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==Overview== | ==Overview== | ||
Congenital Syphilis is caused by Treponema pallidum, its transmitted to the fetus in utero from an infected mother via the placenta. The severity of the disease is dependent on the stage of maternal infection and the duration of exposure to the fetus. Transmission is typically in the second trimester and the highest rates of transmission are seen in women with primary syphilis. The rates of transmission decrease with the increasing duration of the maternal infection as the concentration of spirochetes in the blood stream decreases. Syphilis infection to the fetus in utero can result in stillborn, | Congenital [[Congenital syphilis|Syphilis]] is caused by [[Treponema pallidum]], its transmitted to the [[fetus]] in utero from an infected mother via the [[placenta]]. The severity of the disease is dependent on the stage of maternal infection and the duration of exposure to the [[fetus]]. Transmission is typically in the [[second trimester]] and the highest rates of transmission are seen in women with [[primary syphilis]]. The rates of transmission decrease with the increasing duration of the maternal infection, as the concentration of [[spirochetes]] in the blood stream decreases. [[Syphilis]] infection to the fetus in utero can result in [[stillborn]], [[miscarriage]] and a live birth with severe manifestations of [[hydrops]]. [[Prenatal screening]] for [[syphilis]] during the [[first trimester]] is recommended to all pregnant women and adequate treatment with penicillin prevents the transmission to the [[fetus]]. | ||
==Historical Perspective== | ==Historical Perspective== | ||
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==Classification== | ==Classification== | ||
Congenital Syphilis is classified based on the timing of appearance of signs and symptoms into:<ref name="pmid23919053">{{cite journal| author=Balaji G, Kalaivani S| title=Observance of Kassowitz law-late congenital syphilis: Palatal perforation and saddle nose deformity as presenting features. | journal=Indian J Sex Transm Dis | year= 2013 | volume= 34 | issue= 1 | pages= 35-7 | pmid=23919053 | doi=10.4103/0253-7184.112869 | pmc=3730472 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23919053 }} </ref> | Congenital Syphilis is classified based on the timing of appearance of signs and symptoms into:<ref name="pmid23919053">{{cite journal| author=Balaji G, Kalaivani S| title=Observance of Kassowitz law-late congenital syphilis: Palatal perforation and saddle nose deformity as presenting features. | journal=Indian J Sex Transm Dis | year= 2013 | volume= 34 | issue= 1 | pages= 35-7 | pmid=23919053 | doi=10.4103/0253-7184.112869 | pmc=3730472 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23919053 }} </ref> | ||
*'''Early congenital Syphilis:'''If the signs and symptoms are identified in children aged less than 2 years. It is | *'''Early congenital Syphilis:''' If the signs and symptoms are identified in children aged less than 2 years. It is usually diagnosed in new born or in the first few weeks after birth.<ref name="pmid25079189">{{cite journal| author=Cavagnaro S M F, Pereira R T, Pérez P C, Vargas Del V F, Sandoval C C| title=[Early congenital syphilis: a case report]. | journal=Rev Chil Pediatr | year= 2014 | volume= 85 | issue= 1 | pages= 86-93 | pmid=25079189 | doi=10.4067/S0370-41062014000100012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25079189 }} </ref> | ||
*'''Late congenital Syphilis:''' If the signs and symptoms of the disease are identified in children aged more than 2 years. The signs are usually non-specific and more than half the children are asymptomatic. They can present with interstitial keratitis, eighth nerve deafness or clutton's joints. | *'''Late congenital Syphilis:''' If the signs and symptoms of the disease are identified in children aged more than 2 years. The signs are usually non-specific and more than half the children are asymptomatic. They can present with interstitial keratitis, eighth nerve deafness or clutton's joints. | ||
*'''Stigmata:''' These are the scars resulting from early or late congenital syphilis. The features of stigmata in early congenital syphilis include saddle nose deformity, Hutchinson's teeth, rhagades, choriod scarring and onychia. Stigmata secondary to late congenital syphilis include perforation of the palate, corneal opacities, optic atrophy and periosteal changes of tibia. | *'''Stigmata:''' These are the scars resulting from early or late congenital syphilis. The features of stigmata in early congenital syphilis include [[saddle nose]] deformity, [[Hutchinson's teeth|Hutchinson's]] teeth, rhagades, choriod scarring and [[onychia]]. Stigmata secondary to late congenital syphilis include perforation of the palate, corneal opacities, [[optic atrophy]] and [[Periosteal reaction|periosteal]] changes of tibia. | ||
==Causes== | ==Causes== | ||
The causative pathogen for Congenital syphilis Treponema pallidum. | The causative pathogen for [[Congenital syphilis]] [[Treponema pallidum]]. | ||
==Pathophysiology== | ==Pathophysiology== | ||
===Pathogenesis=== | ===Pathogenesis=== | ||
*Transmission to the fetus is transplacental, it can also occur during delivery in the presence of maternal genital lesions.<ref name="pmid11438902">{{cite journal| author=Wicher V, Wicher K| title=Pathogenesis of maternal-fetal syphilis revisited. | journal=Clin Infect Dis | year= 2001 | volume= 33 | issue= 3 | pages= 354-63 | pmid=11438902 | doi=10.1086/321904 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11438902 }} </ref><ref name="pmid27333146">{{cite journal| author=Domingues RM, Leal Mdo C| title=[Incidence of congenital syphilis and factors associated with vertical transmission: data from the Birth in Brazil study]. | journal=Cad Saude Publica | year= 2016 | volume= 32 | issue= 6 | pages= | pmid=27333146 | doi=10.1590/0102-311X00082415 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27333146 }} </ref><ref name="pmid16362988">{{cite journal| author=Peeling RW, Hook EW| title=The pathogenesis of syphilis: the Great Mimicker, revisited. | journal=J Pathol | year= 2006 | volume= 208 | issue= 2 | pages= 224-32 | pmid=16362988 | doi=10.1002/path.1903 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16362988 }} </ref> | *Transmission to the [[fetus]] is [[transplacental]], it can also occur during [[delivery]] in the presence of maternal genital lesions.<ref name="pmid11438902">{{cite journal| author=Wicher V, Wicher K| title=Pathogenesis of maternal-fetal syphilis revisited. | journal=Clin Infect Dis | year= 2001 | volume= 33 | issue= 3 | pages= 354-63 | pmid=11438902 | doi=10.1086/321904 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11438902 }} </ref><ref name="pmid27333146">{{cite journal| author=Domingues RM, Leal Mdo C| title=[Incidence of congenital syphilis and factors associated with vertical transmission: data from the Birth in Brazil study]. | journal=Cad Saude Publica | year= 2016 | volume= 32 | issue= 6 | pages= | pmid=27333146 | doi=10.1590/0102-311X00082415 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27333146 }} </ref><ref name="pmid16362988">{{cite journal| author=Peeling RW, Hook EW| title=The pathogenesis of syphilis: the Great Mimicker, revisited. | journal=J Pathol | year= 2006 | volume= 208 | issue= 2 | pages= 224-32 | pmid=16362988 | doi=10.1002/path.1903 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16362988 }} </ref> | ||
*The risk of transmission to the fetus is dependent on the stage of the maternal disease(dependent on the spirochete concentration in the blood stream) and the duration of exposure to the fetus in utero.<ref name="pmid15356936">{{cite journal| author=Berman SM| title=Maternal syphilis: pathophysiology and treatment. | journal=Bull World Health Organ | year= 2004 | volume= 82 | issue= 6 | pages= 433-8 | pmid=15356936 | doi= | pmc=2622860 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15356936 }} </ref> | *The risk of transmission to the fetus is dependent on the stage of the maternal disease(dependent on the spirochete concentration in the blood stream) and the duration of exposure to the fetus in utero.<ref name="pmid15356936">{{cite journal| author=Berman SM| title=Maternal syphilis: pathophysiology and treatment. | journal=Bull World Health Organ | year= 2004 | volume= 82 | issue= 6 | pages= 433-8 | pmid=15356936 | doi= | pmc=2622860 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15356936 }} </ref> | ||
*The risk of vertical transmission of syphilis from an infected untreated mother decreases as maternal disease duration progresses: transmission risk of 70–100% for primary syphilis and 40% for early latent syphilis to 10% for late latent disease. The variation in the percentages with the duration of infection is because the concentration of spirochetes in the blood stream decrease with the duration of maternal syphilis infection.<ref name="pmid10858706">{{cite journal |vauthors=Genç M, Ledger WJ |title=Syphilis in pregnancy |journal=Sex Transm Infect |volume=76 |issue=2 |pages=73–9 |year=2000 |pmid=10858706 |pmc=1758294 |doi= |url=}}</ref> | *The risk of vertical transmission of syphilis from an infected untreated mother decreases as maternal disease duration progresses: transmission risk of 70–100% for primary syphilis and 40% for early latent syphilis to 10% for late latent disease. The variation in the percentages with the duration of infection is because the concentration of spirochetes in the blood stream decrease with the duration of maternal syphilis infection.<ref name="pmid10858706">{{cite journal |vauthors=Genç M, Ledger WJ |title=Syphilis in pregnancy |journal=Sex Transm Infect |volume=76 |issue=2 |pages=73–9 |year=2000 |pmid=10858706 |pmc=1758294 |doi= |url=}}</ref> | ||
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===Microscopic Pathology=== | ===Microscopic Pathology=== | ||
*Skin lesion on histopahological exam demonstrate perivascular infiltration by lymphocytes, plasma cells and histiocytes, with endarteritis and extensive fibrosis. | *Skin lesion on histopahological exam demonstrate perivascular infiltration by lymphocytes, plasma cells and histiocytes, with endarteritis and extensive fibrosis. | ||
==Risk Factors== | ==Risk Factors== | ||
Risk factors for congenital syphilis include all the risk factors which predispose a pregnant woman to have syphilis infection:<ref name="pmid2356911">{{cite journal| author=Rolfs RT, Goldberg M, Sharrar RG| title=Risk factors for syphilis: cocaine use and prostitution. | journal=Am J Public Health | year= 1990 | volume= 80 | issue= 7 | pages= 853-7 | pmid=2356911 | doi= | pmc=1404975 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2356911 }} </ref><ref name="pmid17675391">{{cite journal| author=Zhou H, Chen XS, Hong FC, Pan P, Yang F, Cai YM et al.| title=Risk factors for syphilis infection among pregnant women: results of a case-control study in Shenzhen, China. | journal=Sex Transm Infect | year= 2007 | volume= 83 | issue= 6 | pages= 476-80 | pmid=17675391 | doi=10.1136/sti.2007.026187 | pmc=2598725 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17675391 }} </ref><ref name="pmid15247352">{{cite journal| author=Hook EW, Peeling RW| title=Syphilis control--a continuing challenge. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 2 | pages= 122-4 | pmid=15247352 | doi=10.1056/NEJMp048126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15247352 }} </ref><ref name="pmid16205297">{{cite journal| author=Buchacz K, Greenberg A, Onorato I, Janssen R| title=Syphilis epidemics and human immunodeficiency virus (HIV) incidence among men who have sex with men in the United States: implications for HIV prevention. | journal=Sex Transm Dis | year= 2005 | volume= 32 | issue= 10 Suppl | pages= S73-9 | pmid=16205297 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16205297 }} </ref><ref name="pmid25514173">{{cite journal| author=Solomon MM, Mayer KH| title=Evolution of the syphilis epidemic among men who have sex with men. | journal=Sex Health | year= 2015 | volume= 12 | issue= 2 | pages= 96-102 | pmid=25514173 | doi=10.1071/SH14173 | pmc=4470884 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25514173 }} </ref><ref name="pmid24927712">{{cite journal| author=Hakre S, Arteaga GB, Núñez AE, Arambu N, Aumakhan B, Liu M et al.