Congenital syphilis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2] Kalsang Dolma, M.B.B.S.[3]

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.

Congenital syphilis was first described in an English 17th century in a pediatric textbook. Transplacental transmission from an asymptomatic infected mother was first described in 1906. Sir Jonathan Hutchinson described the triad of notched incisors, interstitial keratitis, and eighth cranial nerve deafness as a criterion for diagnosis of congenital syphilis.

Congenital syphilis can be classified into early (presenting 0-2 years) and late (greater 2 years) based upon on time of presentation. There is also a diagnostic classification of syphilis used for surveillance purpose.

Pathophysiology of congenital syphilis is still unclear.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. 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 due to the concentration of spirochetes in the blood stream, which decrease with the duration of maternal syphilis infection.

Congenital syphilis is caused by the bacterium Treponema pallidum, which is passed from mother to child during fetal development or at birth.

Routine screening for syphilis during the antenatal period is recommended.

Infants present with symptoms such as failure to gain weight or failure to thrive, fever, irritability, small blisters on the palms and soles, and with watery discharge from the nose.

Physical examination findings suggestive of congenital syphilis include low birth weight, signs of prematurity, skin edema, pleural effusion, vesicular skin rash, corneal clouding, jaundice and deafness.

Prental diagnosis is by detection of IgM antibodies aganist T.pallidum in the blood collected by chordocentesis, 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. Postnatal diagnosis is by examination of the placenta or umbilical cord using a silver stain demonstrates spirochetes or a T. pallidum PCR test can be done.

Medical therapy for neonate presenting with symptoms of congenital syphilis is aqueous penicillin G. However evaluation and management is dependent on the clinical senario of presentation.

Primary preventive measures include 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 and practice of safe sex.

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.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2] Aravind Kuchkuntla, M.B.B.S[3]

Congenital syphilis was first described in an English 17th century in a pediatric textbook. Transplacental transmission from an asymptomatic infected mother was first described in 1906. Sir Jonathan Hutchinson described the triad of notched incisors, interstitial keratitis, and eighth cranial nerve deafness as a criterion for diagnosis of congenital syphilis.

• Sir Jonathan Hutchinson described the triad of notched incisors, interstitial keratitis, and eighth cranial nerve deafness as a criterion for diagnosis of congenital syphilis. The condition was well described in the 15th century and has long been recognized as a syndrome transmitted from an infected adult.
• In the 19th century congenital syphilis was believed to be transmitted during conception by the father’s sperm or 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.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]; Kalsang Dolma, M.B.B.S.[3]; Aravind Kuchkuntla, M.B.B.S[4]

Congenital syphilis can be classified into early (presenting 0-2 years) and late (greater 2 years) based upon on time of presentation. There is also a diagnostic classification of syphilis used for surveillance purpose.

Congenital syphilis is classified based on the timing of appearance of signs and symptoms into:^[1]

• 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.^[2]
• 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, sensorineural 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 (linear scars at the angles of the mouth and nose result from bacterial infection of skin lesions), choriod scarring and onychia. Stigmata secondary to late congenital syphilis include perforation of the palate, corneal opacities, optic atrophy and periosteal changes of tibia.

The provisional case definition includes every infant (person <12 months of age) with one of the following:^[3]

• A reactive nontreponemal serologic test for syphilis confirmed by a reactive treponemal test.

• A positive darkfield microscopic examination on a non oral mucous membrane or

• A positive fluorescent antibody examination for Treponema pallidum on any lesion.

All cases that are classified as confirmed or compatible or that require additional information to be classified should be reported to the state public health authority.

• Identification of T. pallidum by darkfield microscopy, fluorescent antibody, or other specific stains in specimens from lesions, autopsy material, placenta, or umbilical cord.

• A reactive STS (serologic test for syphilis) in a stillborn.

OR

• A reactive STS in an infant whose mother had syphilis during pregnancy and was not adequately treated, regardless of symptoms in the infant.

