Early congenital syphilis: clinico-radiologic features in 202 patients

British Association of Sexual Health and HIV (BASHH) UK guidelines for the management of syphilis in pregnancy and children 2024

This new guideline details the specific management of syphilis in pregnancy and in children. It is to be used in clinical practice alongside the BASHH UK guidelines for the management of syphilis 2024.

Syphilitic hepatitis in infants, the forgotten disease that hepatologists have to brush up on: from a case series to a revision of literature

Clinical manifestations of congenital syphilis (CS) include liver disease with/without impaired liver function, identified as syphilitic hepatitis. Hepatic involvement may be dramatic; therefore, early diagnosis is crucial to provide treatment and prevent fatal outcomes. A new resurgence of CS cases has been described in recent years worldwide. We reported our experience with a case series of infants hospitalized for liver disease with a final diagnosis of CS, highlighting the wide spectrum of liver involvement, the rapid progression in cases with late diagnosis, and the pitfalls of the management of this forgotten but reemerging disease. A retrospective analysis of CS patients with hepatic presentation in the period 2008-2023 was conducted. We collected five cases (three female) with a median age of 13.8 days (range 1-84 days). In three cases, mothers were not screened for syphilis during pregnancy, and in two cases, they were seronegative in the first trimester screening. None practiced specific therapy during pregnancy. Hepatic involvement was characterized by hepatosplenomegaly, in four cases associated with cholestatic jaundice and in three cases with liver failure. Rapid plasma reagin (RPR) and Treponema pallidum hemagglutination assay (TPHA) were positive in all cases in mothers and infants. CS presented with multiorgan involvement and was fatal in one case.Conclusions: It is important to consider CS in infants with cholestasis and acute liver failure, but also in sick infants with isolated hepatomegaly. Early recognition of infants with CS is critical to identify missed cases during pregnancy and to start early treatment.

Ultrasound findings in early congenital syphilis: Two case reports and literature review

Syphilis is caused by treponema pallidum. If untreated, or inadequately treated, during pregnancy, it can result in congenital syphilis (CS), which is classified as early and late. Early CS displays before 2 years of age. We herein describe 2 cases of early CS, whose clinical onset included liver failure, edema, organomegaly, and respiratory distress. We focus on liver, intestinal, and brain ultrasound (US) and other peculiar radiological findings. To date, there are no scientific data on intestinal and brain US findings in patients with early CS whereas data on abdominal US are scarce. Increasing knowledge about US findings in early CS could be useful to improve the diagnostic and therapeutic approach to these patients.

Clinical characteristics of infants hospitalized with early congenital syphilitic nephropathy: a single-center retrospective cross-sectional study in China

BACKGROUND

Early studies claimed that early congenital syphilitic (CS) nephropathy was rare, and systematic studies about this disease are absent, which may lead to poor awareness of early CS nephropathy in clinicians and result in misdiagnosis and poor patient prognosis. The present study systematically and comprehensively analyzes the clinical characteristics of infants with early CS nephropathy hospitalized in Beijing Ditan Hospital, an infectious disease hospital in China in order to improve the understanding and management of this disorder.

METHODS

Data of the children with early CS from July 1, 2008, to December 31, 2021, were collected from the electronic medical record system of the hospital. Each patient's demographic characteristics, clinical history, mother's history of syphilitic infection, and laboratory values were extracted. The patients were enrolled to either the nephropathy group or the non-nephropathy group depending on diagnosis. Descriptive statistics was used to report basic demographics, clinical and laboratory test values, and variables were compared between the two groups by nonparametric tests, t test or χ2 tests.

RESULTS

Of the 122 children with early CS enrolled, 24(19.7%) were diagnosed with early CS nephropathy. All of the children with CS nephropathy were young infants < 6 months old. A majority of them showed typical congenital syphilitic skin lesions, but a quarter of them did not have skin lesions. Compared with non-nephropathic children with early CS, those with nephropathy had higher frequency of hepatosplenomegaly, fever, edema, gastrointestinal (GI) symptoms, and anemia, as well as decreased C3 levels. Urinalysis results showed hematuria in all patients with early CS nephropathy, with proteinuria and renal function impairment in 91.7% and 12.5% of the patients, respectively. Nephritic-type nephrotic syndrome and glomerulonephritis were diagnosed in 45.8% and 54.2% of these patients, respectively. All infants with CS nephropathy were cured or improved after appropriate treatments.

