Congenital syphilis: Difference between revisions
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− | == |
+ | ==Background== |
− | === |
+ | ===Epidemiology=== |
− | * Rare, with about 20 per 100,000 live births in the US |
||
− | * Greatest risk to child is with untreated primary maternal syphilis |
||
+ | *Rare, with about 20 per 100,000 live births in the US |
||
− | === Pathophysiology === |
||
+ | *Greatest risk to child is with untreated primary [[Syphilis in pregnancy|maternal syphilis]], and almost exclusively to those mothers with an RPR titre of 1:8 or greater |
||
− | * Transplacental transmission while bacteremic |
||
− | * Can be transmitted during delivery, as well |
||
+ | ===Pathophysiology=== |
||
− | == Clinical Presentation == |
||
− | * Mothers typically have had no prenatal care |
||
− | * To the fetus, can cause [[Causes::spontaneous abortion]] (40% in untreated primary syphilis), [[Causes::preterm delivery]], [[Causes::polyhydramnios]], [[Causes::intra-uterine growth restriction]], [[Causes::hydrops fetalis]], or [[Causes::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: |
||
− | ** [[Causes::Rhinitis]] (called [[Causes::snuffles]], often bloody and copious), [[Causes::desquamating rash]], [[Causes::hepatosplenomegaly]], [[Causes::lymphadenopathy]], and skeletal abnormalities |
||
− | ** Also: [[Causes::condyloma lata]], [[Causes::vesicular rash]] or [[Causes::bullous rash]], [[Causes::periostitis]], [[Causes::hydrops]], [[Causes::thrombocytopenia]], [[Causes::hepatitis]], [[Causes::jaundice]], or [[Causes::glomerulonephritis]] |
||
− | ** About 20% involve the CNS |
||
− | * Late disease, after the first two years, includes: |
||
− | ** [[Causes::Sensorineural hearing loss]], [[Causes::intellectual impairment]], [[Causes::saddle nose deformity]], [[Causes::frontal bossing]], jaw, dental, and palatal abnormalities including [[Causes::Hutchison teeth]], [[Causes::saber tibia]], [[Causes::short stature]], and [[Causes::keratitis]] |
||
+ | *Transplacental transmission while bacteremic |
||
− | == Diagnosis == |
||
+ | *Can be transmitted during delivery, as well |
||
− | * 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 |
||
+ | ==Clinical Manifestations== |
||
− | == Management == |
||
+ | |||
− | * Treat syphilis in pregnancy with high-dose penicillin to prevent congenital syphilis |
||
+ | *Mothers typically have had no prenatal care |
||
− | * Treat affected infant with [[Is treated by::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 |
||
+ | *To the fetus, can cause [[Causes::spontaneous abortion]] (40% in untreated primary syphilis), [[Causes::preterm delivery]], [[Causes::polyhydramnios]], [[Causes::intra-uterine growth restriction]], [[Causes::hydrops fetalis]], or [[Causes::intra-uterine fetal demise]] |
||
− | * Can treat lower-risk infants with [[Is treated by::benzathine penicillin G]] 50,000 U/kg IM once |
||
+ | *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: |
||
+ | **At birth: [[Causes::necrotizing funisitis]] ("barbershop pole" umbilical cord) |
||
+ | **Shortly after birth: |
||
+ | ***[[Causes::Rhinitis]]: called [[Causes::snuffles]], often bloody and copious, which is often the first manifestation and present in about 40% of cases |
||
+ | ***Musculoskeletal abnormalities start within a week of birth and develop over the child's lifetime |
||
+ | ****Start as radiographic osteochondritis or perichondritis |
||
+ | ****Later, pseudoparalysis, followed by the late findings described below |
||
+ | **At birth or delayed: |
||
+ | ***Hematologic abnormalities, including [[Causes::anemia]] and [[Causes::thrombocytopenia]] |
||
+ | ***[[Causes::Neurosyphilis]] in 50% of cases and usually asymptomatic |
||
+ | **Within the first eight weeks: |
||