| title=Prevalence of HIV, syphilis, and other sexually transmitted infections among MSM from three cities in Panama. | journal=J Urban Health | year= 2014 | volume= 91 | issue= 4 | pages= 793-808 | pmid=24927712 | doi=10.1007/s11524-014-9885-4 | pmc=4134449 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24927712 }} </ref><ref name="newell">Newell, J., et al. "A population-based study of syphilis and sexually transmitted disease syndromes in north-western Tanzania. 2. Risk factors and health seeking behaviour." Genitourinary medicine 69.6 (1993): 421-426.</ref> | Risk factors for congenital syphilis include all the risk factors which predispose a pregnant woman to have syphilis infection:<nowiki><ref name="pmid2356911">{{cite journal| author=Rolfs RT, Goldberg M, Sharrar RG| title=Risk factors for syphilis: cocaine use and prostitution. | journal=Am J Public Health | year= 1990 | volume= 80 | issue= 7 | pages= 853-7 | pmid=2356911 | doi= | pmc=1404975 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2356911 }} </ref></nowiki><nowiki><ref name="pmid17675391">{{cite journal| author=Zhou H, Chen XS, Hong FC, Pan P, Yang F, Cai YM et al.| title=Risk factors for syphilis infection among pregnant women: results of a case-control study in Shenzhen, China. | journal=Sex Transm Infect | year= 2007 | volume= 83 | issue= 6 | pages= 476-80 | pmid=17675391 | doi=10.1136/sti.2007.026187 | pmc=2598725 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17675391 }} </ref></nowiki><nowiki><ref name="pmid15247352">{{cite journal| author=Hook EW, Peeling RW| title=Syphilis control--a continuing challenge. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 2 | pages= 122-4 | pmid=15247352 | doi=10.1056/NEJMp048126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15247352 }} </ref></nowiki><nowiki><ref name="pmid16205297">{{cite journal| author=Buchacz K, Greenberg A, Onorato I, Janssen R| title=Syphilis epidemics and human immunodeficiency virus (HIV) incidence among men who have sex with men in the United States: implications for HIV prevention. | journal=Sex Transm Dis | year= 2005 | volume= 32 | issue= 10 Suppl | pages= S73-9 | pmid=16205297 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16205297 }} </ref></nowiki><nowiki><ref name="pmid25514173">{{cite journal| author=Solomon MM, Mayer KH| title=Evolution of the syphilis epidemic among men who have sex with men. | journal=Sex Health | year= 2015 | volume= 12 | issue= 2 | pages= 96-102 | pmid=25514173 | doi=10.1071/SH14173 | pmc=4470884 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25514173 }} </ref></nowiki><nowiki><ref name="pmid24927712">{{cite journal| author=Hakre S, Arteaga GB, Núñez AE, Arambu N, Aumakhan B, Liu M et al.| title=Prevalence of HIV, syphilis, and other sexually transmitted infections among MSM from three cities in Panama. | journal=J Urban Health | year= 2014 | volume= 91 | issue= 4 | pages= 793-808 | pmid=24927712 | doi=10.1007/s11524-014-9885-4 | pmc=4134449 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24927712 }} </ref></nowiki><nowiki><ref name="newell">Newell, J., et al. "A population-based study of syphilis and sexually transmitted disease syndromes in north-western Tanzania. 2. Risk factors and health seeking behaviour." Genitourinary medicine 69.6 (1993): 421-426.</ref></nowiki> | ||
*Inadequate antenatal care | *Inadequate antenatal care | ||
*Multiple sexual partners | *Multiple sexual partners | ||
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*It is estimated that every year 2 million pregnant women are infected with syphilis every year. | *It is estimated that every year 2 million pregnant women are infected with syphilis every year. | ||
*In 2005, WHO reported that 460,000 abortions or still birth and 270,000 cases of congenital syphilis every year can be attributed to maternal syphilis. | *In 2005, WHO reported that 460,000 abortions or still birth and 270,000 cases of congenital syphilis every year can be attributed to maternal syphilis. | ||
*The incidence of congenital syphilis in United States in the year 2014 is 11.6 cases per 100,000 live births. The incidence of congenital syphilis has increased when compared to the numbers from 2008 to 2012 and the change is attributed to the increase in the number of women with primary and secondary syphilis.<ref name="pmid25487961">{{cite journal| author=Peterman TA, Su J, Bernstein KT, Weinstock H| title=Syphilis in the United States: on the rise? | journal=Expert Rev Anti Infect Ther | year= 2015 | volume= 13 | issue= 2 | pages= 161-8 | pmid=25487961 | doi=10.1586/14787210.2015.990384 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25487961 }} </ref><ref name="pmid26562206">{{cite journal| author=Bowen V, Su J, Torrone E, Kidd S, Weinstock H| title=Increase in incidence of congenital syphilis - United States, 2012-2014. | journal=MMWR Morb Mortal Wkly Rep | year= 2015 | volume= 64 | issue= 44 | pages= 1241-5 | pmid=26562206 | doi=10.15585/mmwr.mm6444a3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26562206 }} </ref> | *The incidence of congenital syphilis in United States in the year 2014 is 11.6 cases per 100,000 live births. The incidence of congenital syphilis has increased when compared to the numbers from 2008 to 2012 and the change is attributed to the increase in the number of women with primary and secondary syphilis.<nowiki><ref name="pmid25487961">{{cite journal| author=Peterman TA, Su J, Bernstein KT, Weinstock H| title=Syphilis in the United States: on the rise? | journal=Expert Rev Anti Infect Ther | year= 2015 | volume= 13 | issue= 2 | pages= 161-8 | pmid=25487961 | doi=10.1586/14787210.2015.990384 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25487961 }} </ref></nowiki><nowiki><ref name="pmid26562206">{{cite journal| author=Bowen V, Su J, Torrone E, Kidd S, Weinstock H| title=Increase in incidence of congenital syphilis - United States, 2012-2014. | journal=MMWR Morb Mortal Wkly Rep | year= 2015 | volume= 64 | issue= 44 | pages= 1241-5 | pmid=26562206 | doi=10.15585/mmwr.mm6444a3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26562206 }} </ref></nowiki> | ||
===Race=== | ===Race=== | ||
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==Natural History, Complications and Prognosis== | ==Natural History, Complications and Prognosis== | ||
===Natural History=== | ===Natural History=== | ||
Syphilis is a sexually transmitted disease and is prevalent in high risk population. Women with syphilis infection can transmit the infection to the fetus in utero resulting in a wide spectrum of outcomes. The risk of transmission is higher in pregnant women who do not undergo regular antenatal screening or in women who are untreated or adequately treated during the period of gestation. The risk of transmission to the fetus is dependent on the stage of syphilis infection in the mother (primary, secondary, tertiary or latent), duration of maternal infection and the exposure to fetus in utero. The transmission of infection typically occurs during the second trimester but early transmission also occurs. Syphilis can complicate the outcome of pregnancy and is dependent on the severity of infection in the fetus, severe infection has adverse outcomes in the new born.<ref name="pmid6340889">{{cite journal| author=Charles D| title=Syphilis. | journal=Clin Obstet Gynecol | year= 1983 | volume= 26 | issue= 1 | pages= 125-37 | pmid=6340889 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6340889 }} </ref><ref name="QinFeng2014">{{cite journal|last1=Qin|first1=Jia-Bi|last2=Feng|first2=Tie-Jian|last3=Yang|first3=Tu-Bao|last4=Hong|first4=Fu-Chang|last5=Lan|first5=Li-Na|last6=Zhang|first6=Chun-Lai|last7=Yang|first7=Fan|last8=Mamady|first8=Keita|last9=Dong|first9=Willa|title=Risk Factors for Congenital Syphilis and Adverse Pregnancy Outcomes in Offspring of Women With Syphilis in Shenzhen, China|journal=Sexually Transmitted Diseases|volume=41|issue=1|year=2014|pages=13–23|issn=0148-5717|doi=10.1097/OLQ.0000000000000062}}</ref> | Syphilis is a sexually transmitted disease and is prevalent in high risk population. Women with syphilis infection can transmit the infection to the fetus in utero resulting in a wide spectrum of outcomes. The risk of transmission is higher in pregnant women who do not undergo regular antenatal screening or in women who are untreated or adequately treated during the period of gestation. The risk of transmission to the fetus is dependent on the stage of syphilis infection in the mother (primary, secondary, tertiary or latent), duration of maternal infection and the exposure to fetus in utero. The transmission of infection typically occurs during the second trimester but early transmission also occurs. Syphilis can complicate the outcome of pregnancy and is dependent on the severity of infection in the fetus, severe infection has adverse outcomes in the new born.<nowiki><ref name="pmid6340889">{{cite journal| author=Charles D| title=Syphilis. | journal=Clin Obstet Gynecol | year= 1983 | volume= 26 | issue= 1 | pages= 125-37 | pmid=6340889 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6340889 }} </ref></nowiki><nowiki><ref name="QinFeng2014">{{cite journal|last1=Qin|first1=Jia-Bi|last2=Feng|first2=Tie-Jian|last3=Yang|first3=Tu-Bao|last4=Hong|first4=Fu-Chang|last5=Lan|first5=Li-Na|last6=Zhang|first6=Chun-Lai|last7=Yang|first7=Fan|last8=Mamady|first8=Keita|last9=Dong|first9=Willa|title=Risk Factors for Congenital Syphilis and Adverse Pregnancy Outcomes in Offspring of Women With Syphilis in Shenzhen, China|journal=Sexually Transmitted Diseases|volume=41|issue=1|year=2014|pages=13–23|issn=0148-5717|doi=10.1097/OLQ.0000000000000062}}</ref></nowiki> | ||
===Complications=== | ===Complications=== | ||
*Severe infection in the fetus can result in spontaneous abortion, stillbirth, non-immune hydrops, intrauterine growth restriction, and perinatal death, and serious sequelae in liveborn infected children.<ref name="pmid24275265">{{cite journal| author=Cohen SE, Klausner JD, Engelman J, Philip S| title=Syphilis in the modern era: an update for physicians. | journal=Infect Dis Clin North Am | year= 2013 | volume= 27 | issue= 4 | pages= 705-22 | pmid=24275265 | doi=10.1016/j.idc.2013.08.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24275265 }} </ref> | *Severe infection in the fetus can result in spontaneous abortion, stillbirth, non-immune hydrops, intrauterine growth restriction, and perinatal death, and serious sequelae in liveborn infected children.<nowiki><ref name="pmid24275265">{{cite journal| author=Cohen SE, Klausner JD, Engelman J, Philip S| title=Syphilis in the modern era: an update for physicians. | journal=Infect Dis Clin North Am | year= 2013 | volume= 27 | issue= 4 | pages= 705-22 | pmid=24275265 | doi=10.1016/j.idc.2013.08.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24275265 }} </ref></nowiki> | ||
===Prognosis=== | ===Prognosis=== | ||
*Adequate treatment of infected mother during the period of gestation can prevent the transmission of disease significantly and treatment of the mother with one dose of pencillin is proven to improve outcomes in the fetus.<ref name="pmid12232835">{{cite journal |vauthors=Watson-Jones D, Gumodoka B, Weiss H, Changalucha J, Todd J, Mugeye K, Buvé A, Kanga Z, Ndeki L, Rusizoka M, Ross D, Marealle J, Balira R, Mabey D, Hayes R |title=Syphilis in pregnancy in Tanzania. II. The effectiveness of antenatal syphilis screening and single-dose benzathine penicillin treatment for the prevention of adverse pregnancy outcomes |journal=J. Infect. Dis. |volume=186 |issue=7 |pages=948–57 |year=2002 |pmid=12232835 |doi=10.1086/342951 |url=}}</ref> | *Adequate treatment of infected mother during the period of gestation can prevent the transmission of disease significantly and treatment of the mother with one dose of pencillin is proven to improve outcomes in the fetus.<nowiki><ref name="pmid12232835">{{cite journal |vauthors=Watson-Jones D, Gumodoka B, Weiss H, Changalucha J, Todd J, Mugeye K, Buvé A, Kanga Z, Ndeki L, Rusizoka M, Ross D, Marealle J, Balira R, Mabey D, Hayes R |title=Syphilis in pregnancy in Tanzania. II. The effectiveness of antenatal syphilis screening and single-dose benzathine penicillin treatment for the prevention of adverse pregnancy outcomes |journal=J. Infect. Dis. |volume=186 |issue=7 |pages=948–57 |year=2002 |pmid=12232835 |doi=10.1086/342951 |url=}}</ref></nowiki> | ||
