A case series of 130 neonates with congenital syphilis: preterm neonates had more clinical evidences of infection than term neonates

Congenital syphilis unusually presenting with prematurity-related severe neonatal morbidities including meconium obstruction: A case report and review of the literature

RATIONALE

Congenital syphilis (CS) can manifest as a variety of clinical presentations according to the severity in symptomatic infants during neonatal period. Preterm neonates with CS may have more clinical evidences of infection and be more severely affected by CS compared with term ones. With increasing survival of markedly premature infants for recent decades, CS may be a challenging problem in those with severe manifestations associated with combined pathophysiologies of CS and prematurity.

PATIENT CONCERNS

A very low birth weight infant at 32 weeks gestation presented with an unusual CS presentation consisting of prematurity-associated severe neonatal morbidities including meconium obstruction, prolonged cholestatic jaundice with elevated liver enzymes, and disseminated intravascular coagulation with a bleeding diathesis, in addition to common or typical manifestations of CS.

DIAGNOSES

Congenital syphilis.

INTERVENTIONS

Therapy consisting of a complete course of parenteral penicillin, blood component therapy, proximal ileotomy with inspissated meconium evacuation and distal loop ileostomy, and other conservative treatments.

OUTCOMES

Resolution with normal gastrointestinal function and improved liver function was observed.

LESSONS

This case suggests that in premature infants CS may manifest as unusual severe neonatal morbidities that may result from combination of syphilitic pathologies and contributors or conditions associated with prematurity including multisystem immaturity.

Congenital syphilis: A prospective study of 22 cases diagnosed by PCR

Congenital syphilis (CS) is caused by Treponema pallidum infection in utero. There is a need to develop new tools to diagnose CS: the diagnostic value of PCR is difficult to assess. The aim of this study was to describe the clinical and laboratory characteristics of mothers and infants with CS as diagnosed by PCR tests on various maternal and neonatal samples.

PATIENTS AND METHODS

We included all infants epidemiologically linked to a mother diagnosed with syphilis whose samples were referred to the Syphilis Reference Center, and for whom at least one positive PCR result was obtained.

RESULTS

Twenty-two mother-infant pairs (8.3%) with assay performed on samples from one to four different anatomic sites were included between February 2011 and April 2018. Seven mothers (31.8%) were born abroad, fifteen (68.2%) presented psychological and/or social problems, eight (36.4%) had not been screened for syphilis prior to delivery, and eleven (50%) were referred from French overseas departments or territories, or from the Paris region. Six infants (27.3%) were stillborn and six were born preterm, while fifteen infants (68.2%) presented clinical features of CS. All infants born preterm were symptomatic. Infant VDRL/RPR titer was no greater than four times that in the mother's serum, except in two cases.

DISCUSSION

Lack of antenatal care, social disadvantage and psychological issues were common. There is a need for enhanced surveillance both in the French overseas departments/territories and in the Paris region. A larger study is required to assess the sensitivity and specificity of PCR. The best site for sampling has yet to be established. We recommend the collection of as many samples as possible to avoid underdiagnosis of CS.

Syphilis in Children

Syphilis, caused by Treponema pallidum, is transmitted both sexually and transplacentally. Untreated syphilis is a progressive disease that may result in death or disability in children and adults. Syphilis diagnosis requires 2-stage serologic testing for nontreponemal and treponemal antibodies. Congenital syphilis diagnosis requires careful review of maternal testing and treatment, comparison of maternal and neonatal nontreponemal antibody titers, and clinical evaluation of the neonate. In this review, we present the current epidemiology of syphilis, and the clinical manifestations, diagnosis, and management of syphilis as they relate to pediatric practice, specifically, congenital syphilis and acquired syphilis in adolescents and pregnant women.

Fetal and infant mortality of congenital syphilis reported to the Health Information System

Background

Congenital syphilis (CS) is a major cause of mortality in several countries, especially in Latin America and the Caribbean. This study aimed to analyze fetal and infant mortality of CS reported to the Health Information System in a State in Northeastern Brazil.

Methods and results

This was a cross-sectional study that analyzed the deaths of CS from 2010 to 2014 through the linkage of the Mortality Information System (SIM) and the Notifiable Diseases Information System (Sinan). The Statistical Package for the Social Sciences (SPSS) version 23.0 was used to calculate the rates of Fetal, Perinatal, Neonatal (early and late), and Postneonatal Mortality. Simple linear regression was performed. Fisher's exact test or Pearson's chi-square test were used for comparison of proportions and Student's t-test was used for comparison of means.

Of the 414 cases reported to the SIM as deaths possibly caused by CS, 44 (10.6%) presented CS as the underlying cause. From 2010 to 2014 the Infant Mortality Rate of CS was 16.3 per 100,000 live births (y = 0.65x + 14.33, R² = 0.2338, p = 0.003). There was an 89.4% underreporting of deaths. Perinatal deaths and fetal deaths of CS accounted for 87.7% and 73.9% of total deaths, respectively.

Conclusions

The results of the study revealed a significant Fetal and Infant Mortality rate of CS and demonstrated the importance of using the linkage method in studies that involve the analysis of secondary data obtained from mortality and disease reporting systems. The underreporting of CS as a cause of fetal and infant mortality leads to unawareness of the reality of deaths from this disease, hindering the development of public policies aimed at its prevention.