+ | ***[[Causes::Hepatomegaly]] and [[Causes::splenomegaly]] in 20%, and persists for years |
||
+ | ***Rash in 50%, usually a diffuse [[Causes::maculopapular rash]], but may be [[Causes::desquamating rash|desquamating]], [[Causes::vesicular rash|vesicular]], [[Causes::bullous rash|bullous]], [[Causes::papulosquamous rash|papulosquamous]], or involve [[Causes::mucosal lesion|mucosal lesions]] |
||
+ | **Also: [[Causes::lymphadenopathy]], [[Causes::condyloma lata]], [[Causes::vesicular rash]] or [[Causes::bullous rash]], [[Causes::periostitis]], [[Causes::hydrops]], [[Causes::hepatitis]], [[Causes::jaundice]], or [[Causes::glomerulonephritis]] |
||
+ | *Late disease, after the first two years, includes: |
||
+ | **Age 2-20 years: [[Causes::interstitial keratitis]] |
||
+ | **When permanent dentition appears: [[Causes::Hutchison teeth]], with widely-spaced, screwdriver-shaped central and lateral incisors |
||
+ | **Age 10-40 years: [[Causes::sensorineural hearing loss]] |
||
+ | **Age 13-19 years: [[Causes::mulberry molars]], where the first molars have dwarfing of the cusps and hypertrophy of the enamel surrounding the cusp |
||
+ | **Musculoskeletal abnormalities: |
||
+ | ***Eventually [[Causes::frontal bossing]], poorly-developed maxilae, [[Causes::saddle nose deformity]], winged scapulae, and [[Causes::sabre shins]], [[Causes::short stature]] |
||
+ | ***Recurrent arthropathy and painless knee effusions (Clutton joints) as late disease |
||
+ | **[[Causes::Intellectual impairment]] |
||
+ | |||
+ | === Hutchison Triad === |
||
+ | |||
+ | * The classic triad of late congenital syphilis |
||
+ | * Includes: |
||
+ | ** [[Sensorineural hearing loss]] from cranial nerve VIII |
||
+ | ** [[Interstitial keratitis]] |
||
+ | ** Abnormal dentition, including [[Hutchison teeth]] and [[mulberry molars]] |
||
+ | |||
+ | ==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 penicillin to prevent congenital syphilis |
||
+ | *For infants that require treatment, the treatment of choice is [[Is treated by::crystalline penicillin G]] |
||
+ | **Age 1 to 7 days: 50,000 U/kg IV q12h |
||
+ | **Age 1-4 weeks: 50,000 U/kg q8h |
||
+ | **Age >4 weeks: 50,000 U/kg q6h |
||
+ | *Duration is typically 10 days |
||
+ | **Don't forget to dose adjust from q12h to q8h after the first 7 days |
||
+ | *Can treat lower-risk infants with [[Is treated by::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 can't be ensured |
||
+ | *Specific scenarios are described in the table below |
||
− | === Canadian guidelines === |
||
{| class="wikitable sortable" |
{| class="wikitable sortable" |
||
− | ! colspan=3 | |
+ | ! colspan="3" |Maternal treatment |
− | ! rowspan=2 | |
+ | ! rowspan="2" |Neonatal assessment |
− | ! colspan=4 | |
+ | ! colspan="4" |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 |
+ | | rowspan="6" |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 |
||
+ | |- |
||
+ | |≤4 weeks before delivery |
||
| |
| |
||
+ | |normal exam, RPR < 4-fold maternal |
||
− | | yes |
||
+ | |yes |
||
− | | 0, 3, 6, and 18 months |
||
+ | |0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
− | | no |
||
+ | |yes |
||
− | | none |
||
+ | |usually |
||
|- |
|- |
||
+ | | |
||
− | | primary, secondary, or early latent |
||
+ | |not penicillin |
||
− | | ≤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 |
||
+ | |yes |
||
− | | 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
+ | |usually |
||
− | | yes |
||
− | | usually |
||
|- |
|- |
||
+ | |before or during pregnancy |
||
− | | primary, secondary, or early latent |
||
+ | |RPR not decline as expected |
||
− | | |
||
+ | |normal exam, RPR < 4-fold maternal |
||
− | | not penicillin |
||
− | | |
+ | |yes |
+ | |0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
− | | yes |
||
+ | |yes |
||
− | | 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