*In newborns and infants with congenital syphilis treatment with penicillin has a good prognosis with normal development.<ref name="pmid21639965">{{cite journal| author=Caddy SC, Lee BE, Sutherland K, Robinson JL, Plitt SS, Read R et al.| title=Pregnancy and neonatal outcomes of women with reactive syphilis serology in Alberta, 2002 to 2006. | journal=J Obstet Gynaecol Can | year= 2011 | volume= 33 | issue= 5 | pages= 453-9 | pmid=21639965 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21639965 }} </ref> | *In newborns and infants with congenital syphilis treatment with penicillin has a good prognosis with normal development.<nowiki><ref name="pmid21639965">{{cite journal| author=Caddy SC, Lee BE, Sutherland K, Robinson JL, Plitt SS, Read R et al.| title=Pregnancy and neonatal outcomes of women with reactive syphilis serology in Alberta, 2002 to 2006. | journal=J Obstet Gynaecol Can | year= 2011 | volume= 33 | issue= 5 | pages= 453-9 | pmid=21639965 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21639965 }} </ref></nowiki> | ||
==Diagosis== | ==Diagosis== | ||
===History and Symptoms=== | ===History and Symptoms=== | ||
A combination of maternal risk factors and symptoms in the baby are essential to suspect congenital syphilis. The most common symptoms in the new born include: <ref name="pmid3288424">{{cite journal| author=Wendel GD| title=Gestational and congenital syphilis. | journal=Clin Perinatol | year= 1988 | volume= 15 | issue= 2 | pages= 287-303 | pmid=3288424 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3288424 }} </ref><ref name="pmid16649151">{{cite journal| author=Kremenová S, Zákoucká H, Kremen J| title=[Issues of congenital syphilis in the past twenty years. II. Clinical picture]. | journal=Klin Mikrobiol Infekc Lek | year= 2006 | volume= 12 | issue= 2 | pages= 51-7 | pmid=16649151 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16649151 }} </ref> | A combination of maternal risk factors and symptoms in the baby are essential to suspect congenital syphilis. The most common symptoms in the new born include: <nowiki><ref name="pmid3288424">{{cite journal| author=Wendel GD| title=Gestational and congenital syphilis. | journal=Clin Perinatol | year= 1988 | volume= 15 | issue= 2 | pages= 287-303 | pmid=3288424 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3288424 }} </ref></nowiki><nowiki><ref name="pmid16649151">{{cite journal| author=Kremenová S, Zákoucká H, Kremen J| title=[Issues of congenital syphilis in the past twenty years. II. Clinical picture]. | journal=Klin Mikrobiol Infekc Lek | year= 2006 | volume= 12 | issue= 2 | pages= 51-7 | pmid=16649151 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16649151 }} </ref></nowiki> | ||
*Skin rash occurs in 70% of affected cases | *Skin rash occurs in 70% of affected cases | ||
*Yellowish discoloration of the skin | *Yellowish discoloration of the skin | ||
Line 115: | Line 113: | ||
===Physical Examination=== | ===Physical Examination=== | ||
The physical examination findings suggestive of congenital syphilis include:<ref name="EwingRoberts1985">{{cite journal|last1=Ewing|first1=C I|last2=Roberts|first2=C|last3=Davidson|first3=D C|last4=Arya|first4=O P|title=Early congenital syphilis still occurs.|journal=Archives of Disease in Childhood|volume=60|issue=12|year=1985|pages=1128–1133|issn=0003-9888|doi=10.1136/adc.60.12.1128}}</ref> | The physical examination findings suggestive of congenital syphilis include:<nowiki><ref name="EwingRoberts1985">{{cite journal|last1=Ewing|first1=C I|last2=Roberts|first2=C|last3=Davidson|first3=D C|last4=Arya|first4=O P|title=Early congenital syphilis still occurs.|journal=Archives of Disease in Childhood|volume=60|issue=12|year=1985|pages=1128–1133|issn=0003-9888|doi=10.1136/adc.60.12.1128}}</ref></nowiki> | ||
*Vesiculobullous or maculopapular rash occurring on the palms and soles is present in 70% of the children with congenital syphilis. Other patterns of rash such as vesiculobullous lesions, condylomata lata lesions, annular lesions, and erythema multiforme-like targetoid lesions are present in affected infants.<ref name="FerreiraCorreia2016">{{cite journal|last1=Ferreira|first1=Sara Tavares|last2=Correia|first2=Cátia|last3=Marçal|first3=Monica|last4=Tuna|first4=Madalena Lopo|title=Skin rash: a manifestation of early congenital syphilis|journal=BMJ Case Reports|year=2016|pages=bcr2016216148|issn=1757-790X|doi=10.1136/bcr-2016-216148}}</ref> | *Vesiculobullous or maculopapular rash occurring on the palms and soles is present in 70% of the children with congenital syphilis. Other patterns of rash such as vesiculobullous lesions, condylomata lata lesions, annular lesions, and erythema multiforme-like targetoid lesions are present in affected infants.<nowiki><ref name="FerreiraCorreia2016">{{cite journal|last1=Ferreira|first1=Sara Tavares|last2=Correia|first2=Cátia|last3=Marçal|first3=Monica|last4=Tuna|first4=Madalena Lopo|title=Skin rash: a manifestation of early congenital syphilis|journal=BMJ Case Reports|year=2016|pages=bcr2016216148|issn=1757-790X|doi=10.1136/bcr-2016-216148}}</ref></nowiki> | ||
*Low birth weight with signs of prematurity | *Low birth weight with signs of prematurity | ||
*Nonimmune hydrops : It is characteristic of congenital syphilis and the features of non-immune hydrops include ascites, pericardial effusion, pleural effusion and skin edema, however Rh incompatability should be ruled out as a cause of hydrops.<ref name="pmid8822333">{{cite journal| author=Barron SD, Pass RF| title=Infectious causes of hydrops fetalis. | journal=Semin Perinatol | year= 1995 | volume= 19 | issue= 6 | pages= 493-501 | pmid=8822333 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8822333 }} </ref> | *Nonimmune hydrops : It is characteristic of congenital syphilis and the features of non-immune hydrops include ascites, pericardial effusion, pleural effusion and skin edema, however Rh incompatability should be ruled out as a cause of hydrops.<nowiki><ref name="pmid8822333">{{cite journal| author=Barron SD, Pass RF| title=Infectious causes of hydrops fetalis. | journal=Semin Perinatol | year= 1995 | volume= 19 | issue= 6 | pages= 493-501 | pmid=8822333 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8822333 }} </ref></nowiki> | ||
*Jaundice | *Jaundice | ||
*Hepatosplenomegaly | *Hepatosplenomegaly | ||
Line 127: | Line 125: | ||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
====Prenatal Diagnosis==== | ====Prenatal Diagnosis==== | ||
*Detection of IgM antibodies aganist T.pallidum in the blood collected by chordocentesis.<ref name="pmid1923218">{{cite journal |vauthors=Wendel GD, Sánchez PJ, Peters MT, Harstad TW, Potter LL, Norgard MV |title=Identification of Treponema pallidum in amniotic fluid and fetal blood from pregnancies complicated by congenital syphilis |journal=Obstet Gynecol |volume=78 |issue=5 Pt 2 |pages=890–5 |year=1991 |pmid=1923218 |doi= |url=}}</ref><ref name="pmid26753496">{{cite journal| author=Park JY, Han GH, Kwon DY, Hong HR, Seol HJ| title=Prenatal diagnosis of congenital syphilis presenting with transient pleural effusion in the fetus: a case report and rising incidence of congenital syphilis in South Korea. | journal=Clin Exp Obstet Gynecol | year= 2015 | volume= 42 | issue= 6 | pages= 822-4 | pmid=26753496 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26753496 }} </ref> | *Detection of IgM antibodies aganist T.pallidum in the blood collected by chordocentesis.<nowiki><ref name="pmid1923218">{{cite journal |vauthors=Wendel GD, Sánchez PJ, Peters MT, Harstad TW, Potter LL, Norgard MV |title=Identification of Treponema pallidum in amniotic fluid and fetal blood from pregnancies complicated by congenital syphilis |journal=Obstet Gynecol |volume=78 |issue=5 Pt 2 |pages=890–5 |year=1991 |pmid=1923218 |doi= |url=}}</ref></nowiki><nowiki><ref name="pmid26753496">{{cite journal| author=Park JY, Han GH, Kwon DY, Hong HR, Seol HJ| title=Prenatal diagnosis of congenital syphilis presenting with transient pleural effusion in the fetus: a case report and rising incidence of congenital syphilis in South Korea. | journal=Clin Exp Obstet Gynecol | year= 2015 | volume= 42 | issue= 6 | pages= 822-4 | pmid=26753496 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26753496 }} </ref></nowiki> | ||
*PCR of the amniotic fluid to detect the T. pallidum DNA.<ref name="MullerEwert2006">{{cite journal|last1=Muller|first1=M|last2=Ewert|first2=I|last3=Hansmann|first3=F|last4=Tiemann|first4=C|last5=Hagedorn|first5=H J|last6=Solbach|first6=W|last7=Roider|first7=J|last8=Nolle|first8=B|last9=Laqua|first9=H|last10=Hoerauf|first10=H|title=Detection of Treponema pallidum in the vitreous by PCR|journal=British Journal of Ophthalmology|volume=91|issue=5|year=2006|pages=592–595|issn=0007-1161|doi=10.1136/bjo.2006.110288}}</ref> | *PCR of the amniotic fluid to detect the T. pallidum DNA.<nowiki><ref name="MullerEwert2006">{{cite journal|last1=Muller|first1=M|last2=Ewert|first2=I|last3=Hansmann|first3=F|last4=Tiemann|first4=C|last5=Hagedorn|first5=H J|last6=Solbach|first6=W|last7=Roider|first7=J|last8=Nolle|first8=B|last9=Laqua|first9=H|last10=Hoerauf|first10=H|title=Detection of Treponema pallidum in the vitreous by PCR|journal=British Journal of Ophthalmology|volume=91|issue=5|year=2006|pages=592–595|issn=0007-1161|doi=10.1136/bjo.2006.110288}}</ref></nowiki> | ||
*Antenatal ultrasound is commonly done and the findings suggestive of congenital syphilis include: hydrops fetalis characterised by scalp oedema, placental thickening, serous cavity effusion, and polyhydramnios. Other additional findings inlcude hepatosplenomegaly, placentomegaly, non-continuous gastrointestinal obstruction and dilatation of the small bowel.<ref name="pmid9565220">{{cite journal |vauthors=Levine Z, Sherer DM, Jacobs A, Rotenberg O |title=Nonimmune hydrops fetalis due to congenital syphilis associated with negative intrapartum maternal serology screening |journal=Am J Perinatol |volume=15 |issue=4 |pages=233–6 |year=1998 |pmid=9565220 |doi=10.1055/s-2007-993933 |url=}}</ref><ref name="Russell1974">{{cite journal|last1=Russell|first1=Peter|title=Placental Abnormalities of Congenital Syphilis|journal=American Journal of Diseases of Children|volume=128|issue=2|year=1974|pages=160|issn=0002-922X|doi=10.1001/archpedi.1974.02110270034007}}</ref><ref name="pmid7927729">{{cite journal |vauthors=Riley BS, Oppenheimer-Marks N, Radolf JD, Norgard MV |title=Virulent Treponema pallidum promotes adhesion of leukocytes to human vascular endothelial cells |journal=Infect. Immun. |volume=62 |issue=10 |pages=4622–5 |year=1994 |pmid=7927729 |pmc=303152 |doi= |url=}}</ref> | *Antenatal ultrasound is commonly done and the findings suggestive of congenital syphilis include: hydrops fetalis characterised by scalp oedema, placental thickening, serous cavity effusion, and polyhydramnios. Other additional findings inlcude hepatosplenomegaly, placentomegaly, non-continuous gastrointestinal obstruction and dilatation of the small bowel.<nowiki><ref name="pmid9565220">{{cite journal |vauthors=Levine Z, Sherer DM, Jacobs A, Rotenberg O |title=Nonimmune hydrops fetalis due to congenital syphilis associated with negative intrapartum maternal serology screening |journal=Am J Perinatol |volume=15 |issue=4 |pages=233–6 |year=1998 |pmid=9565220 |doi=10.1055/s-2007-993933 |url=}}</ref></nowiki><nowiki><ref name="Russell1974">{{cite journal|last1=Russell|first1=Peter|title=Placental Abnormalities of Congenital Syphilis|journal=American Journal of Diseases of Children|volume=128|issue=2|year=1974|pages=160|issn=0002-922X|doi=10.1001/archpedi.1974.02110270034007}}</ref></nowiki><nowiki><ref name="pmid7927729">{{cite journal |vauthors=Riley BS, Oppenheimer-Marks N, Radolf JD, Norgard MV |title=Virulent Treponema pallidum promotes adhesion of leukocytes to human vascular endothelial cells |journal=Infect. Immun. |volume=62 |issue=10 |pages=4622–5 |year=1994 |pmid=7927729 |pmc=303152 |doi= |url=}}</ref></nowiki> | ||
====Postnatal Diagnosis==== | ====Postnatal Diagnosis==== | ||
*Examination of the placenta or umbilical cord using a silver stain demonstrates spirochetes or a T. pallidum PCR test can be done. | *Examination of the placenta or umbilical cord using a silver stain demonstrates spirochetes or a T. pallidum PCR test can be done. | ||