Republication: Two Premature Neonates of Congenital Syphilis with Severe Clinical Manifestations

Congenital syphilis (CS) is a public health burden in both developing and developed countries. We report two cases of CS in premature neonates with severe clinical manifestations; Patient 1 (gestational age 31 weeks, birth weight 1423 g) had disseminated idiopathic coagulation (DIC) while Patient 2 (gestational age 34 weeks and 6 days, birth weight 2299 g) had refractory syphilitic meningitis. Their mothers were single and had neither received antenatal care nor undergone syphilis screening. Both neonates were delivered via an emergency cesarean section and had birth asphyxia and transient tachypnea of newborn. Physical examination revealed massive hepatosplenomegaly. Laboratory testing of maternal and neonatal blood showed increased rapid plasma reagin (RPR) titer and positive Treponema pallidum hemagglutination assay. Diagnosis of CS was further supported by a positive IgM fluorescent treponemal antibody absorption test and large amounts of T. pallidum spirochetes detected in the placenta. Each neonate was initially treated with ampicillin and cefotaxime for early bacterial sepsis/meningitis that coexisted with CS. Patient 1 received fresh frozen plasma and antithrombin III to treat DIC. Patient 2 experienced a relapse of CS during initial antibiotic treatment, necessitating parenteral penicillin G. Treatment was effective in both neonates, as shown by reductions in RPR. Monitoring of growth and neurological development through to age 4 showed no evidence of apparent delay or complications. Without adequate antenatal care and maternal screening tests for infection, CS is difficult for non-specialists to diagnose at birth, because the clinical manifestations are similar to those of neonatal sepsis and meningitis. Ampicillin was insufficient for treating CS and penicillin G was necessary.

The C in TORCH: a cost-effective alternative to screening small-for-gestational-age infants

BACKGROUND

Infants born with birth weights under the 10th percentile for their gestational age are classified as small for gestational age (SGA). TORCH infections are reported to be associated with SGA infants. With the low incidence of infections, screening is likely to be expensive and of low utility.

OBJECTIVE

The objective of this study was to determine the utility and cost-effectiveness of screening SGA infants with TORCH serology titers, urine cytomegalovirus (CMV) cultures and cranial ultrasounds.

METHODS

A retrospective review was conducted on all infants admitted to the neonatal intensive care unit (NICU) at Los Angeles County and University of Southern California (LAC+USC) Medical Center from January 2003 to December 2011 with a diagnosis of SGA or intrauterine growth restriction. Birth characteristics such as birth weight, length, head circumference and gestational age were recorded. TORCH titer results, urine CMV results and cranial ultrasound findings were collected.

RESULTS

Between 2003 and 2011, 232 SGA infants were admitted to the NICU at LAC+USC Medical Center. Of these, 117 infants (50%) had TORCH titer testing performed; there was only 1 positive CMV IgM and 1 positive HSV IgM result. Repeat urine CMV testing was performed on 109 infants (47%), with a total of 296 urine CMV samples collected from these infants; 6 infants had positive results, of whom 3 had repeat positive urine CMV samples. Overall, 149 of the infants had a cranial ultrasound done, none of which were positive for calcifications.

CONCLUSIONS

TORCH titer testing, urine CMV screening and cranial ultrasound screening are of low yield in screening clinically asymptomatic SGA infants for TORCH infections. Given the low number of positive results, a cost-effective alternative of selective TORCH testing may be limited to infants with additional clinical findings. This study serves as a reminder to periodically examine testing practices and patient population to maximize cost-effectiveness.

Neonatal-perinatal medicine in a transitional period in China

With an annual birth rate of 12‰, or 16 millions, of all population (1.34 billions), and an implementation of universal healthcare policy for all rural residents in recent years, China is undergoing a dramatic and profound transition in perinatal and neonatal healthcare as a part of the global campaign for reduction in mortality of children under 5 years old. This review describes recent development in neonatal-perinatal medicine, with special emphasis on general neonatal-perinatal care, respiratory and intensive care, neurological and infectious diseases, for a comprehensive view of the trend and challenge in relation with problems and solutions of the field.

Curse on two generations: a history of congenital syphilis

Before the microbiologic era, venereal diseases were poorly distinguished. 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. The most frequent maternofetal transmission was not considered because the mother's primary infection remained undiagnosed. The concept of treating infants with mercury transmitted by nurses' milk prompted the founding of a specialized infant hospital in Vaugirard in 1780: lactating syphilitic women received mercury orally and by rubbing it into the skin. Their own infant and a second infected infant from the foundling hospital were believed to be cured by their milk. Underwood described snuffles in 1789 and Bertin periosteal bone disease in 1810. Tardive congenital lues with keratitis, deafness, and notched upper incisors were described by Hutchinson in 1863. Feeding remained difficult, as wet nursing transmitted syphilis to the nurse and other infants. Specialized institutions tried goat or donkey milk. A debate between contagionists assuming exclusively maternal infection and hereditists assuming germinal transmission by the father's sperm continued throughout the 19th century. Schaudinn and Hoffmann identified Spirochaeta pallida in 1905. When Ehrlich discovered the efficacy of salvarsan in 1910, Noeggerath treated infants with the new drug, pioneering the injection into scalp veins. In 1943, Lentz and Ingraham established penicillin treatment for congenital syphilis. Whereas this drug effectively prevented maternofetal transmission, treating infants remained difficult due to the Jarisch-Herxheimer reaction.