CONCLUSION

Infants with early CS nephropathy often presented with nephritic-type nephrotic syndrome or glomerulonephritis, and the typical skin lesions, fever, hepatosplenomegaly, and edema, etc., were its common clinical presentations, and these characteristics could help with the diagnosis. But for infants with nephropathy who did not have typical clinical presentations, CS should also be screened as an important etiology to avoid misdiagnosis.

Congenital Syphilis Presenting with Brain Abnormalities at Neuroscan: A Case Report and a Brief Literature Review

A case of vertical transmission in a 35-year-old pregnant woman, gravida 4, para 2 with an unknown medical history of carrying primary syphilis is described. A routine 3rd trimester scan was performed at 30 + 5 weeks of pregnancy, which revealed fetal growth restriction (FGR) associated with absent fetal movement, a pathologic neuroscan characterized by cortical calcifications and ominous Doppler waveform analysis of the umbilical artery and ductus venosus. Computerized electronic fetal monitoring (EFM) showed a Class III tracing, according to the American College of Obstetricians and Gynecologists (ACOG) guidelines. An emergency C-section was performed and a female newborn weighing 1470 g was delivered. The Apgar scores were 5 and 8 at the first and fifth min, respectively. Besides the prompted obstetrical and neonatal interventions, the neonate died after 7 days. A histologic examination of the placenta revealed a chorioamnionitis at stage 1/2 and grade 2/3. The parenchyma showed diffuse delayed villous maturation, focal infarcts, and intraparenchymal hemorrhages. The decidua presented with chronic deciduitis with plasma cells. The parents declined the autopsy. Congenital syphilis is an emerging worldwide phenomenon and the multidisciplinary management of the mother and the fetus should be mandatory.

Fetal and neonatal abnormalities due to congenital syphilis: a literature review

OBJECTIVE

The recent recrudescence of syphilis among women of childbearing age is associated with an increasing number of cases of congenital syphilis. We aimed to summarize the fetal and neonatal abnormalities due to congenital syphilis infection, particularly signs amenable to prenatal diagnosis.

METHODS

Eligible studies were retrieved from the PubMed collection database. Articles focusing on postnatal and antenatal abnormalities covered the periods from 1969 to 2019 and 1975 to 2019, respectively. This review included cohort studies, case series and case reports reporting findings regarding congenital syphilis infections described before and/or after birth. Articles were reviewed by three experts in prenatal diagnosis, and all findings were classified as amenable or not amenable to prenatal diagnosis.

RESULTS

A total of 432 cases of congenital syphilis infection were reported. Abnormalities were described antenatally in 161 cases, postnatally in 319 cases, and in both the antenatal and postnatal periods in 57 cases. The most frequently reported signs amenable to prenatal diagnosis were abdominal abnormalities (hepatomegaly, splenomegaly, and bowel abnormalities), fetal growth restriction, and elevated middle cerebral artery peak systolic velocity in the context of ascites or atypical hydrops. Brain abnormalities were rare and never isolated. In the neonatal period, the most common abnormalities were hepatosplenomegaly, bone damage and skin lesions.

CONCLUSION

We found that no individual sonographic sign or pattern of signs is pathognomonic for fetal syphilis. In fetuses with ultrasound abnormalities suggestive of congenital infection, syphilis must be considered as part of the work-up. This article is protected by copyright. All rights reserved.

Fetal Hepatomegaly: Causes and Associations

Fetal hepatomegaly is associated with significant fetal morbidity and mortality. However, hepatomegaly might be overlooked when numerous other fetal anomalies are present, or it might not be noticed when it is an isolated entity. As the largest solid organ in the abdomen, the liver can be seen well with US or MRI, and the normal imaging characteristics are well described. The length of the fetal liver, which can be used to identify hepatomegaly, can be determined by measuring the liver from the diaphragm to the tip of the right lobe in the sagittal plane. Fetal hepatomegaly is seen with infection, transient abnormal myelopoiesis, liver storage and deposition diseases, some syndromes, large liver tumors, biliary atresia, and anemia. Some of these diagnoses are treatable during the fetal period. Attention to the associated findings and specific hepatic and nonhepatic imaging characteristics can help facilitate more accurate diagnoses and appropriate patient counseling.^©RSNA, 2020.

Syphilis in Pregnancy

Importance

Since 2013, the United States has seen a rise in cases of congenital syphilis, culminating in a relative increase of 153% from 2013 to 2017 and 918 reported cases in 2017. In all, 50% to 80% of pregnant women with syphilis experience an adverse pregnancy outcome including stillbirth or spontaneous abortion.