*The use of serological tests to identify the infection in infants less than 15months of age born to infected mothers is not performed as passive transfer of IgG antibodies to the fetus occurs during the pregnancy. | *The use of serological tests to identify the infection in infants less than 15months of age born to infected mothers is not performed as passive transfer of IgG antibodies to the fetus occurs during the pregnancy. | ||
*Other laboratory findings in the new born include:<ref name="pmid11384701">{{cite journal |vauthors=Hollier LM, Harstad TW, Sanchez PJ, Twickler DM, Wendel GD |title=Fetal syphilis: clinical and laboratory characteristics |journal=Obstet Gynecol |volume=97 |issue=6 |pages=947–53 |year=2001 |pmid=11384701 |doi= |url=}}</ref> | *Other laboratory findings in the new born include:<nowiki><ref name="pmid11384701">{{cite journal |vauthors=Hollier LM, Harstad TW, Sanchez PJ, Twickler DM, Wendel GD |title=Fetal syphilis: clinical and laboratory characteristics |journal=Obstet Gynecol |volume=97 |issue=6 |pages=947–53 |year=2001 |pmid=11384701 |doi= |url=}}</ref></nowiki> | ||
*Elevated liver enzymes | *Elevated liver enzymes | ||
*Leucocytosis | *Leucocytosis | ||
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*Skeletal survey in a still born, typical osseous lesions are demonstrated in congenital syphilis. | *Skeletal survey in a still born, typical osseous lesions are demonstrated in congenital syphilis. | ||
====Long Bone Radiographs==== | ====Long Bone Radiographs==== | ||
*Radiographs typically demonstrate bilateral, symmetric, and polyostotic lesions in femur, humerus, and tibia.<ref name="pmid2584243">{{cite journal| author=Rasool MN, Govender S| title=The skeletal manifestations of congenital syphilis. A review of 197 cases. | journal=J Bone Joint Surg Br | year= 1989 | volume= 71 | issue= 5 | pages= 752-5 | pmid=2584243 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2584243 }} </ref><ref name="pmid8609122">{{cite journal| author=Kocher MS, Caniza M| title=Parrot pseudoparalysis of the upper extremities. A case report. | journal=J Bone Joint Surg Am | year= 1996 | volume= 78 | issue= 2 | pages= 284-7 | pmid=8609122 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8609122 }} </ref> | *Radiographs typically demonstrate bilateral, symmetric, and polyostotic lesions in femur, humerus, and tibia.<nowiki><ref name="pmid2584243">{{cite journal| author=Rasool MN, Govender S| title=The skeletal manifestations of congenital syphilis. A review of 197 cases. | journal=J Bone Joint Surg Br | year= 1989 | volume= 71 | issue= 5 | pages= 752-5 | pmid=2584243 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2584243 }} </ref></nowiki><nowiki><ref name="pmid8609122">{{cite journal| author=Kocher MS, Caniza M| title=Parrot pseudoparalysis of the upper extremities. A case report. | journal=J Bone Joint Surg Am | year= 1996 | volume= 78 | issue= 2 | pages= 284-7 | pmid=8609122 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8609122 }} </ref></nowiki> | ||
*Common findings on radiographs include: | *Common findings on radiographs include: | ||
**Metaphyseal lucent bands | **Metaphyseal lucent bands | ||
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====Ultrasound==== | ====Ultrasound==== | ||
Antenatal sonographic features include:<ref name="radiop2"> https://radiopaedia.org/articles/in-utero-syphilis-infection. Accessed on September 28th, 2016. </ref><ref name="pmid21844732">{{cite journal| author=Reyna-Figueroa J, Esparza-Aguilar M, Hernández-Hernández Ldel C, Fernández-Canton S, Richardson-Lopez Collada VL| title=Congenital syphilis, a reemergent disease in Mexico: its epidemiology during the last 2 decades. | journal=Sex Transm Dis | year= 2011 | volume= 38 | issue= 9 | pages= 798-801 | pmid=21844732 | doi=10.1097/OLQ.0b013e31821898ca | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21844732 }} </ref> | Antenatal sonographic features include:<nowiki><ref name="radiop2"> https://radiopaedia.org/articles/in-utero-syphilis-infection. Accessed on September 28th, 2016. </ref></nowiki><nowiki><ref name="pmid21844732">{{cite journal| author=Reyna-Figueroa J, Esparza-Aguilar M, Hernández-Hernández Ldel C, Fernández-Canton S, Richardson-Lopez Collada VL| title=Congenital syphilis, a reemergent disease in Mexico: its epidemiology during the last 2 decades. | journal=Sex Transm Dis | year= 2011 | volume= 38 | issue= 9 | pages= 798-801 | pmid=21844732 | doi=10.1097/OLQ.0b013e31821898ca | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21844732 }} </ref></nowiki> | ||
*Fetal [[hepatosplenomegaly]] | *Fetal [[hepatosplenomegaly]] | ||
* Placentomegaly | * Placentomegaly | ||
Line 161: | Line 159: | ||
*Bent fetal long bones | *Bent fetal long bones | ||
====Doppler Studies==== | ====Doppler Studies==== | ||
Doppler ultrasound of the uterine and umbilical arteries show increases in the mean systolic to diastolic ratios in mothers infected with syphilis indicating an increased resistance to perfusion of the placenta secondary to vasculitis, placental villitis and obliterative arteritis caused by syphilis.<ref name="Genc2000">{{cite journal|last1=Genc|first1=M.|title=Syphilis in pregnancy|journal=Sexually Transmitted Infections|volume=76|issue=2|year=2000|pages=73–79|issn=13684973|doi=10.1136/sti.76.2.73}}</ref> | Doppler ultrasound of the uterine and umbilical arteries show increases in the mean systolic to diastolic ratios in mothers infected with syphilis indicating an increased resistance to perfusion of the placenta secondary to vasculitis, placental villitis and obliterative arteritis caused by syphilis.<nowiki><ref name="Genc2000">{{cite journal|last1=Genc|first1=M.|title=Syphilis in pregnancy|journal=Sexually Transmitted Infections|volume=76|issue=2|year=2000|pages=73–79|issn=13684973|doi=10.1136/sti.76.2.73}}</ref></nowiki> | ||
===Other Diagnostic Studies=== | ===Other Diagnostic Studies=== | ||
====CSF Analysis==== | ====CSF Analysis==== | ||
'''Indications : ''' Lumbar puncture is indicated in the following situations.<ref name="Phiske2014">{{cite journal|last1=Phiske|first1=MeghanaMadhukar|title=Current trends in congenital syphilis|journal=Indian Journal of Sexually Transmitted Diseases and AIDS|volume=35|issue=1|year=2014|pages=12|issn=0253-7184|doi=10.4103/0253-7184.132404}}</ref> | '''Indications : ''' Lumbar puncture is indicated in the following situations.<nowiki><ref name="Phiske2014">{{cite journal|last1=Phiske|first1=MeghanaMadhukar|title=Current trends in congenital syphilis|journal=Indian Journal of Sexually Transmitted Diseases and AIDS|volume=35|issue=1|year=2014|pages=12|issn=0253-7184|doi=10.4103/0253-7184.132404}}</ref></nowiki> | ||
*If the infant or child has signs and symptoms of congenital Syphilis. | *If the infant or child has signs and symptoms of congenital Syphilis. | ||
*If there is no documentation of treatment for maternal infection during the period of gestation. | *If there is no documentation of treatment for maternal infection during the period of gestation. | ||
Line 170: | Line 168: | ||
*If the mother was inadequately treated or documentation of the treatment is incomplete. | *If the mother was inadequately treated or documentation of the treatment is incomplete. | ||
*A four-fold decline in titer following therapy in the mother is not documented. | *A four-fold decline in titer following therapy in the mother is not documented. | ||
'''CSF Findings:<ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815 }} </ref> | '''CSF Findings:<nowiki><ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815 }} </ref></nowiki>''' | ||
*Reactive CSF VDRL. | *Reactive CSF VDRL. | ||
*CSF pleocytosis(>25 white blood cells [WBC]/microL for infants <1 month) | *CSF pleocytosis(>25 white blood cells [WBC]/microL for infants <1 month) | ||
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| | | | ||
*All women should be screened [[Syphilis laboratory tests#Serology|serologically]] for syphilis early in pregnancy.<ref name=syphilis>https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/syphilis-infection-in-pregnancy-screening Accessed on september 27,2016</ref><ref name=cdc2015>http://www.cdc.gov/std/tg2015/references.htm#424 Accessed on September 27, 2016</ref> | *All women should be screened [[Syphilis laboratory tests#Serology|serologically]] for syphilis early in pregnancy.<ref name=syphilis>https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/syphilis-infection-in-pregnancy-screening Accessed on september 27,2016</ref><ref name=cdc2015>http://www.cdc.gov/std/tg2015/references.htm#424 Accessed on September 27, 2016</ref> | ||
*Most states mandate screening at the first prenatal visit for all women;<ref name="pmid11384701">Hollier LM, Harstad TW, Sanchez PJ, Twickler DM, Wendel GD (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11384701 Fetal syphilis: clinical and laboratory characteristics.] ''Obstet Gynecol'' 97 (6):947-53. PMID: [http://pubmed.gov/11384701 11384701]</ref> antepartum screening by [[Syphilis laboratory findings#Nontreponemal test|nontreponemal antibody testing]] is typical, but in some settings, [[Syphilis laboratory findings#Treponemal test|treponemal antibody testing]] is being used. | *Most states mandate screening at the first prenatal visit for all women;<nowiki><ref name="pmid11384701">Hollier LM, Harstad TW, Sanchez PJ, Twickler DM, Wendel GD (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11384701 Fetal syphilis: clinical and laboratory characteristics.] ''Obstet Gynecol'' 97 (6):947-53. PMID: [http://pubmed.gov/11384701 11384701]</ref></nowiki> antepartum screening by [[Syphilis laboratory findings#Nontreponemal test|nontreponemal antibody testing]] is typical, but in some settings, [[Syphilis laboratory findings#Treponemal test|treponemal antibody testing]] is being used. | ||
*Pregnant women with reactive treponemal screening tests should have confirmatory testing with nontreponemal tests with titers to monitor treatment response. | *Pregnant women with reactive treponemal screening tests should have confirmatory testing with nontreponemal tests with titers to monitor treatment response. | ||
*In populations in which use of prenatal care is not optimal, [[Rapid plasma reagent|RPR test]] screening and treatment (if the RPR test is reactive) should be performed at the time that pregnancy is confirmed. | *In populations in which use of prenatal care is not optimal, [[Rapid plasma reagent|RPR test]] screening and treatment (if the RPR test is reactive) should be performed at the time that pregnancy is confirmed. | ||
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!'''Recommended Regimen for Treatment''' | !'''Recommended Regimen for Treatment''' | ||
| | | | ||
*Pregnant women should be treated with the [[penicillin]] regimen appropriate for their stage of infection.<ref name="urlSexually Transmitted Diseases Treatment Guidelines, 2010">{{cite web|url=http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm |title=Sexually Transmitted Diseases Treatment Guidelines, 2010 |format= |work= |accessdate=2012-12-19}}</ref> | *Pregnant women should be treated with the [[penicillin]] regimen appropriate for their stage of infection.<nowiki><ref name="urlSexually Transmitted Diseases Treatment Guidelines, 2010">{{cite web|url=http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm |title=Sexually Transmitted Diseases Treatment Guidelines, 2010 |format= |work= |accessdate=2012-12-19}}</ref></nowiki> | ||
* [[Penicillin]] is effective for preventing maternal transmission to the fetus and for treating fetal infection.<ref name="pmid9916946">Alexander JM, Sheffield JS, Sanchez PJ, Mayfield J, Wendel GD (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9916946 Efficacy of treatment for syphilis in pregnancy.] ''Obstet Gynecol'' 93 (1):5-8. PMID: [http://pubmed.gov/9916946 9916946]</ref> Evidence is insufficient to determine optimal, recommended penicillin regimens.<ref name="pmid11686978">Walker GJ (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11686978 Antibiotics for syphilis diagnosed during pregnancy.] ''Cochrane Database Syst Rev'' (3):CD001143. [http://dx.doi.org/10.1002/14651858.CD001143 DOI:10.1002/14651858.CD001143] PMID: [http://pubmed.gov/11686978 11686978]</ref> | * [[Penicillin]] is effective for preventing maternal transmission to the fetus and for treating fetal infection.<nowiki><ref name="pmid9916946">Alexander JM, Sheffield JS, Sanchez PJ, Mayfield J, Wendel GD (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9916946 Efficacy of treatment for syphilis in pregnancy.] ''Obstet Gynecol'' 93 (1):5-8. PMID: [http://pubmed.gov/9916946 9916946]</ref></nowiki> Evidence is insufficient to determine optimal, recommended penicillin regimens.<nowiki><ref name="pmid11686978">Walker GJ (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11686978 Antibiotics for syphilis diagnosed during pregnancy.] ''Cochrane Database Syst Rev'' (3):CD001143. [http://dx.doi.org/10.1002/14651858.CD001143 DOI:10.1002/14651858.CD001143] PMID: [http://pubmed.gov/11686978 11686978]</ref></nowiki> | ||
