam, RPR < 4-fold maternal	yes	0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months	consider	depends on risk and results of assessments
primary, secondary, or early latent	during pregnancy	unknown	normal exam, RPR < 4-fold maternal	yes	0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months	consider	depends on risk and results of assessments
primary or secondary syphilis	during pregnancy	inadequate	normal exam, RPR < 4-fold maternal	yes	0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months	yes	10 days
late latent	during or after pregnancy	adequate	normal exam, RPR < 4-fold maternal	no	0, 6, and 18 months	no	none
any	during pregnancy	normal exam, RPR < 4-fold maternal	follow-up unlikely	yes	0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months	consider	depends on risk and results of assessments
any	any	any	treponemes on tissue examination	yes	0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months	yes	10 days
any	any	any	infant's RPR four-fold or greater than the mother's at birth	yes	0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months	yes	10 days
any	any	any	four-fold rise in infant's titre	yes	0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months	yes	10 days
any	any	any	signs of congenital syphilis at any age	yes	0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months	yes	10 days
any	any	any	RPR & TT reactive at 6 months	—	—	yes	usually
any	any	any	reactive RPR & TT at 12 months	yes	0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months	yes	10 days
any	any	any	reactive TT at 18 months	yes	0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months	yes	10 days

US guidelines

Initial neonatal assessment		Maternal treatment		Recommendations
RPR/VDRL	Evaluation	Timing	Type	Evaluation	Treatment
any	physical exam suggests congenital syphilis	any	any	LP and CBC	10 days
	spirochete in a clinical specimen
≥ fourfold maternal titre	any	any	any	LP and CBC	10 days
less than fourfold maternal titre	normal	before pregnancy	adequate	none	none (or one dose)
			reinfection or relapse (≥4-fold increase in titre)	LP and CBC	one dose (unless exam at all abnormal)
		during pregnancy	adequate	none	one dose (or none)
			inadequate or suboptimal	LP and CBC	one dose (unless exam at all abnormal)
nonreactive	normal	during pregnancy	adequate	none	none (or one dose)
			inadequate or suboptimal	none	one dose

• LP should be sent for VDRL, cell count, protein
• CBC with differential for platelet count