Syphilis during pregnancy: a preventable threat to maternal-fetal health.

Syphilis remains the most common congenital infection worldwide and has tremendous consequences for the mother and her developing fetus if left untreated. Recently, there has been an increase in the number of congenital syphilis cases in the United States. Thus, recognition and appropriate treatment of reproductive-age women must be a priority. Testing should be performed at initiation of prenatal care and twice during the third trimester in high-risk patients. There are 2 diagnostic algorithms available and physicians should be aware of which algorithm is utilized by their testing laboratory. Women testing positive for syphilis should undergo a history and physical exam as well as testing for other sexually transmitted infections, including HIV. Serofast syphilis can occur in patients with previous adequate treatment but persistent low nontreponemal titers (<1:8). Syphilis can infect the fetus in all stages of the disease regardless of trimester and can sometimes be detected with ultrasound >20 weeks. The most common findings include hepatomegaly and placentomegaly, but also elevated peak systolic velocity in the middle cerebral artery (indicative of fetal anemia), ascites, and hydrops fetalis. Pregnancies with ultrasound abnormalities are at higher risk of compromise during syphilotherapy as well as fetal treatment failure. Thus, we recommend a pretreatment ultrasound in viable pregnancies when feasible. The only recommended treatment during pregnancy is benzathine penicillin G and it should be administered according to maternal stage of infection per Centers for Disease Control and Prevention guidelines. Women with a penicillin allergy should be desensitized and then treated with penicillin appropriate for their stage of syphilis. The Jarisch-Herxheimer reaction occurs in up to 44% of gravidas and can cause contractions, fetal heart rate abnormalities, and even stillbirth in the most severely affected pregnancies. We recommend all viable pregnancies receive the first dose of benzathine penicillin G in a labor and delivery department under continuous fetal monitoring for at least 24 hours. Thereafter, the remaining benzathine penicillin G doses can be given in an outpatient setting. The rate of maternal titer decline is not tied to pregnancy outcomes. Therefore, after adequate syphilotherapy, maternal titers should be checked monthly to ensure they are not increasing four-fold, as this may indicate reinfection or treatment failure.

Progression of ultrasound findings of fetal syphilis after maternal treatment.

OBJECTIVE: The purpose of this study was to evaluate ultrasound findings of fetal syphilis and to describe their progression after maternal treatment. STUDY DESIGN: This was a retrospective cohort study from September 1981 to June 2011 of seropositive women after 18 weeks of gestation who had an ultrasound before treatment to evaluate for fetal syphilis. Only those women who received treatment after the initial ultrasound scan, but before delivery, were included. If the initial ultrasound scan was abnormal, serial sonography was performed until resolution of the abnormality or delivery. Patient demographics, ultrasound findings, stage of syphilis, delivery, and infant outcomes were recorded. Standard statistical analyses were performed. Kaplan-Meier estimates were constructed to estimate time to resolution. RESULTS: Two hundred thirty-five women met the inclusion criteria; 73 of them (30%) had evidence of fetal syphilis on initial ultrasound scan. Abnormalities included hepatomegaly (79%), placentomegaly (27%), polyhydramnios (12%), ascites (10%) and abnormal middle cerebral arterial Doppler assessment (33%). After treatment, middle cerebral arterial Doppler assessment abnormalities, ascites, and polyhydramnios resolved first, followed by placentomegaly and finally hepatomegaly. Infant outcomes were available for 173 deliveries; of these, 32 infants (18%) were diagnosed with congenital syphilis. Congenital syphilis was more common when antenatal ultrasound abnormalities were present (39% vs 12%; P < .001). Infant examination findings at delivery were similar between women with and without an abnormal pretreatment ultrasound scan. However, in those infants with congenital syphilis, hepatomegaly was the most frequent abnormality found, regardless of antenatal ultrasound findings. CONCLUSION: Sonographic signs of fetal syphilis confer a higher risk of congenital syphilis at delivery for all maternal stages. Hepatomegaly develops early and resolves last after antepartum treatment.

A case of congenital syphilis.

We report a case of an asymptomatic 3-month-old girl presenting to the emergency department with concern for congenital syphilis. Radiographs of the lower limbs demonstrate mild diffuse periosteal reaction involving the femur, tibia, and fibula and bilaterally symmetric lucencies and erosions of the medial proximal tibial metaphysis (Wimberger's sign).

Neonates at risk for congenital syphilis: radiographic and cerebrospinal fluid evaluations.