|- | |- | ||
!'''Additional Considerations''' | !'''Additional Considerations''' | ||
| | | | ||
*Some evidence suggests that additional therapy can be beneficial for pregnant women in some settings (e.g., a second dose of [[Penicillin#Benzylpenicillin (penicillin G)|benzathine penicillin]] 2.4 million units IM administered 1 week after the initial dose for women who have [[Syphilis pathophysiology#Primary syphilis|primary]], [[Syphilis pathophysiology#Secondary syphilis|secondary]], or [[Syphilis pathophysiology#Latent syphilis|early latent syphilis]]).<ref name="pmid12353207">Wendel GD, Sheffield JS, Hollier LM, Hill JB, Ramsey PS, Sánchez PJ (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12353207 Treatment of syphilis in pregnancy and prevention of congenital syphilis.] ''Clin Infect Dis'' 35 (Suppl 2):S200-9. [http://dx.doi.org/10.1086/342108 DOI:10.1086/342108] PMID: [http://pubmed.gov/12353207 12353207]</ref> | *Some evidence suggests that additional therapy can be beneficial for pregnant women in some settings (e.g., a second dose of [[Penicillin#Benzylpenicillin (penicillin G)|benzathine penicillin]] 2.4 million units IM administered 1 week after the initial dose for women who have [[Syphilis pathophysiology#Primary syphilis|primary]], [[Syphilis pathophysiology#Secondary syphilis|secondary]], or [[Syphilis pathophysiology#Latent syphilis|early latent syphilis]]).<nowiki><ref name="pmid12353207">Wendel GD, Sheffield JS, Hollier LM, Hill JB, Ramsey PS, Sánchez PJ (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12353207 Treatment of syphilis in pregnancy and prevention of congenital syphilis.] ''Clin Infect Dis'' 35 (Suppl 2):S200-9. [http://dx.doi.org/10.1086/342108 DOI:10.1086/342108] PMID: [http://pubmed.gov/12353207 12353207]</ref></nowiki> | ||
*When syphilis is diagnosed during the second half of pregnancy, management should include a sonographic fetal evaluation for [[congenital syphilis]], but this evaluation should not delay therapy. | *When syphilis is diagnosed during the second half of pregnancy, management should include a sonographic fetal evaluation for [[congenital syphilis]], but this evaluation should not delay therapy. | ||
*Sonographic signs of fetal or placental syphilis (i.e., [[hepatomegaly]], [[ascites]], [[hydrops]], [[anemia|fetal anemia]], or a thickened placenta) indicate a greater risk for fetal treatment failure;<ref name="pmid11384701">Hollier LM, Harstad TW, Sanchez PJ, Twickler DM, Wendel GD (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11384701 Fetal syphilis: clinical and laboratory characteristics.] ''Obstet Gynecol'' 97 (6):947-53. PMID: [http://pubmed.gov/11384701 11384701]</ref> such cases should be managed in consultation with obstetric specialists. Evidence is insufficient to recommend specific regimens for these situations. | *Sonographic signs of fetal or placental syphilis (i.e., [[hepatomegaly]], [[ascites]], [[hydrops]], [[anemia|fetal anemia]], or a thickened placenta) indicate a greater risk for fetal treatment failure;<nowiki><ref name="pmid11384701">Hollier LM, Harstad TW, Sanchez PJ, Twickler DM, Wendel GD (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11384701 Fetal syphilis: clinical and laboratory characteristics.] ''Obstet Gynecol'' 97 (6):947-53. PMID: [http://pubmed.gov/11384701 11384701]</ref></nowiki> such cases should be managed in consultation with obstetric specialists. Evidence is insufficient to recommend specific regimens for these situations. | ||
*Women treated for syphilis during the second half of pregnancy are at risk for [[premature labor]] and/or [[fetal distress]] if the treatment precipitates the [[Jarisch-Herxheimer reaction]].<ref name="pmid2304710">Klein VR, Cox SM, Mitchell MD, Wendel GD (1990) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2304710 The Jarisch-Herxheimer reaction complicating syphilotherapy in pregnancy.] ''Obstet Gynecol'' 75 (3 Pt 1):375-80. PMID: [http://pubmed.gov/2304710 2304710]</ref> These women should be advised to seek obstetric attention after treatment if they notice any fever, contractions, or decrease in fetal movements. | *Women treated for syphilis during the second half of pregnancy are at risk for [[premature labor]] and/or [[fetal distress]] if the treatment precipitates the [[Jarisch-Herxheimer reaction]].<nowiki><ref name="pmid2304710">Klein VR, Cox SM, Mitchell MD, Wendel GD (1990) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2304710 The Jarisch-Herxheimer reaction complicating syphilotherapy in pregnancy.] ''Obstet Gynecol'' 75 (3 Pt 1):375-80. PMID: [http://pubmed.gov/2304710 2304710]</ref></nowiki> These women should be advised to seek obstetric attention after treatment if they notice any fever, contractions, or decrease in fetal movements. | ||
*[[Stillbirth]] is a rare complication of treatment, but concern for this complication should not delay necessary treatment. | *[[Stillbirth]] is a rare complication of treatment, but concern for this complication should not delay necessary treatment. | ||
*Pregnant women taking treatment for late latent syphilis should not miss any dose, else she must repeat the whole course of therapy.<ref name="pmid8355931">{{cite journal| author=Nathan L, Bawdon RE, Sidawi JE, Stettler RW, McIntire DM, Wendel GD| title=Penicillin levels following the administration of benzathine penicillin G in pregnancy. | journal=Obstet Gynecol | year= 1993 | volume= 82 | issue= 3 | pages= 338-42 | pmid=8355931 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8355931 }} </ref> | *Pregnant women taking treatment for late latent syphilis should not miss any dose, else she must repeat the whole course of therapy.<nowiki><ref name="pmid8355931">{{cite journal| author=Nathan L, Bawdon RE, Sidawi JE, Stettler RW, McIntire DM, Wendel GD| title=Penicillin levels following the administration of benzathine penicillin G in pregnancy. | journal=Obstet Gynecol | year= 1993 | volume= 82 | issue= 3 | pages= 338-42 | pmid=8355931 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8355931 }} </ref></nowiki> | ||
*All patients who have syphilis should be offered testing for HIV infection. | *All patients who have syphilis should be offered testing for HIV infection. | ||
|- | |- | ||
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*Pregnant women who have a history of [[Syphilis medical therapy#Pencillin allergy|penicillin allergy]] should be desensitized and treated with [[penicillin]]. | *Pregnant women who have a history of [[Syphilis medical therapy#Pencillin allergy|penicillin allergy]] should be desensitized and treated with [[penicillin]]. | ||
*Oral step-wise penicillin dose challenge or [[Syphilis medical therapy#Pencillin allergy: Penicillin skin test|skin testing]] may be helpful in identifying women at risk for acute allergic reactions. | *Oral step-wise penicillin dose challenge or [[Syphilis medical therapy#Pencillin allergy: Penicillin skin test|skin testing]] may be helpful in identifying women at risk for acute allergic reactions. | ||
*[[Tetracycline]] and [[doxycycline]] usually are not used during pregnancy. [[Erythromycin]] and [[azithromycin]] should not be used, because neither reliably cures maternal infection or treats an infected fetus.<ref name="pmid11686978">Walker GJ (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11686978 Antibiotics for syphilis diagnosed during pregnancy.] ''Cochrane Database Syst Rev'' (3):CD001143. [http://dx.doi.org/10.1002/14651858.CD001143 DOI:10.1002/14651858.CD001143] PMID: [http://pubmed.gov/11686978 11686978]</ref> Data are insufficient to recommend [[ceftriaxone]] for treatment of maternal infection and prevention of [[congenital syphilis]]. | *[[Tetracycline]] and [[doxycycline]] usually are not used during pregnancy. [[Erythromycin]] and [[azithromycin]] should not be used, because neither reliably cures maternal infection or treats an infected fetus.<nowiki><ref name="pmid11686978">Walker GJ (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11686978 Antibiotics for syphilis diagnosed during pregnancy.] ''Cochrane Database Syst Rev'' (3):CD001143. [http://dx.doi.org/10.1002/14651858.CD001143 DOI:10.1002/14651858.CD001143] PMID: [http://pubmed.gov/11686978 11686978]</ref></nowiki> Data are insufficient to recommend [[ceftriaxone]] for treatment of maternal infection and prevention of [[congenital syphilis]]. | ||
|- | |- | ||
!'''Pregnant Woman with HIV Infection''' | !'''Pregnant Woman with HIV Infection''' | ||
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*Serologic titers should be repeated at 28-32 weeks' gestation and at delivery as recommended for the disease stage. Providers should ensure that the clinical and antibody responses are appropriate for the patient's stage of disease, although most women will deliver before their serologic response to treatment can be assessed definitively. | *Serologic titers should be repeated at 28-32 weeks' gestation and at delivery as recommended for the disease stage. Providers should ensure that the clinical and antibody responses are appropriate for the patient's stage of disease, although most women will deliver before their serologic response to treatment can be assessed definitively. | ||
*Inadequate maternal treatment is likely if delivery occurs within 30 days of therapy, if clinical signs of infection are present at delivery, or if the maternal antibody titer at delivery is fourfold higher than the pretreatment titer. | *Inadequate maternal treatment is likely if delivery occurs within 30 days of therapy, if clinical signs of infection are present at delivery, or if the maternal antibody titer at delivery is fourfold higher than the pretreatment titer. | ||
*Serologic titers can be checked monthly in women at high risk for reinfection or in geographic areas in which the prevalence of syphilis is high. <ref name="urlSexually Transmitted Diseases Treatment Guidelines, 2010">{{cite web|url=http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm |title=Sexually Transmitted Diseases Treatment Guidelines, 2010 |format= |work= |accessdate=2012-12-19}}</ref> | *Serologic titers can be checked monthly in women at high risk for reinfection or in geographic areas in which the prevalence of syphilis is high. <nowiki><ref name="urlSexually Transmitted Diseases Treatment Guidelines, 2010">{{cite web|url=http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm |title=Sexually Transmitted Diseases Treatment Guidelines, 2010 |format= |work= |accessdate=2012-12-19}}</ref></nowiki> | ||
|} | |} | ||
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* Data are insufficient regarding the use of other antimicrobial agents (e.g., ceftriaxone) for congenital syphilis in infants and children. | * Data are insufficient regarding the use of other antimicrobial agents (e.g., ceftriaxone) for congenital syphilis in infants and children. | ||
|} | |} | ||
{| border="1" | {| border="1" | ||
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===Primary Prevention=== | ===Primary Prevention=== | ||
