Syphilis is a sexually transmitted disease caused by the bacterium Treponema pallidum. It can be transmitted from mother to fetus during pregnancy, causing congenital syphilis. Congenital syphilis presents as early onset disease within 2 years or late onset disease near puberty. Early signs include rashes, fever, hepatosplenomegaly, rhinitis, and bone abnormalities. Late signs involve dental, skeletal, and eye abnormalities. Diagnosis involves maternal and infant serology and treatment is with penicillin. Untreated congenital syphilis can cause severe health issues, so prevention focuses on screening and treating pregnant women and their partners.

1. Syphilis in Neonates and
Infants
Dr Rakhitha Munasinghe

2. INTRODUCTION
• Causal agent of syphilis : Treponema Pallidum ( spirochaete )
• Discovered in Germany from a vulvar lesion in 1905
• First serologic test : 1906
• Fastidious organism, Only briefly survive outside host
• Neonatal infection due to fetal infection during maternal
spirochetemia

3. EPIDEMIOLOGY
• Prevalence : worldwide
• 2000 had the lowest rates since
1941 ( penicillin in puerperal
sepsis )
• 2000-2012 – steady increase in
case numbers
• Post 2013 – cases among women
of childbearing age increased
• Along with congenital syphilis
rates

4. • Source : Annual report of STD- AIDS control program, Srilanka, 2020

5. TRANSMISSION
1. Vertical transplacental transmission : during maternal
spirochetemia
• TP isolated from Amniotic fluid and Cord blood in animal studies
• Specific IgM obtained from fetal serum / neonatal serum in humans
2. During delivery : contact with maternal genital lesions
3. Contact with open and weeping non genital lesions of caregiver
4. Rarely through breastmilk
( untreated mother with breast chancre – BF contraindicated)

6. TRANSMISSION
• Anytime during gestation ( as early as 9-10 weeks)
• Risk increase with advancing POA
• Congenital syphilis risk increase with stage of
maternal syphilis
• Untreated primary : 25%
• Secondary: 60%
• Early latent : 40%
• Late latent : 7%

7. CLINICAL MANIFESTATIONS
• Adverse pregnancy outcomes : Preterm labor, spontaneous abortion,
stillbirth, perinatal mortality
• Large sized, pale placenta with villous enlargement and necrotizing
funisitis
• Fetal infection : hepatomegaly, anemia, and nonimmune hydrops
• Congenital syphilis
1. Early congenital syphilis  presents in first 2 years
2. Late congenital syphilis  presents in children / adolescents

8. Early congenital syphilis (<2 years of age)
• IUGR / SGA , Fever
• Hepatomegaly +/- Splenomegaly (+/- jaundice)
• Rhinitis ( snuffles)
• Rashes : pemphigus syphilitics , condylomata lata
• Adenopathy ( epitrochlear)
• Pseudoparalysis of Parrot
• Eye : chorioretinitis , cataract
• CNS : Seizures, hypopituitarism, cranial DI, CN palsies
• Pancreatitis , myocarditis

10. Early congenital syphilis (<2 years of age)
• LABORATORY FINDINGS
Anemia/ thrombocytopenia
Hypoglycemia
Liver transaminitis and direct hyperbilirubinemia
Cerebrospinal fluid pleocytosis, elevated protein content
Reactive VDRL test
Proteinuria (nephrotic syndrome)
Hypopituitarism (diabetes insipidus)

11. Early congenital syphilis (<2 years of age)
• RADIOGRAPHIC FINDINGS
Periostitis : 5 weeks after infection
Osteochondritis : 16 weeks after infection
• Symmetrical
• Preferentially involve lower than upper limbs
Sub epiphyseal fracture and epiphyseal dislocation 
pseudoparalysis of Parrot
Wimberger sign : demineralization and destruction of proximal
medial tibial metaphysis
Pneumonia alba

12. • Metaphyseal lytic lesions (#) and periosteal reactions (*)