Objective

This article aims to review the current evidence and recommendations for management of syphilis in pregnancy.

Evidence Acquisition

Original research articles, review articles, and guidelines on syphilis were reviewed.

Results

In pregnancy, routine screening for syphilis is recommended on initiation of prenatal care. In high-risk populations, repeat testing is recommended in the early third trimester and at delivery. Penicillin remains the recommended treatment in pregnancy. After treatment, nontreponemal titers should be repeated at minimum during the early third trimester and at delivery to assess for serologic response. In high-risk populations, titers should be repeated monthly.

Conclusion and Relevance

Routine screening in pregnancy is essential for identification of syphilis infection and prevention of congenital syphilis. Subsequent adequate treatment with penicillin therapy more than 30 days before delivery and at the correct dosages depending on the stage of infection should be incorporated into clinical practice.

Challenges in the Contemporary Management of Syphilis among Pregnant Women in New Orleans, LA

Objective

The aim of this retrospective review is to evaluate trends in the management of maternal and congenital syphilis (CS) in a tertiary care center in New Orleans, LA.

Study Design

All cases of maternal and neonatal syphilis over a five year period at Touro Infirmary, New Orleans, LA, were identified using ICD-9/10 codes. Charts were reviewed for demographic and obstetrical variables, stage of syphilis at diagnosis, lab values, and treatment regimen. Newborn treatment and other outcomes were recorded.

Results

During the study period 106 infected mother-baby pairs were identified. Of these, 73 charts are available for review. 41% (n = 30) of women received inadequate therapy according to their stage of disease. 9% of newborns (n = 6) were found to be symptomatic for CS; however, only 83.3% of these were admitted to the neonatal intensive care unit. Only 20% (n = 6) of infants were adequately treated with an extended penicillin regimen if the mother was not adequately treated. Furthermore, only 63.0% of newborns had a nontreponemal titer performed.

Conclusion

With rising rates of CS, strict adherence to the 2015 CDC guidelines for treatment of syphilis must be maintained.

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

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

Progression of ultrasound findings of fetal syphilis after maternal treatment

OBJECTIVE

The purpose of this study was to evaluate ultrasound findings of fetal syphilis and to describe their progression after maternal treatment.

STUDY DESIGN

This was a retrospective cohort study from September 1981 to June 2011 of seropositive women after 18 weeks of gestation who had an ultrasound before treatment to evaluate for fetal syphilis. Only those women who received treatment after the initial ultrasound scan, but before delivery, were included. If the initial ultrasound scan was abnormal, serial sonography was performed until resolution of the abnormality or delivery. Patient demographics, ultrasound findings, stage of syphilis, delivery, and infant outcomes were recorded. Standard statistical analyses were performed. Kaplan-Meier estimates were constructed to estimate time to resolution.

RESULTS

Two hundred thirty-five women met the inclusion criteria; 73 of them (30%) had evidence of fetal syphilis on initial ultrasound scan. Abnormalities included hepatomegaly (79%), placentomegaly (27%), polyhydramnios (12%), ascites (10%) and abnormal middle cerebral arterial Doppler assessment (33%). After treatment, middle cerebral arterial Doppler assessment abnormalities, ascites, and polyhydramnios resolved first, followed by placentomegaly and finally hepatomegaly. Infant outcomes were available for 173 deliveries; of these, 32 infants (18%) were diagnosed with congenital syphilis. Congenital syphilis was more common when antenatal ultrasound abnormalities were present (39% vs 12%; P < .001). Infant examination findings at delivery were similar between women with and without an abnormal pretreatment ultrasound scan. However, in those infants with congenital syphilis, hepatomegaly was the most frequent abnormality found, regardless of antenatal ultrasound findings.

CONCLUSION

Sonographic signs of fetal syphilis confer a higher risk of congenital syphilis at delivery for all maternal stages. Hepatomegaly develops early and resolves last after antepartum treatment.

Congenital syphilis: still a serious, under-diagnosed threat for children in resource-poor countries

BACKGROUND

With 700,000 to 1.5 million new cases annually, congenital syphilis remains a major infectious cause of morbidity and mortality in neonates, infants and children in resource-poor countries. We therefore analyzed the extent of congenital syphilis in the pediatric patient population at our rural hospital in Tanzania.

METHODS

For this retrospective analysis, from January 1, 1998 to August 31, 2000, all cases of congenital syphilis were collected from the medical records of the neonatal and pediatric department at Haydom Lutheran Hospital in rural northern Tanzania. Age, sex, weight, clinical signs and symptoms, venereal disease research laboratory (VDRL) results of mother and/or child, hemoglobin concentration, treatment, and outcome were recorded and analyzed.