OBJECTIVE: To review the infants at risk for congenital syphilis (CS) and determine the optimal use of evaluations such as cerebrospinal fluid (CSF), the venereal disease research laboratory (VDRL) test, and long bone radiography studies. METHODS: A retrospective chart review of all of the infants at risk for CS from January 1997 to December 2002 at the Regional Medical Center at Memphis was conducted. Subjects were identified from a database of prenatal maternal records. Infant charts showing a diagnosis of presumptive CS were reviewed and data were collected. RESULTS: Of the 24,245 deliveries, maternal serology (rapid plasma reagin and microhemagglutination for treponemal antibody) was reactive in 250 women during pregnancy. Of 92 infants with a presumptive diagnosis of syphilis, only 2 (2.1%) were symptomatic. CSF examination for VDRL was feasible in 74 (80%) of the 92 infants. Only 1 (1.35%) of the 74 infants had a positive CSF-VDRL. Three infants had radiographic changes that were consistent with CS. CONCLUSIONS: The burden of syphilis in pregnancy remains high. Proper evaluation of neonates is important in preventing long-term consequences. The frequency of positive CSF and long bone radiography studies remains low. These evaluations should be made based on the symptoms and plan of treatment for individual neonates.

[SPECT and FDG-PET in diagnostics of neurolues]. / SPECT und FDG-PET in der Diagnostik der Neurolues.

Syphilis is a recurrent treponematosis of acute and chronic evolution. In general it is either sexually or congenitally transmitted. Primary syphilis appears as a single and painless lesion. Secondary syphilis may manifest years later, the secondary bacteremic stage is accompanied by generalized mucocutaneous lesions. Tertiary disease can be disseminated to bones and virtually any organ, involving principally the ascending aorta and the central nervous system. Nuclear medicine provides diagnostic methods in case of skeletal manifestations by bone scan - identifying periostitis and osteomyelitis. Hepatic gummas can be imaged by 99m-Tc-colloid liver scintigraphy. In neurosyphilis brain perfusion SPECT enables imaging of cerebral involvement by small vessel endarteritis resulting from syphilitic vascular disease. 18-FDG PET is also useful to evaluate neurosyphilis, a reduction of brain glucose consumption is observed. The technique adequately enables imaging of therapeutic response and might be superior to morphologic imaging. We present our experiences with these nuclear medicine methods in patients with neurolues. The incidence of neurolues is estimated at 2 per 100.000 inhabitants worldwide, migration processes might bring a re-emergence of this disease to Austria and other developed countries of the EU. Scintigraphic methods should be kept in mind for diagnostic evaluation of neurosyphilis.

Congenital syphilis as a differential diagnosis of non-accidental injury.

A two-month-old infant presented with swelling and tenderness of his right forearm. Initially, non-accidental injury was suspected but X-ray appearances were typical of congenital syphilis, which was confirmed on serological testing.

[Not a fall--not abuse--not a rare finding?]. / Kein Sturz--keine Misshandlung--kein seltener Befund?

A baby was brought into the accident and emergency department with X-ray pictures and with a plaster cast in place because of a pain reaction in the right arm. The pictures showed destruction of the epiphyseal region and double periosteal contours. Alterations of the same kind were found in all long bones; they were recognized as compatible with florid congenital syphilis, which was confirmed by reference to the history and the laboratory findings and was successfully treated with penicillin G in the pediatric department. Both parents were also treated. No traumatological/orthopedic treatment was given, and the plaster cast was removed. Following recognition of the signs described a complete cure was possible.

The girl from the church of the sacrament: a case of congenital syphilis in XVIII century Lisbon.

Syphilis is a sexually or congenitally transmitted infectious disease with an impact on the health of human populations that has undergone important cycles in different countries and periods of history. Its presence was first diagnosed in Europe in the late XIV century. In Portugal, although there are various written records of the infection in the last centuries, there are rare references to it in archeological findings (mummified bodies are also rare in Portugal). The current study describes a probable case of congenital syphilis in an 18-month-old girl buried in the Church of the Sacrament in Lisbon. Her body, dating to the XVIII century, was found mummified together with dozens of others, still not studied. Symmetrical periostitis of the long bones, osteitis, metaphyseal lesions, left knee articular, and epiphyseal destruction, and a rarefied lesion with a radiological appearance compatible with Wimberger's sign all point to a diagnosis of congenital syphilis. The diagnosis of this severe form of the infection, possibly related to the cause of death in this upper-class girl, calls attention to the disease's presence in XVIII century Lisbon and is consistent with the intense mobilization at the time in relation to the risks posed by so-called heredosyphilis. It is the first case of congenital syphilis in a child reported in archeological findings in Portugal, and can be correlated with other cases in skeletons of adults buried in cemeteries in Lisbon (in the XVI to XVIII centuries) and Coimbra (XIX century). Finally, this finding highlights the need to study the entire series of mummified bodies in the Church of the Sacrament in order to compare the paleopathological findings and existing historical documents on syphilis, so as to expand the paleoepidemiological knowledge of this infection in XVIII century Lisbon.

Cortical hyperostosis in an infant on prolonged prostaglandin infusion: case report and literature review.