+ | |usually |
||
− | | yes |
||
− | | usually |
||
|- |
|- |
||
+ | |before pregnancy |
||
− | | primary, secondary, or early latent |
||
+ | |inadequate, or reinfection |
||
− | | before or during pregnancy |
||
+ | |normal exam, RPR < 4-fold maternal |
||
− | | RPR not decline as expected |
||
− | | |
+ | |yes |
+ | |0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
− | | yes |
||
+ | |consider |
||
− | | 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
+ | |depends on risk and results of assessments |
||
− | | yes |
||
− | | usually |
||
|- |
|- |
||
+ | |during pregnancy |
||
− | | primary, secondary, or early latent |
||
+ | |unknown |
||
− | | before pregnancy |
||
+ | |normal exam, RPR < 4-fold maternal |
||
− | | inadequate, or reinfection |
||
− | | |
+ | |yes |
+ | |0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
− | | yes |
||
+ | |consider |
||
− | | 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
+ | |depends on risk and results of assessments |
||
− | | consider |
||
− | | depends on risk and results of assessments |
||
|- |
|- |
||
− | | |
+ | |primary or secondary syphilis |
− | | |
+ | |during pregnancy |
+ | |inadequate |
||
− | | unknown |
||
+ | |normal exam, RPR < 4-fold maternal |
||
− | | |
||
− | | |
+ | |yes |
− | | |
+ | |0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
+ | |yes |
||
− | | consider |
||
+ | |10 days |
||
− | | depends on risk and results of assessments |
||
|- |
|- |
||
+ | |late latent |
||
− | | primary or secondary syphilis |
||
− | | |
+ | |during or after pregnancy |
+ | |adequate |
||
− | | inadequate |
||
+ | |normal exam, RPR < 4-fold maternal |
||
− | | |
||
+ | |no |
||
− | | yes |
||
− | | |
+ | |0, 6, and 18 months |
+ | |no |
||
− | | yes |
||
+ | |none |
||
− | | 10 days |
||
|- |
|- |
||
+ | | rowspan="8" |any |
||
− | | late latent |
||
− | | |
+ | |during pregnancy |
+ | |normal exam, RPR < 4-fold maternal |
||
− | | adequate |
||
+ | |follow-up unlikely |
||
− | | |
||
− | | |
+ | |yes |
− | | |
+ | |0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
+ | |consider |
||
− | | no |
||
+ | |depends on risk and results of assessments |
||
− | | none |
||
|- |
|- |
||
− | | any |
+ | | rowspan="7" |any |
+ | | rowspan="7" |any |
||
− | | during pregnancy |
||
+ | |treponemes on tissue examination |
||
− | | |
||
+ | |yes |
||
− | | follow-up unlikely |
||
+ | |0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
− | | yes |
||
+ | |yes |
||
− | | 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
+ | |10 days |
||
− | | consider |
||
− | | depends on risk and results of assessments |
||
|- |
|- |
||
+ | |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 |
||
− | | treponemes on tissue examination |
||
− | | |
+ | |10 days |
− | | 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
− | | yes |
||
− | | 10 days |
||
|- |
|- |
||
+ | |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 |
||
− | | infant's RPR four-fold or greater than the mother's at birth |
||
− | | |
+ | |10 days |
− | | 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
− | | yes |
||
− | | 10 days |
||
|- |
|- |
||
+ | |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 |
||
− | | four-fold rise in infant's titre |
||
− | | |
+ | |10 days |
− | | 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
− | | yes |
||
− | | 10 days |
||
|- |
|- |
||
+ | |RPR & TT reactive at 6 months |
||
− | | |
||
− | | |
+ | |— |
− | | |
+ | |— |
+ | |yes |
||
− | | signs of congenital syphilis at any age |
||
+ | |usually |
||
− | | yes |
||
− | | 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
− | | yes |
||
− | | 10 days |
||
|- |
|- |
||
+ | |reactive RPR & TT at 12 months |
||
− | | |
||
− | | |
+ | |yes |
+ | |0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
− | | |