Primary prevention of syphilis in women of reproductive age and men who have sex with women and prevention of mother to infant transmission in infected individuals plays a important role in decreasing incidence of congenital syphilis.Effective measures for the primary prevention of congenital syphilis include reducing the risk of mother having syphilis infection and also screening during the antenatal period:<ref name="pmid19805553">{{cite journal |author=Stamm LV |title=Global challenge of atibiotic-resistant Treponema pallidum |journal=[[Antimicrobial Agents and Chemotherapy]] |volume=54 |issue=2 |pages=583–9 |year=2010 |month=February |pmid=19805553 |pmc=2812177 |doi=10.1128/AAC.01095-09 |url=http://aac.asm.org/cgi/pmidlookup?view=long&pmid=19805553 |accessdate=2012-02-21}}</ref><ref name="pmid24135571">{{cite journal |vauthors=Cameron CE, Lukehart SA |title=Current status of syphilis vaccine development: need, challenges, prospects |journal=Vaccine |volume=32 |issue=14 |pages=1602–9 |year=2014 |pmid=24135571 |pmc=3951677 |doi=10.1016/j.vaccine.2013.09.053 |url=}}</ref><ref name=CDCsyphilis>http://www.cdc.gov/std/tg2015/syphilis.htm Accessed on September 27, 2016</ref><ref name="pmid27081586">{{cite journal| author=Lago EG| title=Current Perspectives on Prevention of Mother-to-Child Transmission of Syphilis. | journal=Cureus | year= 2016 | volume= 8 | issue= 3 | pages= e525 | pmid=27081586 | doi=10.7759/cureus.525 | pmc=4829408 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27081586 }} </ref> | Primary prevention of syphilis in women of reproductive age and men who have sex with women and prevention of mother to infant transmission in infected individuals plays a important role in decreasing incidence of congenital syphilis.Effective measures for the primary prevention of congenital syphilis include reducing the risk of mother having syphilis infection and also screening during the antenatal period:<nowiki><ref name="pmid19805553">{{cite journal |author=Stamm LV |title=Global challenge of atibiotic-resistant Treponema pallidum |journal=[[Antimicrobial Agents and Chemotherapy]] |volume=54 |issue=2 |pages=583–9 |year=2010 |month=February |pmid=19805553 |pmc=2812177 |doi=10.1128/AAC.01095-09 |url=http://aac.asm.org/cgi/pmidlookup?view=long&pmid=19805553 |accessdate=2012-02-21}}</ref></nowiki><nowiki><ref name="pmid24135571">{{cite journal |vauthors=Cameron CE, Lukehart SA |title=Current status of syphilis vaccine development: need, challenges, prospects |journal=Vaccine |volume=32 |issue=14 |pages=1602–9 |year=2014 |pmid=24135571 |pmc=3951677 |doi=10.1016/j.vaccine.2013.09.053 |url=}}</ref></nowiki><nowiki><ref name=CDCsyphilis>http://www.cdc.gov/std/tg2015/syphilis.htm Accessed on September 27, 2016</ref></nowiki><nowiki><ref name="pmid27081586">{{cite journal| author=Lago EG| title=Current Perspectives on Prevention of Mother-to-Child Transmission of Syphilis. | journal=Cureus | year= 2016 | volume= 8 | issue= 3 | pages= e525 | pmid=27081586 | doi=10.7759/cureus.525 | pmc=4829408 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27081586 }} </ref></nowiki> | ||
*Routine screening in pregnant females, individuals with high risk behaviours, and those residing in highly prevalent areas. | *Routine screening in pregnant females, individuals with high risk behaviours, and those residing in highly prevalent areas. | ||
*Abstinence from intimate physical contact with an infected person. | *Abstinence from intimate physical contact with an infected person. | ||
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===Secondary Prevention=== | ===Secondary Prevention=== | ||
*Regular follow up of infants with congenital syphilis to examine for the re-appearance of signs and symptoms of syphilis after recommended treatment has shown to improve outcomes.<ref name="pmid28146163">{{cite journal| author=Feliz MC, Prizybicien AR, Rossoni AM, Tahnus T, Pereira AM, Rodrigues C| title=Adherence to the follow-up of the newborn exposed to syphilis and factors associated with loss to follow-up. | journal=Rev Bras Epidemiol | year= 2016 | volume= 19 | issue= 4 | pages= 727-739 | pmid=28146163 | doi=10.1590/1980-5497201600040004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28146163 }} </ref><ref name="pmid26474815">{{cite journal| author=Wallace HE, Broomhall HM, Isitt CE, Miall LS, Wilson JD| title=Serological follow-up of infants born to mothers with positive syphilis serology - real-world experiences. | journal=Int J STD AIDS | year= 2016 | volume= 27 | issue= 13 | pages= 1213-1217 | pmid=26474815 | doi=10.1177/0956462415612394 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26474815 }} </ref><ref name="pmid27622443">{{cite journal| author=Vallejo C, Cifuentes Y| title=Characterization and six-month follow-up on a cohort of newborns with congenital syphilis. | journal=Biomedica | year= 2016 | volume= 36 | issue= 1 | pages= 101-8 | pmid=27622443 | doi=10.7705/biomedica.v36i1.2661 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27622443 }} </ref> | *Regular follow up of infants with congenital syphilis to examine for the re-appearance of signs and symptoms of syphilis after recommended treatment has shown to improve outcomes.<nowiki><ref name="pmid28146163">{{cite journal| author=Feliz MC, Prizybicien AR, Rossoni AM, Tahnus T, Pereira AM, Rodrigues C| title=Adherence to the follow-up of the newborn exposed to syphilis and factors associated with loss to follow-up. | journal=Rev Bras Epidemiol | year= 2016 | volume= 19 | issue= 4 | pages= 727-739 | pmid=28146163 | doi=10.1590/1980-5497201600040004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28146163 }} </ref></nowiki><nowiki><ref name="pmid26474815">{{cite journal| author=Wallace HE, Broomhall HM, Isitt CE, Miall LS, Wilson JD| title=Serological follow-up of infants born to mothers with positive syphilis serology - real-world experiences. | journal=Int J STD AIDS | year= 2016 | volume= 27 | issue= 13 | pages= 1213-1217 | pmid=26474815 | doi=10.1177/0956462415612394 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26474815 }} </ref></nowiki><nowiki><ref name="pmid27622443"></nowiki>{{cite journal| author=Vallejo C, Cifuentes Y| title=Characterization and six-month follow-up on a cohort of newborns with congenital syphilis. | journal=Biomedica | year= 2016 | volume= 36 | issue= 1 | pages= 101-8 | pmid=27622443 | doi=10.7705/biomedica.v36i1.2661 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27622443 }} </ref> | ||
==References== | ==References== |
Revision as of 15:33, 6 February 2017
Overview
Congenital Syphilis is caused by Treponema pallidum, its transmitted to the fetus in utero from an infected mother via the placenta. The severity of the disease is dependent on the stage of maternal infection and the duration of exposure to the fetus. Transmission is typically in the second trimester and the highest rates of transmission are seen in women with primary syphilis. The rates of transmission decrease with the increasing duration of the maternal infection, as the concentration of spirochetes in the blood stream decreases. Syphilis infection to the fetus in utero can result in stillborn, miscarriage and a live birth with severe manifestations of hydrops. Prenatal screening for syphilis during the first trimester is recommended to all pregnant women and adequate treatment with penicillin prevents the transmission to the fetus.
Historical Perspective
- In the 19th century congenital syphilis was believed to be transmitted during conception by the father’s sperm, during delivery in the birth canal, or from infected milk or breasts.[1]
- In 1905, Schaudinn and Hoffmann identified Spirochaeta pallida.
- Transplacental transmission from an asymptomatic infected mother was first described in 1906.[2]
- In 1943, Lentz and Ingraham reported penicillin as treatment for congenital syphilis.
- In 2006, the WHO launched a global effort to eliminate congenital syphilis.
Classification
Congenital Syphilis is classified based on the timing of appearance of signs and symptoms into:[3]
- Early congenital Syphilis: If the signs and symptoms are identified in children aged less than 2 years. It is usually diagnosed in new born or in the first few weeks after birth.[4]
- Late congenital Syphilis: If the signs and symptoms of the disease are identified in children aged more than 2 years. The signs are usually non-specific and more than half the children are asymptomatic. They can present with interstitial keratitis, eighth nerve deafness or clutton's joints.
- Stigmata: These are the scars resulting from early or late congenital syphilis. The features of stigmata in early congenital syphilis include saddle nose deformity, Hutchinson's teeth, rhagades, choriod scarring and onychia. Stigmata secondary to late congenital syphilis include perforation of the palate, corneal opacities, optic atrophy and periosteal changes of tibia.
Causes
The causative pathogen for Congenital syphilis Treponema pallidum.
Pathophysiology
Pathogenesis
- Transmission to the fetus is transplacental, it can also occur during delivery in the presence of maternal genital lesions.[5][6][7]
- The risk of transmission to the fetus is dependent on the stage of the maternal disease(dependent on the spirochete concentration in the blood stream) and the duration of exposure to the fetus in utero.[8]
- The risk of vertical transmission of syphilis from an infected untreated mother decreases as maternal disease duration progresses: transmission risk of 70–100% for primary syphilis and 40% for early latent syphilis to 10% for late latent disease. The variation in the percentages with the duration of infection is because the concentration of spirochetes in the blood stream decrease with the duration of maternal syphilis infection.[9]
- Kassowitz's law describes the an inverse relationship of interval between the disease and pregnancy. Longer the interval between infection and pregnancy more benign is the outcome.[3]
- Transmission of infection typically takes place between the 16th and 28th week of pregnancy, however the transmission can be as early as the first trimester of pregnancy.</nowiki><ref name="pmid17675391">{{cite journal| author=Zhou H, Chen XS, Hong FC, Pan P, Yang F, Cai YM et al.| title=Risk factors for syphilis infection among pregnant women: results of a case-control study in Shenzhen, China. | journal=Sex Transm Infect | year= 2007 | volume= 83 | issue= 6 | pages= 476-80 | pmid=17675391 | doi=10.1136/sti.2007.026187 | pmc=2598725 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17675391 }} </ref><ref name="pmid15247352">{{cite journal| author=Hook EW, Peeling RW| title=Syphilis control--a continuing challenge. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 2 | pages= 122-4 | pmid=15247352 | doi=10.1056/NEJMp048126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15247352 }} </ref><ref name="pmid16205297">{{cite journal| author=Buchacz K, Greenberg A, Onorato I, Janssen R| title=Syphilis epidemics and human immunodeficiency virus (HIV) incidence among men who have sex with men in the United States: implications for HIV prevention. | journal=Sex Transm Dis | year= 2005 | volume= 32 | issue= 10 Suppl | pages= S73-9 | pmid=16205297 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16205297 }} </ref><ref name="pmid25514173">{{cite journal| author=Solomon MM, Mayer KH| title=Evolution of the syphilis epidemic among men who have sex with men. | journal=Sex Health | year= 2015 | volume= 12 | issue= 2 | pages= 96-102 | pmid=25514173 | doi=10.1071/SH14173 | pmc=4470884 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25514173 }} </ref><ref name="pmid24927712">{{cite journal| author=Hakre S, Arteaga GB, Núñez AE, Arambu N, Aumakhan B, Liu M et al.| title=Prevalence of HIV, syphilis, and other sexually transmitted infections among MSM from three cities in Panama. | journal=J Urban Health | year= 2014 | volume= 91 | issue= 4 | pages= 793-808 | pmid=24927712 | doi=10.1007/s11524-014-9885-4 | pmc=4134449 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24927712 }} </ref><ref name="newell">Newell, J., et al. "A population-based study of syphilis and sexually transmitted disease syndromes in north-western Tanzania. 2. Risk factors and health seeking behaviour." Genitourinary medicine 69.6 (1993): 421-426.</ref>
- Inadequate antenatal care
- Multiple sexual partners
- Prostitution
- Illicit drug use
- Unprotected sex
- Residence in highly prevalent areas
- HIV infection
- Presence of other STIs
- Previous history of STIs
- Intravenous drug use
- Health care professionals who are predisposed to occupational risk
- Low socioeconomic status
Screening
Effective prevention and detection of congenital syphilis depends on the identification of syphilis in pregnant women and screening is a key component to decrease the incidence of congenital syphilis. The recommendations for screening are as follows:
Screening Recommendations | |
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Timing of Screening | Test all pregnant women at the first prenatal visit. |
Screening Tests |
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High Risk Population |
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Epidemiology, Demographics
Incidence
- It is estimated that every year 2 million pregnant women are infected with syphilis every year.