RESULTS

Fourteen neonates and infants were included. The earlier the diagnosis, the more it rested on maternal data because the presentation of neonatal congenital syphilis resembled neonatal sepsis. Syphilitic skin lesions were only seen in the post-neonatal age group. VDRL results were positive in 11 of the 14 mothers, and in 4 of the infants. Anemia was common in older infants. No patient showed signs of central nervous system involvement. Two patients died, and the remaining were cured after standard treatment with procaine penicillin.

CONCLUSIONS

Highlighting the variable picture of congenital syphilis, this report demonstrates how difficult it is to make a correct diagnosis by solely history and clinical presentation in a resource-poor setting. Hence false-positive and false-negative diagnoses are common, and clinicians have to maintain a high index of suspicion in diagnosing congenital syphilis. Therefore, an important approach to control and finally eliminate congenital syphilis as a major public health problem will be universal on-site syphilis screening of all pregnant women at their first antenatal visit and immediate treatment for those who test positive.

Disorders of the fetomaternal unit: hematologic manifestations in the fetus and neonate

Histoarchitectural characteristics of the human placenta place the fetus at a high risk of growth restriction, abnormal fetomaternal cell traffic, and vertical transmission of pathogens. These abnormalities of the fetomaternal unit are frequently associated with hematological abnormalities in the fetus/neonate and may be the first, most common, or the only clinical manifestations of these conditions. This article reviews the pathophysiology and characteristic hematological manifestations of these conditions in the fetus and the neonate.

Managing congenital syphilis again? The more things change …

PURPOSE OF REVIEW

Untreated syphilis may have profound adverse effects on pregnancy outcome, resulting in spontaneous abortion, stillbirth, premature delivery or perinatal death, or can result in significant morbidity during infancy, childhood or adolescence. In this article, we review current strategies for the management of maternal and congenital syphilis nationally and in resource-poor settings.

RECENT FINDINGS

Since 1998, a dramatic increase in syphilis diagnoses has been documented among women of child-bearing age in the UK and elsewhere. The low prevalence of congenital syphilis in many developed countries may have led to complacency, hindering modern-day management of this historically important condition. Follow-up studies indicate that present antenotal and postnatal interventions could be improved. This conclusion extends to resource-poor settings endemic for syphilis in which rapid diagnostic techniques are currently being validated.

SUMMARY

A stringent follow-up of pregnant women with syphilis before delivery and a proactive approach to identifying and treating exposed neonates born to such patients are needed.

Life-threatening cutaneous conditions in neonates

One of the major medical concerns in neonates is their vulnerability to life-threatening complications. Early diagnosis of potentially serious medical conditions is essential in prevention of such complication by prompt administration of appropriate treatments. Recognition of cutaneous manifestations of potentially fatal diseases may assist a clinician in management of newborns. To overview the full spectrum of this category of conditions, Medline search was performed for cases of cutaneous manifestations associated with mortality during the first month of live that were published in the English language literature since 1977. This is a concise review of the clinical aspects of most of the potentially life-threatening disorders in neonates divided by basic morphology of their cutaneous manifestations.

A premature newborn with vesiculobullous skin lesions

Although the rate of congenital syphilis is declining in Western Europe and in the USA, a significant increase is observed in the developing countries. In this contribution, a newborn with cutaneous manifestations of congenital syphilis is presented.

CONCLUSION

Pediatricians should be attentive when confronted with vesiculobullous skin lesions in a newborn, and congenital syphilis should be considered in the differential diagnosis.

Symptomatic congenital syphilis presenting at birth

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

Seroprevalence of HIV, HTLV-I/II and other perinatally-transmitted pathogens in Salvador, Bahia