||
+ | |yes |
||
− | | reactive RPR+TT at 12 months |
||
− | | |
+ | |10 days |
− | | 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
− | | yes |
||
− | | 10 days |
||
|- |
|- |
||
+ | |reactive TT at 18 months |
||
− | | |
||
− | | |
+ | |yes |
+ | |0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
− | | |
||
+ | |yes |
||
− | | reactive TT at 18 months |
||
− | | |
+ | |10 days |
− | | 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months |
||
− | | yes |
||
− | | 10 days |
||
− | |- |
||
− | | |
||
− | | |
||
− | | |
||
− | | RPR+TT reactive at 6 months |
||
− | | — |
||
− | | — |
||
− | | yes |
||
− | | usually |
||
|} |
|} |
||
+ | * Serology includes RPR and treponemal tests |
||
− | ===US guidelines=== |
||
+ | ** In the absence of congenital syphilis, RPR declines by about three months and is usually non-reactive by 6 months, and treponemal tests usually clear by 12 months and always by 18 months |
||
+ | * Investigations include long-bone x-rays, CBC, and CSF (for glucose, protein, and VDRL), ± ophthalmological and audiological tests |
||
+ | * Skin lesions, nasal discharge, placental lesions, and the umbilical cord can be sent for darkfield microscopy or DFA testing |
||
+ | |||
+ | ===US Guidelines=== |
||
{| class="wikitable" |
{| class="wikitable" |
||
− | ! colspan=2 | |
+ | ! colspan="2" |Initial neonatal assessment |
− | ! colspan=2 | |
+ | ! colspan="2" |Maternal treatment |
− | ! colspan=2 | |
+ | ! colspan="2" |Recommendations |
|- |
|- |
||
− | ! |
+ | !RPR/VDRL |
− | ! |
+ | !Evaluation |
− | ! |
+ | !Timing |
− | ! |
+ | !Type |
− | ! |
+ | !Evaluation |
− | ! |
+ | !Treatment |
|- |
|- |
||
− | | rowspan=2 | |
+ | | rowspan="2" |any |
− | | |
+ | |physical exam suggests congenital syphilis |
− | | rowspan=2 | |
+ | | rowspan="2" |any |
− | | rowspan=2 | |
+ | | rowspan="2" |any |
− | | rowspan=2 | |
+ | | rowspan="2" |LP and CBC |
− | | rowspan=2 | |
+ | | rowspan="2" |10 days |
|- |
|- |
||
− | | |
+ | |spirochete in a clinical specimen |
|- |
|- |
||
− | | |
+ | |≥ fourfold maternal titre |
− | | |
+ | |any |
− | | |
+ | |any |
− | | |
+ | |any |
− | | |
+ | |LP and CBC |
− | | |
+ | |10 days |
|- |
|- |
||
− | | rowspan=4 | |
+ | | rowspan="4" |less than fourfold maternal titre |
− | | rowspan=4 | |
+ | | rowspan="4" |normal |
− | | rowspan=2 | |
+ | | rowspan="2" |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) |
|- |
|- |
||
− | | rowspan=2 | |
+ | | rowspan="2" |during pregnancy |
− | | |
+ | |adequate |
− | | |
+ | |none |
− | | |
+ | |one dose (or none) |
|- |
|- |
||
− | | |
+ | |inadequate or suboptimal |
− | | |
+ | |LP and CBC |
− | | |
+ | |one dose (unless exam at all abnormal) |
|- |
|- |
||
− | | rowspan=2 | |
+ | | rowspan="2" |nonreactive |
− | | rowspan=2 | |
+ | | rowspan="2" |normal |
− | | rowspan=2 | |
+ | | rowspan="2" |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 |
+ | |||
+ | == Further Reading == |
||
+ | |||
+ | * [https://cps.ca/en/documents/position/congenital-syphilis Congenital syphilis: No longer just of historical interest]. Canadian Paediatric Society Practice Point, reaffirmed 2018. |
||
[[Category:Sexually-transmitted infections]] |
[[Category:Sexually-transmitted infections]] |
||
− | [[Category: |
+ | [[Category:Congenital infections]] |
Latest revision as of 06:57, 1 March 2023
Background
Epidemiology
- Rare, with about 20 per 100,000 live births in the US
- Greatest risk to child is with untreated primary maternal syphilis, and almost exclusively to those mothers with an RPR titre of 1:8 or greater
Pathophysiology
- Transplacental transmission while bacteremic
- Can be transmitted during delivery, as well
Clinical Manifestations
- 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:
- At birth: necrotizing funisitis ("barbershop pole" umbilical cord)