- In 2005, WHO reported that 460,000 abortions or still birth and 270,000 cases of congenital syphilis every year can be attributed to maternal syphilis.
- The incidence of congenital syphilis in United States in the year 2014 is 11.6 cases per 100,000 live births. The incidence of congenital syphilis has increased when compared to the numbers from 2008 to 2012 and the change is attributed to the increase in the number of women with primary and secondary syphilis.<ref name="pmid25487961">{{cite journal| author=Peterman TA, Su J, Bernstein KT, Weinstock H| title=Syphilis in the United States: on the rise? | journal=Expert Rev Anti Infect Ther | year= 2015 | volume= 13 | issue= 2 | pages= 161-8 | pmid=25487961 | doi=10.1586/14787210.2015.990384 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25487961 }} </ref><ref name="pmid26562206">{{cite journal| author=Bowen V, Su J, Torrone E, Kidd S, Weinstock H| title=Increase in incidence of congenital syphilis - United States, 2012-2014. | journal=MMWR Morb Mortal Wkly Rep | year= 2015 | volume= 64 | issue= 44 | pages= 1241-5 | pmid=26562206 | doi=10.15585/mmwr.mm6444a3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26562206 }} </ref>
Race
- Congenital syphilis is ten times and three times more prevalent in black population compared to whites and Hispanics respectively.
Natural History, Complications and Prognosis
Natural History
Syphilis is a sexually transmitted disease and is prevalent in high risk population. Women with syphilis infection can transmit the infection to the fetus in utero resulting in a wide spectrum of outcomes. The risk of transmission is higher in pregnant women who do not undergo regular antenatal screening or in women who are untreated or adequately treated during the period of gestation. The risk of transmission to the fetus is dependent on the stage of syphilis infection in the mother (primary, secondary, tertiary or latent), duration of maternal infection and the exposure to fetus in utero. The transmission of infection typically occurs during the second trimester but early transmission also occurs. Syphilis can complicate the outcome of pregnancy and is dependent on the severity of infection in the fetus, severe infection has adverse outcomes in the new born.<ref name="pmid6340889">{{cite journal| author=Charles D| title=Syphilis. | journal=Clin Obstet Gynecol | year= 1983 | volume= 26 | issue= 1 | pages= 125-37 | pmid=6340889 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6340889 }} </ref><ref name="QinFeng2014">{{cite journal|last1=Qin|first1=Jia-Bi|last2=Feng|first2=Tie-Jian|last3=Yang|first3=Tu-Bao|last4=Hong|first4=Fu-Chang|last5=Lan|first5=Li-Na|last6=Zhang|first6=Chun-Lai|last7=Yang|first7=Fan|last8=Mamady|first8=Keita|last9=Dong|first9=Willa|title=Risk Factors for Congenital Syphilis and Adverse Pregnancy Outcomes in Offspring of Women With Syphilis in Shenzhen, China|journal=Sexually Transmitted Diseases|volume=41|issue=1|year=2014|pages=13–23|issn=0148-5717|doi=10.1097/OLQ.0000000000000062}}</ref>
Complications
- Severe infection in the fetus can result in spontaneous abortion, stillbirth, non-immune hydrops, intrauterine growth restriction, and perinatal death, and serious sequelae in liveborn infected children.<ref name="pmid24275265">{{cite journal| author=Cohen SE, Klausner JD, Engelman J, Philip S| title=Syphilis in the modern era: an update for physicians. | journal=Infect Dis Clin North Am | year= 2013 | volume= 27 | issue= 4 | pages= 705-22 | pmid=24275265 | doi=10.1016/j.idc.2013.08.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24275265 }} </ref>
Prognosis
- Adequate treatment of infected mother during the period of gestation can prevent the transmission of disease significantly and treatment of the mother with one dose of pencillin is proven to improve outcomes in the fetus.<ref name="pmid12232835">{{cite journal |vauthors=Watson-Jones D, Gumodoka B, Weiss H, Changalucha J, Todd J, Mugeye K, Buvé A, Kanga Z, Ndeki L, Rusizoka M, Ross D, Marealle J, Balira R, Mabey D, Hayes R |title=Syphilis in pregnancy in Tanzania. II. The effectiveness of antenatal syphilis screening and single-dose benzathine penicillin treatment for the prevention of adverse pregnancy outcomes |journal=J. Infect. Dis. |volume=186 |issue=7 |pages=948–57 |year=2002 |pmid=12232835 |doi=10.1086/342951 |url=}}</ref>
- In newborns and infants with congenital syphilis treatment with penicillin has a good prognosis with normal development.<ref name="pmid21639965">{{cite journal| author=Caddy SC, Lee BE, Sutherland K, Robinson JL, Plitt SS, Read R et al.| title=Pregnancy and neonatal outcomes of women with reactive syphilis serology in Alberta, 2002 to 2006. | journal=J Obstet Gynaecol Can | year= 2011 | volume= 33 | issue= 5 | pages= 453-9 | pmid=21639965 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21639965 }} </ref>
Diagosis
History and Symptoms
A combination of maternal risk factors and symptoms in the baby are essential to suspect congenital syphilis. The most common symptoms in the new born include: <ref name="pmid3288424">{{cite journal| author=Wendel GD| title=Gestational and congenital syphilis. | journal=Clin Perinatol | year= 1988 | volume= 15 | issue= 2 | pages= 287-303 | pmid=3288424 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3288424 }} </ref><ref name="pmid16649151">{{cite journal| author=Kremenová S, Zákoucká H, Kremen J| title=[Issues of congenital syphilis in the past twenty years. II. Clinical picture]. | journal=Klin Mikrobiol Infekc Lek | year= 2006 | volume= 12 | issue= 2 | pages= 51-7 | pmid=16649151 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16649151 }} </ref>
- Skin rash occurs in 70% of affected cases
- Yellowish discoloration of the skin
- Abdominal distension
- Generalized edema
- Irritability
- Low birth weight
- Failure to thrive
- Fever
- Difficulty breathing
Late Syphilis: It is diagnosed in children aged greater than 2 years. The symptoms are non specific.
Physical Examination
The physical examination findings suggestive of congenital syphilis include:<ref name="EwingRoberts1985">{{cite journal|last1=Ewing|first1=C I|last2=Roberts|first2=C|last3=Davidson|first3=D C|last4=Arya|first4=O P|title=Early congenital syphilis still occurs.|journal=Archives of Disease in Childhood|volume=60|issue=12|year=1985|pages=1128–1133|issn=0003-9888|doi=10.1136/adc.60.12.1128}}</ref>
- Vesiculobullous or maculopapular rash occurring on the palms and soles is present in 70% of the children with congenital syphilis. Other patterns of rash such as vesiculobullous lesions, condylomata lata lesions, annular lesions, and erythema multiforme-like targetoid lesions are present in affected infants.<ref name="FerreiraCorreia2016">{{cite journal|last1=Ferreira|first1=Sara Tavares|last2=Correia|first2=Cátia|last3=Marçal|first3=Monica|last4=Tuna|first4=Madalena Lopo|title=Skin rash: a manifestation of early congenital syphilis|journal=BMJ Case Reports|year=2016|pages=bcr2016216148|issn=1757-790X|doi=10.1136/bcr-2016-216148}}</ref>
- Low birth weight with signs of prematurity
- Nonimmune hydrops : It is characteristic of congenital syphilis and the features of non-immune hydrops include ascites, pericardial effusion, pleural effusion and skin edema, however Rh incompatability should be ruled out as a cause of hydrops.<ref name="pmid8822333">{{cite journal| author=Barron SD, Pass RF| title=Infectious causes of hydrops fetalis. | journal=Semin Perinatol | year= 1995 | volume= 19 | issue= 6 | pages= 493-501 | pmid=8822333 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8822333 }} </ref>
- Jaundice
- Hepatosplenomegaly
- Rhinitis
- Lympadenopathy
- Pseudoparalysis of an extremities
Laboratory Findings
Prenatal Diagnosis
- Detection of IgM antibodies aganist T.pallidum in the blood collected by chordocentesis.<ref name="pmid1923218">{{cite journal |vauthors=Wendel GD, Sánchez PJ, Peters MT, Harstad TW, Potter LL, Norgard MV |title=Identification of Treponema pallidum in amniotic fluid and fetal blood from pregnancies complicated by congenital syphilis |journal=Obstet Gynecol |volume=78 |issue=5 Pt 2 |pages=890–5 |year=1991 |pmid=1923218 |doi= |url=}}</ref><ref name="pmid26753496">{{cite journal| author=Park JY, Han GH, Kwon DY, Hong HR, Seol HJ| title=Prenatal diagnosis of congenital syphilis presenting with transient pleural effusion in the fetus: a case report and rising incidence of congenital syphilis in South Korea. | journal=Clin Exp Obstet Gynecol | year= 2015 | volume= 42 | issue= 6 | pages= 822-4 | pmid=26753496 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26753496 }} </ref>
- PCR of the amniotic fluid to detect the T. pallidum DNA.<ref name="MullerEwert2006">{{cite journal|last1=Muller|first1=M|last2=Ewert|first2=I|last3=Hansmann|first3=F|last4=Tiemann|first4=C|last5=Hagedorn|first5=H J|last6=Solbach|first6=W|last7=Roider|first7=J|last8=Nolle|first8=B|last9=Laqua|first9=H|last10=Hoerauf|first10=H|title=Detection of Treponema pallidum in the vitreous by PCR|journal=British Journal of Ophthalmology|volume=91|issue=5|year=2006|pages=592–595|issn=0007-1161|doi=10.1136/bjo.2006.110288}}</ref>
- Antenatal ultrasound is commonly done and the findings suggestive of congenital syphilis include: hydrops fetalis characterised by scalp oedema, placental thickening, serous cavity effusion, and polyhydramnios. Other additional findings inlcude hepatosplenomegaly, placentomegaly, non-continuous gastrointestinal obstruction and dilatation of the small bowel.<ref name="pmid9565220">{{cite journal |vauthors=Levine Z, Sherer DM, Jacobs A, Rotenberg O |title=Nonimmune hydrops fetalis due to congenital syphilis associated with negative intrapartum maternal serology screening |journal=Am J Perinatol |volume=15 |issue=4 |pages=233–6 |year=1998 |pmid=9565220 |doi=10.1055/s-2007-993933 |url=}}</ref><ref name="Russell1974">{{cite journal|last1=Russell|first1=Peter|title=Placental Abnormalities of Congenital Syphilis|journal=American Journal of Diseases of Children|volume=128|issue=2|year=1974|pages=160|issn=0002-922X|doi=10.1001/archpedi.1974.02110270034007}}</ref><ref name="pmid7927729">{{cite journal |vauthors=Riley BS, Oppenheimer-Marks N, Radolf JD, Norgard MV |title=Virulent Treponema pallidum promotes adhesion of leukocytes to human vascular endothelial cells |journal=Infect. Immun. |volume=62 |issue=10 |pages=4622–5 |year=1994 |pmid=7927729 |pmc=303152 |doi= |url=}}</ref>
Postnatal Diagnosis
- Examination of the placenta or umbilical cord using a silver stain demonstrates spirochetes or a T. pallidum PCR test can be done.
- The use of serological tests to identify the infection in infants less than 15months of age born to infected mothers is not performed as passive transfer of IgG antibodies to the fetus occurs during the pregnancy.
- Other laboratory findings in the new born include:<ref name="pmid11384701">{{cite journal |vauthors=Hollier LM, Harstad TW, Sanchez PJ, Twickler DM, Wendel GD |title=Fetal syphilis: clinical and laboratory characteristics |journal=Obstet Gynecol |volume=97 |issue=6 |pages=947–53 |year=2001 |pmid=11384701 |doi= |url=}}</ref>
- Elevated liver enzymes
- Leucocytosis
- Coombs negative haemolytic anaemia
- Thrombocytopenia
- Hypoalbuminemia
- Hyperbilirubinemia
Imaging Studies
X-Ray
- Skeletal survey in a still born, typical osseous lesions are demonstrated in congenital syphilis.