The common side effects associated with the use of prostaglandins in newborn infants include apnoea, hyperthermia, diarrhoea, skin flushing and oedema. Periosteal reaction or cortical thickening of the bones, also known as cortical hyperostosis, is associated with a prolonged use of prostaglandins. This is a radiological diagnosis; therefore, its occurrence is most likely underestimated. We describe an infant who developed cortical hyperostosis simulating osteomyelitis with elevated alkaline phosphatase. The radiologic changes were initially attributed to congenital syphilis. This occurred after a prolonged infusion of prostaglandin E(1) for a cyanotic congenital heart disease.

Value of routine long bone radiographs in management of babies with a positive VDRL at the Mount Hope Women's Hospital.

This retrospective study examined the records of 44 mothers and 44 babies with a positive blood VDRL test and/or who showed symptoms of congenital syphilis at the Mount Hope Women's Hospital (MHWH), Trinidad, between June 1, 1996 and September 30, 1998. Long bone radiographs of 40/44 (91%) babies were assessed independently by two radiologists for signs of congenital syphilis and the data were analysed using frequency tables. Of the 44 mothers in the study, 34 (77%) were VDRL positive and the rest were either negative or unknown. Maternal age ranged from 14 to 39 years and most (92%) had antenatal care. Fourteen of the 34 (41%) VDRL positive mothers received treatment antenatally. All mothers were asymptomatic and none had any clinical features of syphilis. In 35/44 babies, the VDRL test was positive and in nine, the test was either negative or unknown. Twenty-six of the babies had signs suggestive of congenital syphilis and in 12, (46%) long bone radiographs revealed changes compatible with the diagnosis of congenital syphilis. Radiographic abnormalities were present only in infants with VDRL titres > 1:8.

Symptomatic congenital syphilis presenting at birth.

We report here a case of congenital syphilis presenting in a newborn infant at birth. A negative infant VDRL test, pseudoparesis and more notably, joint swellings (arthritis) were features seen uncommonly. Florid skeletal involvement, which is rarely seen in the early neonatal period, prompted us to draw attention to the varied presentation of this disease, rightly referred to as the "master masquerader".

Clinical and epidemiological features of syphilis in pregnant women: the course and outcome of pregnancy.

Clinical and epidemiological features of syphilis and the course and outcome of pregnancy were studied in 155 pregnant women infected with syphilis; 95 (61%) women were unemployed, 47% were unmarried. Syphilis proceeded without clinical manifestations in 121 cases (78%). Discordant results of complement fixation (Wassermann) test, precipitation test, Treponema pallidum immobilization test, and fluorescent antibody test were observed in 22 (14%) of the women. Pregnancy pathology was observed in 75 cases (48.8%) and more often appeared as anemia in 49 (31.5%), stillborn in 46 (29.8%) and toxicosis in 44 (28.4%). Fetal ultrasonic stigmas of infection were evident in 23 cases (49%). There was distension of the brain ventricle system and hepatomegaly each in 1 case (2%), transvascular infiltration of liver in 2 cases (4%), dilation of intestinal loops, gastromegaly, ventriculomegaly and petrifaction in lungs each in 1 case; ultrasonic changes in vessels of organs: of the liver in 4 cases (8%), intestines and stomach in 16 cases (32%), lungs in 4 cases (8%), kidneys in 10 cases (21%) and of the ventricular system in 9 cases (19%). Fetus development retardation was revealed in 3 cases (6%), fetal hypoxia in 1 (2%), hypohydrosis in 2 (4%) and hydropsy in 1 case (2%). The pregnancy pathology in women with syphilis was considered not pathognomonic.

Incidence and clinical significance of echogenic vasculature in the basal ganglia of newborns.

Cranial sonography has become the main modality of the investigation and diagnosis of a wide variety of neonatal intracranial abnormalities. Occasionally, cranial sonograms reveal basal ganglia and thalami bright echoes. It is believed that these lesions are indicative of vasculitis due to intrauterine infections, in particular with cytomegalovirus (CMV). We hypothesized that the incidence of proven neonatal intrauterine TORCH infection is low and that screening of all asymptomatic infants with bright lenticulostriate echodensities would not be cost-effective. We reviewed brain sonograms of 3700 infants, performed over a period of 3 1/2 years. Echogenic basal ganglia vasculature were observed in 75 patients (2%). Chart review performed for clinical presentation and TORCH studies showed that only one infant had confirmed intrauterine congenital infection, which was by CMV. This infant had no signs or symptoms of CMV. In addition, there were 4 patients with chromosomal anomalies among the 75 patients (5%), of these one had trisomy 13 and another-trisomy 21. Our results indicate that echogenic basal ganglia blood vessels are not an exceptional finding on cranial sonograms, and are seldom associated with intrauterine infection. We conclude that it is not cost-effective to screen infants with echogenic basal ganglia blood vessels for intrauterine infection, unless clinical suspicion exists.