- Shortly after birth:
- Rhinitis: called snuffles, often bloody and copious, which is often the first manifestation and present in about 40% of cases
- Musculoskeletal abnormalities start within a week of birth and develop over the child's lifetime
- Start as radiographic osteochondritis or perichondritis
- Later, pseudoparalysis, followed by the late findings described below
- At birth or delayed:
- Hematologic abnormalities, including anemia and thrombocytopenia
- Neurosyphilis in 50% of cases and usually asymptomatic
- Within the first eight weeks:
- Hepatomegaly and splenomegaly in 20%, and persists for years
- Rash in 50%, usually a diffuse maculopapular rash, but may be desquamating, vesicular, bullous, papulosquamous, or involve mucosal lesions
- Also: lymphadenopathy, condyloma lata, vesicular rash or bullous rash, periostitis, hydrops, hepatitis, jaundice, or glomerulonephritis
- Late disease, after the first two years, includes:
- Age 2-20 years: interstitial keratitis
- When permanent dentition appears: Hutchison teeth, with widely-spaced, screwdriver-shaped central and lateral incisors
- Age 10-40 years: sensorineural hearing loss
- Age 13-19 years: mulberry molars, where the first molars have dwarfing of the cusps and hypertrophy of the enamel surrounding the cusp
- Musculoskeletal abnormalities:
- Eventually frontal bossing, poorly-developed maxilae, saddle nose deformity, winged scapulae, and sabre shins, short stature
- Recurrent arthropathy and painless knee effusions (Clutton joints) as late disease
- Intellectual impairment
Hutchison Triad
- The classic triad of late congenital syphilis
- Includes:
- Sensorineural hearing loss from cranial nerve VIII
- Interstitial keratitis
- Abnormal dentition, including Hutchison teeth and mulberry molars
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 penicillin to prevent congenital syphilis
- For infants that require treatment, the treatment of choice is crystalline penicillin G
- Age 1 to 7 days: 50,000 U/kg IV q12h
- Age 1-4 weeks: 50,000 U/kg q8h
- Age >4 weeks: 50,000 U/kg q6h
- Duration is typically 10 days
- Don't forget to dose adjust from q12h to q8h after the first 7 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 can't be ensured
- Specific scenarios are described in the table below
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 |
≤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 | ||
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 | ||
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 | |
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 | |
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 | treponemes on tissue examination | yes | 0, 3, 6, and 18 months; if not treated, also at 1, 2, and 12 months | yes | 10 days | |
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 | |||
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 | |||
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 | |||
RPR & TT reactive at 6 months | — | — | yes | usually | |||
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 | |||
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 |
- Serology includes RPR and treponemal tests
- In the absence of congenital syphilis, RPR declines by about three months and is usually non-reactive by 6 months, and treponemal tests usually clear by 12 months and always by 18 months
- Investigations include long-bone x-rays, CBC, and CSF (for glucose, protein, and VDRL), ± ophthalmological and audiological tests
- Skin lesions, nasal discharge, placental lesions, and the umbilical cord can be sent for darkfield microscopy or DFA testing
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
Further Reading
- Congenital syphilis: No longer just of historical interest. Canadian Paediatric Society Practice Point, reaffirmed 2018.