13. Late congenital syphilis
• Appear near puberty or adolescence
• Persistent inflammation or scarring
• Due to : Initial fetal infection untreated or inadequately treated
Classic Hutchinson’s triad
1. Interstitial keratitis
2. 8th cranial nerve deafness from osteochondritis of the otic capsule
3. Hutchinson’s teeth
( small, widely spaced, notched, barrel-shaped permanent incisors )

14. Late congenital syphilis

15. Late congenital syphilis
• Mulberry molars : lower molars have many small cusps instead of 4
• Fontal bossing
• Tibial bowing or saber shins
• Sternoclavicular thickening (Higoumenakis sign)
• Saddle nose deformity : Syphilitic rhinitis involving cartilage and bone
• Palatal or nasal septal perforation
• Cracks around mouth and nose (Rhagades)
• Interstitial Keratitis
• CNS : Intellectual disability , paresis, personality changes, seizures,
hydrocephalus, optic atrophy

16. DIAGNOSIS
• Difficult in neonates because
1. Detection of TP from lesions / fluids is difficult
2. Transplacental IgG transfer complicates serological test interpretation
• Must rely on
1. Diagnosis of syphilis in mother
2. Adequacy of maternal treatment
3. Clinical and radiographic signs
4. Comparison of maternal and neonatal serologic titers ( same test,
same lab)

17. Serologic tests for syphilis
1. Treponemal Assays – Early detection, non quantitative
• T pallidum particle agglutination (TP-PA) test
• Fluorescent treponemal antibody absorbed (FTA-ABS)
2. Non treponemal Assays - low cost, rapid , quantitative
• RPR ( Rapid plasma Reagin)
• VDRL ( Venereal Disease Research Lab)
• RPR preferred in pregnancy, higher sensitivity

18. Sequence of tests – in mother
Traditional Sequence
1. Screening RPR / VDRL
2. Confirmatory TPPA /FTA-
ABS/ EIA
FALSE POSITIVE VDRL
• Other spirochetes
(lepto)
• SLE
• IMN, measles, hepatitis
• TB, Malaria, lymphoma
Reverse Sequence
1. TP Immunoassay ( EIA)
• Negative  no syphilis
• Positive  quantitative RPR/ VDRL
2. RPR / VDRL
• Positive  Syphilis ( past or present)
• Negative  Do TPPA
3. TPPA
• Positive  Syphilis ( past or present)
• Negative  Syphilis unlikely , initial test false
+ve

19. Maternal Treatment in Pregnancy
Primary, secondary, and early latent syphilis
• Single dose of intramuscular penicillin G2.4 million
units
Late latent infection and syphilis of unknown
duration
• 3 doses, weekly intramuscular injections of
benzathine penicillin G 2.4 million units
• If 1 dose missed, repeat full course
• Penicillin allergic  desensitize and treat with
penicillin

20. Approach to neonate born to mother with
syphilis
• Non treponemal test performed
• Infant serum rather than cord blood
• Maternal blood  contamination
• Wharton jelly  false positive reaction
• Look for features of congenital syphilis
• VDRL / RPR titer > 4X of mother  confirm congenital
syphilis
• Titer < 4X  cannot exclude congenital syphilis

21. Approach to neonate born to mother with
syphilis
• Categorized depending on Maternal treatment,
physical examination and VDRL/RPR titers
1.Proven or highly probable congenital syphilis
2.Possible congenital syphilis
3.Congenital syphilis less likely
4.Congenital syphilis unlikely

22. 1) Proven or highly probable
congenital syphilis
Abnormal physical examination consistent with
syphilis
A serum VDRL / RPR titer that is ≥ 4 than the
mother’s
Or a positive darkfield test or if available
Positive T. Pallidum DNA PCR of lesions or body fluid
• Ix : FBC / PLT/ CSF VDRL and cell count , protein /
long bone XR, CXR, LFT, Neuroimaging, Hearing
tests, Eye ex.