Long Bone Radiographs
- Radiographs typically demonstrate bilateral, symmetric, and polyostotic lesions in femur, humerus, and tibia.<ref name="pmid2584243">{{cite journal| author=Rasool MN, Govender S| title=The skeletal manifestations of congenital syphilis. A review of 197 cases. | journal=J Bone Joint Surg Br | year= 1989 | volume= 71 | issue= 5 | pages= 752-5 | pmid=2584243 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2584243 }} </ref><ref name="pmid8609122">{{cite journal| author=Kocher MS, Caniza M| title=Parrot pseudoparalysis of the upper extremities. A case report. | journal=J Bone Joint Surg Am | year= 1996 | volume= 78 | issue= 2 | pages= 284-7 | pmid=8609122 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8609122 }} </ref>
- Common findings on radiographs include:
- Metaphyseal lucent bands
- Symmetric localized demineralization and osseous destruction of proximal tibial metaphysis
- Metaphyseal serration
Ultrasound
Antenatal sonographic features include:<ref name="radiop2"> https://radiopaedia.org/articles/in-utero-syphilis-infection. Accessed on September 28th, 2016. </ref><ref name="pmid21844732">{{cite journal| author=Reyna-Figueroa J, Esparza-Aguilar M, Hernández-Hernández Ldel C, Fernández-Canton S, Richardson-Lopez Collada VL| title=Congenital syphilis, a reemergent disease in Mexico: its epidemiology during the last 2 decades. | journal=Sex Transm Dis | year= 2011 | volume= 38 | issue= 9 | pages= 798-801 | pmid=21844732 | doi=10.1097/OLQ.0b013e31821898ca | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21844732 }} </ref>
- Fetal hepatosplenomegaly
- Placentomegaly
- Fetal ascites
In severe cases findings include:
- Fetal hydrops
- Bent fetal long bones
Doppler Studies
Doppler ultrasound of the uterine and umbilical arteries show increases in the mean systolic to diastolic ratios in mothers infected with syphilis indicating an increased resistance to perfusion of the placenta secondary to vasculitis, placental villitis and obliterative arteritis caused by syphilis.<ref name="Genc2000">{{cite journal|last1=Genc|first1=M.|title=Syphilis in pregnancy|journal=Sexually Transmitted Infections|volume=76|issue=2|year=2000|pages=73–79|issn=13684973|doi=10.1136/sti.76.2.73}}</ref>
Other Diagnostic Studies
CSF Analysis
Indications : Lumbar puncture is indicated in the following situations.<ref name="Phiske2014">{{cite journal|last1=Phiske|first1=MeghanaMadhukar|title=Current trends in congenital syphilis|journal=Indian Journal of Sexually Transmitted Diseases and AIDS|volume=35|issue=1|year=2014|pages=12|issn=0253-7184|doi=10.4103/0253-7184.132404}}</ref>
- If the infant or child has signs and symptoms of congenital Syphilis.
- If there is no documentation of treatment for maternal infection during the period of gestation.
- If the mother was treated within 4 weeks of delivery.
- If the mother was inadequately treated or documentation of the treatment is incomplete.
- A four-fold decline in titer following therapy in the mother is not documented.
CSF Findings:<ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815 }} </ref>
- Reactive CSF VDRL.
- CSF pleocytosis(>25 white blood cells [WBC]/microL for infants <1 month)
- Elevated CSF protein (>150 mg/dL in term infants <1 month of age and >170 mg/dL in preterm infants <1 month of age)
Treatment
Medical Therapy
Management during the period of gestation
CDC Recommendations for management of pregnant woman with Syphilis infection | |
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Approach during the Prenatal Period |
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Recommended Regimen for Treatment |
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Additional Considerations |
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In patients with Penicillin Allergy |
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Pregnant Woman with HIV Infection |
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Follow Up |
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Management of a Neonate or an Infant with Congenital Syphilis
The diagnosis of congenital syphilis can be difficult, as maternal nontreponemal and treponemal IgG antibodies can be transferred through the placenta to the fetus, complicating the interpretation of reactive serologic tests for syphilis in neonates. Therefore, treatment decisions frequently must be made on the basis of:
- Identification of syphilis in the mother
- Adequacy of maternal treatment
- Presence of clinical, laboratory, or radiographic evidence of syphilis in the neonate
- Comparison of maternal (at delivery) and neonatal nontreponemal serologic titers using the same test, preferably conducted by the same laboratory.
Evaluation and Approach
- All neonates born to mothers who have reactive nontreponemal and treponemal test results should be evaluated with a quantitative nontreponemal serologic test (RPR or VDRL) performed on the neonate's serum, because umbilical cord blood can become contaminated with maternal blood and yield a false-positive result, and Wharton's jelly within the umbilical cord can yield a false-negative result.
- Conducting a treponemal test (i.e., TP-PA, FTA-ABS, EIA, or CIA) on neonatal serum is not recommended because it is difficult to interpret.
- Any neonate at risk for congenital syphilis should receive a full evaluation and testing for HIV infection.
- The following scenarios describe the congenital syphilis evaluation and treatment of neonates born to women who have reactive serologic tests for syphilis during pregnancy. Maternal history of infection with T. pallidum and treatment for syphilis must be considered when evaluating and treating the neonate for congenital syphilis in most scenarios, except when congenital syphilis is proven or highly probable.
CDC Recommendations for management of neonates with Congenital Syphilis | |
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Clinical senario 1 |
Recommended Evaluation
Preferred regimen 1: Aqueous crystalline penicillin G 100,000-150,000 U/kg/day, administered as 50,000 U/kg/dose IV q12h during the first 7 days of life and q8h thereafter for a total of 10 days |
Clinical senario 2 |
Recommended Evaluation
Preferred regimen 1: Aqueous crystalline penicillin G 100,000-150,000 U/kg/day, administered as 50,000 U/kg/dose IV q12h during the first 7 days of life and q8h thereafter for a total of 10 days |
Clinical senario 3 |
Recommended Evaluation'
Preferred regimen: Benzathine penicillin G 50,000 U/kg/dose IM single dose |
Clinical senario 4 |
Recommended evaluation
|
Follow up |
Note: Treponemal tests should not be used to evaluate treatment response because the results are qualitative and passive transfer of maternal IgG treponemal antibody might persist for at least 15 months |
Penicillin Allergy |
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CDC Recommendations for management of Infants and Children with Congenital Syphilis | |
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Congenital Syphilis in infants and children |
Recommended Evaluation
Preferred regimen: Aqueous crystalline penicillin G 50,000 U/kg q4–6h for 10 days
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Follow Up |
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Penicillin Allergy |
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Prevention
Primary Prevention
Primary prevention of syphilis in women of reproductive age and men who have sex with women and prevention of mother to infant transmission in infected individuals plays a important role in decreasing incidence of congenital syphilis.Effective measures for the primary prevention of congenital syphilis include reducing the risk of mother having syphilis infection and also screening during the antenatal period:<ref name="pmid19805553">{{cite journal |author=Stamm LV |title=Global challenge of atibiotic-resistant Treponema pallidum |journal=[[Antimicrobial Agents and Chemotherapy]] |volume=54 |issue=2 |pages=583–9 |year=2010 |month=February |pmid=19805553 |pmc=2812177 |doi=10.1128/AAC.01095-09 |url=http://aac.asm.org/cgi/pmidlookup?view=long&pmid=19805553 |accessdate=2012-02-21}}</ref><ref name="pmid24135571">{{cite journal |vauthors=Cameron CE, Lukehart SA |title=Current status of syphilis vaccine development: need, challenges, prospects |journal=Vaccine |volume=32 |issue=14 |pages=1602–9 |year=2014 |pmid=24135571 |pmc=3951677 |doi=10.1016/j.vaccine.2013.09.053 |url=}}</ref><ref name=CDCsyphilis>http://www.cdc.gov/std/tg2015/syphilis.htm Accessed on September 27, 2016</ref><ref name="pmid27081586">{{cite journal| author=Lago EG| title=Current Perspectives on Prevention of Mother-to-Child Transmission of Syphilis. | journal=Cureus | year= 2016 | volume= 8 | issue= 3 | pages= e525 | pmid=27081586 | doi=10.7759/cureus.525 | pmc=4829408 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27081586 }} </ref>
- Routine screening in pregnant females, individuals with high risk behaviours, and those residing in highly prevalent areas.
- Abstinence from intimate physical contact with an infected person.
- Consistent use of latex condoms.
- Limiting no of sexual partners.
- Avoid sharing sex toys.
- Practising safe sex.
Secondary Prevention
- Regular follow up of infants with congenital syphilis to examine for the re-appearance of signs and symptoms of syphilis after recommended treatment has shown to improve outcomes.<ref name="pmid28146163">{{cite journal| author=Feliz MC, Prizybicien AR, Rossoni AM, Tahnus T, Pereira AM, Rodrigues C| title=Adherence to the follow-up of the newborn exposed to syphilis and factors associated with loss to follow-up. | journal=Rev Bras Epidemiol | year= 2016 | volume= 19 | issue= 4 | pages= 727-739 | pmid=28146163 | doi=10.1590/1980-5497201600040004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28146163 }} </ref><ref name="pmid26474815">{{cite journal| author=Wallace HE, Broomhall HM, Isitt CE, Miall LS, Wilson JD| title=Serological follow-up of infants born to mothers with positive syphilis serology - real-world experiences. | journal=Int J STD AIDS | year= 2016 | volume= 27 | issue= 13 | pages= 1213-1217 | pmid=26474815 | doi=10.1177/0956462415612394 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26474815 }} </ref><ref name="pmid27622443">Vallejo C, Cifuentes Y (2016). "Characterization and six-month follow-up on a cohort of newborns with congenital syphilis". Biomedica. 36 (1): 101–8. doi:10.7705/biomedica.v36i1.2661. PMID 27622443. </ref>
References
- ↑ Obladen, Michael (2013). "Curse on Two Generations: A History of Congenital Syphilis". Neonatology. 103 (4): 274–280. doi:10.1159/000347107. ISSN 1661-7819.
- ↑ "Guidelines for the Prevention and Control of Congenital Syphilis".
- ↑ 3.0 3.1 Balaji G, Kalaivani S (2013). "Observance of Kassowitz law-late congenital syphilis: Palatal perforation and saddle nose deformity as presenting features". Indian J Sex Transm Dis. 34 (1): 35–7. doi:10.4103/0253-7184.112869. PMC 3730472. PMID 23919053.
- ↑ Cavagnaro S M F, Pereira R T, Pérez P C, Vargas Del V F, Sandoval C C (2014). "[Early congenital syphilis: a case report]". Rev Chil Pediatr. 85 (1): 86–93. doi:10.4067/S0370-41062014000100012. PMID 25079189.
- ↑ Wicher V, Wicher K (2001). "Pathogenesis of maternal-fetal syphilis revisited". Clin Infect Dis. 33 (3): 354–63. doi:10.1086/321904. PMID 11438902.
- ↑ Domingues RM, Leal Mdo C (2016). "[Incidence of congenital syphilis and factors associated with vertical transmission: data from the Birth in Brazil study]". Cad Saude Publica. 32 (6). doi:10.1590/0102-311X00082415. PMID 27333146.
- ↑ Peeling RW, Hook EW (2006). "The pathogenesis of syphilis: the Great Mimicker, revisited". J Pathol. 208 (2): 224–32. doi:10.1002/path.1903. PMID 16362988.
- ↑ Berman SM (2004). "Maternal syphilis: pathophysiology and treatment". Bull World Health Organ. 82 (6): 433–8. PMC 2622860. PMID 15356936.
- ↑ Genç M, Ledger WJ (2000). "Syphilis in pregnancy". Sex Transm Infect. 76 (2): 73–9. PMC 1758294. PMID 10858706.
- ↑ https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/syphilis-infection-in-pregnancy-screening Accessed on september 27,2016
- ↑ http://www.cdc.gov/std/tg2015/references.htm#424 Accessed on September 27, 2016