approach to infants born through mother with syphilis infection

1. APPROACH OF INFANTS BORN
TO MOTHER WITH SYPHILIS
INFECTION
DR PRAKASH MAN SHAH
JR2

2. INTRODUCTION
• Pregnant women with syphilis transmit to neonate through placenta or at
birth
• Congenital infection causes several consequences to fetus and newborn
• Perinatal death ●Premature delivery ●LBW ● Congenital anomalies
• Long term sequalae such as deafness & neurologic impairment
• Prevention : Identification and adequate treatment of pregnant women
• Syphilis is STI caused by spirochete Treponema pallidum

3. CLINICAL CLASSIFICATION
A) Congenital syphilis
• Transplacental passage of T. pallidum or contact with infectious
lesions during birth
• More recent maternal infection more likely transmission to fetus
• 1st and 2nd stage of syphilis  transmission high ~ 100%
10-30 % in late latency
• Transplacental transmission can occur throughout the pregnancy
Decreases in later stage

4. CLINICAL PRESENTATION
• Congenital infection results in stillbirth, hydrops fetalis, pretem
• Usually asymptomatic at birth, symptoms develop in first 3 months
Early Congenital syphilis (<2 yrs)
• Hepatosplenomegaly
• Rash
• Condylomata lata
• Watery nasal discharge (snuffles)
• Jaundice
• Anemia or edema
• Skeletal abnormalites
• Osteochondritis
• Petrostitis
• Epiphysitis
• Pseudoparalysis
Late congenital syphilis in
untreated older children (>2 yr)
• Stigmata with bony changes
• frontal bossing
• short maxilla
• High palatal arch
• Hutchinson teeth
• Saddle nose
• Interstitial keratitis
• SNHL

5. LAB CRITERIA FOR DIAGNOSIS
• Demonstration of T. pallidum in nasal secretions, body fluids, lesions,
placenta and umbilical cord by :
a) Dark Field microscopy
b) PCR
c) Immunohistochemistry

6. CASE CLASSIFICATION
• Confirmed : case that is laboratory confirmed.
• Probable
Infant whose mother had untreated or inadequately treated syphilis at delivery
Infant with reactive nontreponemal test for syphilis & any 1 of following
i. Evidence of congenital syphilis on physical examination
ii. Evidence of congenital syphilis on radiograph of long bone
iii. Reactive CSF VDRL test
iv. Elevated CSF cell count or protein (without other cause)
Abnormal First 30 DOL: CSF WBC >15 or protein >120 mg/dl
After 30 DOL: CSF WBC >5 & protein >40
OR

7. DIFFERENTIAL DIAGNOSIS
• Toxoplasmosis
• Herpes simplex
• CMV
• Rubella
• Neonatal sepsis
Clinical data from mother, physical examination and lab test helps to make
diagnosis

8. DIAGNOSIS
• Routine serological screening of pregnant women during first ANC
visit CDC recommends additional testing at 28 WOG and again at
delivery for women who are in increased risk.
• Routine screening of newborn serum or cord blood  not
recommended
A) Serological tests for syphilis

9. I) Non Treponemal test
• RPR test, VDRL slide test, Unheated serum regain (USR) & the toluidine red
unheated serum test (TRUST)
• These test measure antibody directed against a lipoidal antigen from T. pallidum
&/or its interaction with host tissues.
• These test gives quantitative results (baseline titer)
• Sustained 4 fold decrease in titer with treatment  adequate therapy
• Similar increase after treatment suggests reinfection
Normal titer after treatment:
• Primary syphilis: 1 year
• Secondary syphilis : 2 year
• Latent/ tertiary syphilis : 4-5 years or may never turn completely non reactive

10. II) Treponemal test
• Fluorescent treponemal antibody absorption test (FTA-ABS)
• T. pallidum particle agglutination (TP-PA)
• Enzyme immunoassay (EIA)
• They are used to confirm positive nontreponemal test
• Treponemal test correlate poorly with disease activity and usually
remains positive for life, even after successful treatment and
therefore should not be used to assess treatment response.

11. B) CSF Examination
• CSF abnormalities in patients with neurosyphilis include increased
protein count, increased WBC count, &/or reactive CSF VDRL test.
• CSF VDRL is highly specific but in sensitive. Positive is diagnostic of
neurosyphilis but negative does not exclude.
• FTA-ABS is more sensitive, however contamination with blood during
lumbar puncture may result in false positive CSF FTA-ABS
• Negative CSF FTA-ABS test is good evidence against neurosyphilis.

17. Evaluation and treatment of infants & children
older than 1 month
• To determine whether the child has congenital or acquired syphilis. Any
infant or child at risk for congenital syphilis should receive a full evaluation
& testing for HIV infection.
Recommended treatment
• Aqueous crystalline penicillin G 200,000 to 300,000 units/kg/day IV administered as
50,000 units/kg every 4 to 6 hrs for 10 days
• If evaluation is normal ( including CSF) : treatment with 3- weekly dose of penicillin-
G benzathine 50,000 units/kg IM considered.

18. Special consideration:
I. Penicillin allergy : Desensitization & then treated with penicillin.
Skin testing is not established for infants.
II. Penicillin shortage : If aqueous penicillin G not available 
procaine penicillin as single daily dose for same duration
III. If both aqueous & procaine penicillin are not available, then 10
days course of i/v ceftriaxone can be considered.

19. • CSF Examination may be repeated at 6 months if the initial evaluation was
abnormal.
• Ceftriaxone must be used with caution if there is jaundice as it can displace
bilirubin.
CDC:
For infants aged ≥ 30 days, use ceftriaxone 75mg/kg/day IV or IM in a single
daily dose for 10-14 days
For children: Ceftriaxone 100mg/kg/day in a single daily dose is
recommended.

20. FOLLOW-UP OF INFANTS TREATED FOR
CONGENITAL SYPHILIS
• All neonates with reactive nontreponemal tests should receive careful
follow-up examinations and nontreponemal titers every 2 to 3
months until the test becomes nonreactive
• In the neonate who was not treated due to low likelihood of infection,
or infected but adequately treated, nontreponemal antibody titers
should decline by age 3 months and be nonreactive by age 6 months
• At 6 months, if the nontreponemal test is nonreactive, no further
evaluation or treatment is needed

21. • Neonates with negative non-treponemal test at birth born through
mother who was seroreactive at the time of delivery should be
retested at 3 months to r/o incubating congenital syphilis.
• Treated neonates who exhibit persistent nontreponemal test titre by
6-12 months should be re-evaluated through CSF Examination
Retreatment with penicillin-G 10 days course indicated

22. • Neonates whose initial CSF examination was abnormal should
undergo a repeat lumbar puncture approx. every 6 months until the
test results are normal.
If reactive CSF VDRL test or abnormal CSF indices that persist  requires
retreatment for possible neurosyphilis.

26. REFERENCES
1. CLOHERTY AND STARK’S MANUAL OF NEONATAL CARE (9th Edition)
2. AIIMS PROTOCOLS IN NEONATOLOGY (2nd Edition)
3. Journals

27. THANK YOU