OR

• A reactive Venereal Disease Research Laboratory (VDRL) test of cerebrospinal fluid.

OR

• A reactive STS in an infant with any of the following signs: snuffles, condyloma lata, osteitis, periostitis or osteochondritis, ascites, skin and mucous membrane lesions, hepatitis, hepatomegaly, splenomegaly, nephrosis, nephritis, or hemolytic anemia.

OR

• Fourfold or greater rise in titers or nontreponemal tests (VDRL or rapid plasma reagin (RPR) and a confirmed fluorescent treponemal antibody absorption (FTA-ABS) or microhemagglutination assay for antibody to T. pallidum (MHA-TP) over a 3-month period.

OR

• A reactive treponemal test or nontreponemal test that does not revert to nonreactive in 6 months.

• No reactive STS.

OR

• Treponemal tests revert to nonreactive within 6 months.

OR

• No symptoms in live-born infant whose mother, treated for syphilis during pregnancy, had a fourfold or greater fall in titer and the infant’s STS is also fourfold or lower than the maternal titer was at the time of treatment.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2] Aravind Kuchkuntla, M.B.B.S[3]

Pathophysiology of congenital syphilis is still unclear. Several theories have been postulated in regards to the duration of the mother’s infection as well as the stage of pregnancy in which infection occurs.

• Transmission to the fetus is primarily transplacental but it can also occur during delivery in the presence of maternal genital lesions.^[1][2][3]
• 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.^[4]
• 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 due to the concentration of spirochetes in the blood stream, which decrease with the duration of maternal syphilis infection.^[5]
• Kassowitz’s law describes the inverse relationship of interval between the disease and pregnancy. Longer the interval between infection and pregnancy more benign is the outcome.^[6]
• 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.^[7]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Kalsang Dolma, M.B.B.S.[2]Aravind Kuchkuntla, M.B.B.S[3]

Congenital syphilis is caused by the bacterium Treponema pallidum, which is passed from mother to child during fetal development or at birth.

The causative pathogen for congenital syphilis is Treponema pallidum.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]

Congenital syphilis must be differentiated from other TORCH infections.

The most important congenital infections, which can be transmitted vertically from mother to fetus are the TORCH infections. These infections have overlapping features and hence, must be differentiated from congenital syphilis :^[1][2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Kalsang Dolma, M.B.B.S.[2] Aravind Kuchkuntla, M.B.B.S[3]

• 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.^[1][2]

• Congenital syphilis is ten times more prevalent in African American population compared to whites and three times more common in blacks compared to Hispanics.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]

Risk factors for congenital syphilis include all the risk factors which predispose a pregnant woman to have syphilis infection.

Risk factors for congenital syphilis include all the risk factors which predispose a pregnant woman to have syphilis infection:^{[1][2][3][4][5][6][7]}

• Inadequate antenatal care
• Multiple sexual partners
• Prostitution
• Unprotected sex
• Residence in highly prevalent areas
• HIV infection
• Presence of other STI
• Previous history of STIs
• Intravenous drug use
• Health care professionals who are predisposed to occupational risk
• Low socioeconomic status

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2] Aravind Kuchkuntla, M.B.B.S[3]

Routine antenatal screening is recommended for syphilis.

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:^[1][2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Kalsang Dolma, M.B.B.S.[2] Aravind Kuchkuntla, M.B.B.S[3]

Congenital syphilis is a result of transplacental transmission of the infection and severity of manifestations depend on the duration of maternal infection and duration of exposure to the fetus in utero.

Syphilis is a sexually transmitted disease and is more 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.^[1][2]

• Severe infection in the fetus can result in spontaneous abortion, stillbirth, non-immune hydrops, intrauterine growth restriction, and perinatal death, and other serious sequelae in liveborn.^[3]

• 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 penicillin is proven to improve outcomes in the fetus.^[4]
• In newborns and infants with congenital syphilis treatment with penicillin has good prognosis with normal development.^[5]

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