Congenital syphilis: Difference between revisions

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=== Canadian guidelines ===
 
=== 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
  +
 
{| class="wikitable sortable"
 
{| class="wikitable sortable"
 
! colspan=3 | Maternal treatment
 
! colspan=3 | Maternal treatment
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| >4 weeks before delivery
 
| >4 weeks before delivery
 
| adequate
 
| adequate
  +
| normal exam, RPR < 4-fold maternal
|
 
 
| yes
 
| yes
 
| 0, 3, 6, and 18 months
 
| 0, 3, 6, and 18 months
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| ≤4 weeks before delivery
 
| ≤4 weeks before delivery
 
|
 
|
  +
| normal exam, RPR < 4-fold maternal
|
 
 
| yes
 
| yes
 
| 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months
 
| 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months
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|
 
|
 
| not penicillin
 
| not penicillin
  +
| normal exam, RPR < 4-fold maternal
|
 
 
| yes
 
| yes
 
| 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months
 
| 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months
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| before or during pregnancy
 
| before or during pregnancy
 
| RPR not decline as expected
 
| RPR not decline as expected
  +
| normal exam, RPR < 4-fold maternal
|
 
 
| yes
 
| yes
 
| 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months
 
| 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months
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| before pregnancy
 
| before pregnancy
 
| inadequate, or reinfection
 
| inadequate, or reinfection
  +
| normal exam, RPR < 4-fold maternal
|
 
 
| yes
 
| yes
 
| 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months
 
| 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months
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| during pregnancy
 
| during pregnancy
 
| unknown
 
| unknown
  +
| normal exam, RPR < 4-fold maternal
|
 
 
| yes
 
| yes
 
| 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months
 
| 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months
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| during pregnancy
 
| during pregnancy
 
| inadequate
 
| inadequate
  +
| normal exam, RPR < 4-fold maternal
|
 
 
| yes
 
| yes
 
| 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months
 
| 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months
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| during or after pregnancy
 
| during or after pregnancy
 
| adequate
 
| adequate
  +
| normal exam, RPR < 4-fold maternal
|
 
 
| no
 
| no
 
| 0, 6, and 18 months
 
| 0, 6, and 18 months
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| any
 
| any
 
| during pregnancy
 
| during pregnancy
  +
| normal exam, RPR < 4-fold maternal
|
 
 
| follow-up unlikely
 
| follow-up unlikely
 
| yes
 
| yes
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| depends on risk and results of assessments
 
| depends on risk and results of assessments
 
|-
 
|-
  +
| any
|
 
  +
| any
|
 
  +
| any
|
 
 
| treponemes on tissue examination
 
| treponemes on tissue examination
 
| yes
 
| yes
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| 10 days
 
| 10 days
 
|-
 
|-
  +
| any
|
 
  +
| any
|
 
  +
| any
|
 
 
| infant's RPR four-fold or greater than the mother's at birth
 
| infant's RPR four-fold or greater than the mother's at birth
 
| yes
 
| yes
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| 10 days
 
| 10 days
 
|-
 
|-
  +
| any
|
 
  +
| any
|
 
  +
| any
|
 
 
| four-fold rise in infant's titre
 
| four-fold rise in infant's titre
 
| yes
 
| yes
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| 10 days
 
| 10 days
 
|-
 
|-
  +
| any
|
 
  +
| any
|
 
  +
| any
|
 
 
| signs of congenital syphilis at any age
 
| signs of congenital syphilis at any age
 
| yes
 
| yes
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| 10 days
 
| 10 days
 
|-
 
|-
  +
| any
|
 
  +
| any
|
 
  +
| any
|
 
| reactive RPR+TT at 12 months
+
| RPR & TT reactive at 6 months
 
| —
 
| —
 
| yes
 
| usually
 
|-
  +
| any
  +
| any
  +
| any
 
| reactive RPR & TT at 12 months
 
| yes
 
| yes
 
| 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months
 
| 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months
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| 10 days
 
| 10 days
 
|-
 
|-
  +
| any
|
 
  +
| any
|
 
  +
| any
|
 
 
| reactive TT at 18 months
 
| reactive TT at 18 months
 
| yes
 
| yes
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| yes
 
| yes
 
| 10 days
 
| 10 days
|-
 
|
 
|
 
|
 
| RPR+TT reactive at 6 months
 
| —
 
| —
 
| yes
 
| usually
 
 
|}
 
|}
   

Revision as of 21:48, 4 July 2020

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

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