23. 1) Proven or highly probable
congenital syphilis
Treatment
• 10 days of intravenous aqueous penicillin G
• or intramuscular procaine penicillin G 1 dose
• If >1 day is missed, repeat entire course
• 10-days course preferred
(Even if ampicillin was initially given for sepsis)

24. 2) Possible congenital syphilis
• Normal physical examination and VDRL /RPR titer ≤ 4 times
maternal titer with 1 of
1. Mother wasn’t treated / inadequately treated / no record
of treatment
2. Mother treated with a non penicillin G regime
3. Treated but first penicillin G dose given < 4 weeks before
delivery
• Ix : FBC / PLT/ CSF ( cells, protein and VDRL), long bone XR

25. 2) Possible congenital syphilis
Evaluation normal
• single intramuscular injection of benzathine penicillin G
Evaluation abnormal / incomplete
• 10 days of intravenous aqueous penicillin G or
• Intramuscular procaine penicillin G 1 dose
If neonate’s VDRL / RPR negative with normal
examination
• Can give single intramuscular injection of benzathine
penicillin G

26. 3) congenital syphilis less likely
• Normal physical examination and VDRL /RPR titer ≤ 4 times
maternal titer AND
1. Mother was treated appropriately during pregnancy
2. With the first dose of penicillin given > 4 weeks before
delivery,
3. No evidence of reinfection or relapse in mother
• No evaluation needed
• Rx : single dose IM penicillin G ( fetal Rx failure can
occur up to 14%)

27. 4) Congenital syphilis unlikely
• Adequate treatment for syphilis: pre-pregnant period
• AND the VDRL/ RPR titer remained low and stable
• Before and during pregnancy and at delivery
• No evaluation of neonate
• No treatment

28. Penicillin unavailable / allergic
• 10-day course of ceftriaxone with serologic follow-up ( incl.
CSF)
• Caution with TPN containing Ca
• Caution with jaundice
• Alternative: 10-day course of ampicillin
• Efficacy of either not studied properly
• Penicillin allergy : Desensitize and treat

29. Reaction to Penicillin
• Jarisch– Herxheimer reaction
• Due to rapid killing of spirochetes
• Symptoms : Fever, Hemodynamic instability, cutaneous lesions , rise
of AST and ALT
• Supportive care only’

30. PROGNOSIS AND FOLLOW-UP
• Serial monitoring of VDRL / RPR
• Every 2-3 monthly until nonreactive or till titer go down by 4X
• Usually take 6-12 months following correct therapy
• If titers rise by >4X anytime reevaluate and retreat ( 10 days or IV
penicillin-G)
• If initial CSF evaluation positive  Repeat CSF evaluation not
indicated if serum VDRL is responsive
(Previously repeated in 6/12 )

31. PREVENTION – Recommendations
• All pregnant women should be screened for syphilis
1. At the first prenatal care visit
2. Subsequent testing at 28 weeks gestation
3. At delivery  has risky behavior / from high-risk area
• Identify and treat sexual partner(s) prevent maternal
reinfection
• Any women with stillbirth > 20 POA  test for syphilis
• No newborn to be discharged from hospital without knowing
mothers' serologic syphilis status

32. References
1. Medoro, A. K., & Sánchez, P. J. (2021). Syphilis in Neonates and
Infants. Clinics in Perinatology, 48(2), 293–309.
https://doi.org/10.1016/j.clp.2021.03.005
2. Phiske, M. (2014). Current trends in congenital syphilis. Indian
Journal of Sexually Transmitted Diseases and AIDS, 35(1), 12.
https://doi.org/10.4103/0253-7184.132404
3. Md, R. K. M., & Geme, S. J., MD. (2019). Nelson Textbook of
Pediatrics, 2-Volume Set (NelsonPediatrics) (21st ed.). Elsevier.