Generation of epidemiological data on perinatally-transmitted infections is a fundamental tool for the formulation of health policies. In Brazil, this information is scarce, particularly in Northeast, the poorest region of the country. In order to gain some insights of the problem we studied the seroprevalence of some perinatally-transmitted infections in 1,024 low income pregnant women in Salvador, Bahia. The prevalences were as follow: HIV-1 (0.10%), HTLV-I/II (0.88%), T.cruzi (2.34%). T.pallidum (3.91%), rubella virus (77.44%). T.gondii IgM (2.87%) and IgG (69.34%), HBs Ag (0.6%) and anti-HBs (7.62%). Rubella virus and T.gondii IgG antibodies were present in more than two thirds of pregnant women but antibodies against other pathogens were present at much lower rates. We found that the prevalence of HTLV-I/II was nine times higher than that found for HIV-1. In some cases such as T.cruzi and hepatitis B infection there was a decrease in the prevalence over the years. On the other hand, there was an increase in the seroprevalence of T.gondii infection. Our data strongly recommend mandatory screening tests for HTLV-I/II, T.gondii (IgM), T.pallidum and rubella virus in prenatal routine for pregnant women in Salvador. Screening test for T.cruzi, hepatitis and HIV-1 is recommended whenever risk factors associated with these infections are suspected. However in areas with high prevalence for these infections, the mandatory screening test in prenatal care should be considered.

The diagnosis of congenital infections: contemporary strategies

Congenital infections remain an important source of neurologic, ophthalmologic, and audiologic disability for thousands of children throughout the world. This review summarizes the clinical features and describes contemporary approaches to the microbiologic diagnosis of congenital infections. In particular, this review emphasizes the important roles that molecular methods, especially the polymerase chain reaction, have in detecting the many infectious agents capable of damaging the developing nervous system.

Extensive hepatic calcification secondary to fulminant neonatal syphilitic hepatitis

Congenital syphilis is increasingly being diagnosed in developed countries after many years of decline. The liver is characteristically involved. However, fulminant hepatic failure and subsequent liver calcifications are both rare in patients with congenital syphilis. The infant reported here had both of these rare manifestations of this disease.

Pathology of congenital syphilis in rabbits

We have developed a model for congenital syphilis in the rabbit. This report provides additional information on newborn tissue pathology in animals that were infected in utero. A total of 35 pregnancies were evaluated, each containing 6 to 12 newborns. In the infected group, the mortality was approximately 50%; of the live newborns, half appeared normal and half were hyperreflexic, weak, and runty. Gross pathology in the sickly newborns was quite prevalent and involved enlarged spleens with isolated spots of necrosis; enlarged livers that were overtly congested and hemorrhagic and had numerous granular, white spots; and brains with hemorrhage in the occipital area. Histopathology was apparent in different tissues. Lymphocytes, plasma cells, and vacuolated macrophages were prominent in livers, spleens, brains, and bones. A few actively motile treponemes were visualized by dark-field microscopy within extracts of spleen and within cerebrospinal fluid. Low numbers of treponemes were also demonstrated in sections of brain and liver by using the Warthin-Starry silver stain technique. Blood hematocrits were decreased, and extramedullary hematopoiesis was prominent within spleens and livers; this is consistent with anemia. This rabbit model exhibits many of the same pathologic features commonly found in human congenital syphilis.

Congenital syphilis: clinical manifestations in premature infants

During the 4-year period February 1989 to January 1993, 13 premature babies aged 1-21 days and with congenital syphilis were admitted to the National Cheng Kung University Hospital. Of the 13 premature infants, 8 (62%) had unusual desquamation over palms and soles. Bone changes with periosteal reaction and/or metaphyseal dystrophy were observed in 11 cases (85%). Three mothers were diagnosed as being infected during pregnancy; 2 were treated with penicillin. The clinical features of congenital syphilis in premature neonates are somewhat different from those previously reported. Bone changes, hepatosplenomegaly, respiratory distress, skin lesions, especially over the soles and palms, cerebrospinal fluid abnormalities, and jaundice were the major manifestations in our series. In premature infants with these symptoms and signs, congenital syphilis should be considered as one of the differential diagnoses. Once the diagnosis of congenital syphilis is made, adequate penicillin therapy should be given.

Sexually transmitted diseases and travelers

Sexually active travelers are at risk for a variety of STDs, including traditional venereal infections such as gonorrhea, chlamydial urethritis, syphilis, chancroid, and herpes simplex infection. More recently, hepatitis B, hepatitis C, and HIV-1 have also been described. Risk varies depending on the geographic area of travel and the type of sexual contact. Physicians should be aware of the prevalence of antimicrobial resistance of N. gonorrhoeae and H. ducreyi because this will affect empiric antibiotic therapy. Prevention should focus on proper and consistent usage of barrier contraceptives.

Congenital infections and the nervous system

Despite vaccines, new antimicrobials, and improved hygienic practices, congenital infections remain an important cause of death and long-term neurologic morbidity among infants world-wide. Important agents include Toxoplasma gondii, cytomegalovirus, Treponema pallidum, herpes simplex virus types 1 and 2, and rubella virus. In addition, several other agents, such as the varicella zoster virus, human parvovirus B19, and Borrelia burgdorferi, can potentially infect the fetus and cause adverse fetal outcomes. This article provides an overview of these infectious disorders and outlines current strategies for acute treatment and long-term management.

Pulmonary changes in congenital syphilis

Three of seven infants afflicted with congenital syphilis at our institution in the past five years showed diffuse pulmonary infiltrates. These persisted long after adequate antibiotic treatment of the primary infection. Review of pathologic literature suggests these infiltrates represent pulmonary immaturity, extramedullary hematopoiesis, and interstitial scarring.

Syphilitic placentitis: demonstration of Treponema pallidum by immunoperoxidase staining

We report a case of early congenital syphilis in which the placenta showed diffuse proliferative villitis and Treponema pallidum was identified by indirect immunoperoxidase stain in formalin-fixed paraffin-embedded placental tissue. This is the first report demonstrating T. pallidum in placental tissue using an immunohistochemical method.

Syphilis intervention in pregnancy: Zambian demonstration project

Despite availability of simpler serologic tests for syphilis and near cure with penicillin, unacceptably high prevalence of infectious maternal syphilis exist in many developing countries, including Zambia. It is the foremost risk factor for mid-trimester abortions, stillbirths, prematurity and morbidity and mortality among infants born with congenital syphilis in Zambia. An intervention project was conducted in Lusaka aimed at demonstrating the effectiveness of new health education methods and prenatal screening for syphilis in reducing the adverse outcomes during pregnancy. During pre-intervention phase, approximately 150 consecutive pregnant women from each of the three study and the three control centres were recruited when they presented in labour at the University Teaching Hospital. The intervention phase lasted for one year at the three study centres during which new methods of health education were introduced to improve early attendances during pregnancy. Also, on-site syphilis screening was performed twice during pregnancy and seroreactive women, and in many cases their sexual partners, were treated by the existing prenatal clinic staff. During the post-intervention phase the steps of pre-intervention phase were repeated to evaluate the impact of intervention. Overall, 8.0% of women were confirmed seroreactive for syphilis; there was no difference between the study and the control centres (p greater than 0.05). Fifty seven percent (132/230) of syphilitic pregnancies ended with an adverse outcome, that is, abortion (RR 5.0), stillbirth (RR 3.6), prematurity (RR 2.6) and low birth weight (RR 7.8). The overall risk of adverse outcomes due to syphilis was 8.29 (95% confidence interval 6.53, 10.53). The new methods of health education were effective and the percentage of women who had their first prenatal visit under 16 weeks of gestation improved from 9.4 to 42.5. Although screening and treatment during intervention was suboptimal, the adverse outcomes attributable to syphilis were reduced to 28.3%; this is almost a two-third reduction when compared with 72.4% of adverse outcomes at control centres (p < less than 0.001). The intervention is culturally and politically acceptable in Zambia. The cost of each prenatal screening is US$0.60 and of averting each adverse outcome US$12. In countries with high rates of syphilis, there is an urgent need for STD control and Maternal and Child Health (MCH) programmes to pool their resources together to revitalise the prenatal care.

Congenital syphilis is with us still

A baby with neonatal congenital syphilis who was born prematurely at 33-weeks' gestation with hepatosplenomegaly, ascites and respiratory distress that was evident at birth is presented.

Early congenital syphilis and severe haematological disturbance

The early clinical signs and symptoms of congenital syphilis are diverse but, if undiagnosed, signs of the disease may subside until the late stigmata appear. We report a case that illustrates that the haematological signs and symptoms may be so severe as to mimic a diagnosis of leukaemia or disseminated malignant disease.

Syphilis in women of reproductive age in Mogadishu, Somalia: serological survey

In Mogadishu, Somalia 223 women of childbearing age, including prostitutes, were tested for serum markers for syphilis by the Venereal Disease Research Laboratory (VDRL) test and the Treponema pallidum haemagglutination assay (TPHA). Sera reactive in either of these tests were tested for IgM antibodies by solid phase haemadsorption assay (SPHA). Three per cent of sera from 67 pregnant women and none of those from 71 educated women gave positive results that were confirmed with the TPHA. In contrast, 58% of sera from 85 prostitutes were confirmed as being positive, 26% of which were SPHA positive, which indicated active syphilis. The proportion of TPHA positive sera increased with age among the prostitutes. As venereal syphilis is highly prevalent in prostitutes in Mogadishu, a strategy of intervention based on screening followed by treatment seems to be indispensable.