The girl from the church of the sacrament: a case of congenital syphilis in XVIII century Lisbon

Syphilis is a sexually or congenitally transmitted infectious disease with an impact on the health of human populations that has undergone important cycles in different countries and periods of history. Its presence was first diagnosed in Europe in the late XIV century. In Portugal, although there are various written records of the infection in the last centuries, there are rare references to it in archeological findings (mummified bodies are also rare in Portugal). The current study describes a probable case of congenital syphilis in an 18-month-old girl buried in the Church of the Sacrament in Lisbon. Her body, dating to the XVIII century, was found mummified together with dozens of others, still not studied. Symmetrical periostitis of the long bones, osteitis, metaphyseal lesions, left knee articular, and epiphyseal destruction, and a rarefied lesion with a radiological appearance compatible with Wimberger's sign all point to a diagnosis of congenital syphilis. The diagnosis of this severe form of the infection, possibly related to the cause of death in this upper-class girl, calls attention to the disease's presence in XVIII century Lisbon and is consistent with the intense mobilization at the time in relation to the risks posed by so-called heredosyphilis. It is the first case of congenital syphilis in a child reported in archeological findings in Portugal, and can be correlated with other cases in skeletons of adults buried in cemeteries in Lisbon (in the XVI to XVIII centuries) and Coimbra (XIX century). Finally, this finding highlights the need to study the entire series of mummified bodies in the Church of the Sacrament in order to compare the paleopathological findings and existing historical documents on syphilis, so as to expand the paleoepidemiological knowledge of this infection in XVIII century Lisbon.

Cortical hyperostosis in an infant on prolonged prostaglandin infusion: case report and literature review

The common side effects associated with the use of prostaglandins in newborn infants include apnoea, hyperthermia, diarrhoea, skin flushing and oedema. Periosteal reaction or cortical thickening of the bones, also known as cortical hyperostosis, is associated with a prolonged use of prostaglandins. This is a radiological diagnosis; therefore, its occurrence is most likely underestimated. We describe an infant who developed cortical hyperostosis simulating osteomyelitis with elevated alkaline phosphatase. The radiologic changes were initially attributed to congenital syphilis. This occurred after a prolonged infusion of prostaglandin E(1) for a cyanotic congenital heart disease.

Value of routine long bone radiographs in management of babies with a positive VDRL at the Mount Hope Women's Hospital

This retrospective study examined the records of 44 mothers and 44 babies with a positive blood VDRL test and/or who showed symptoms of congenital syphilis at the Mount Hope Women's Hospital (MHWH), Trinidad, between June 1, 1996 and September 30, 1998. Long bone radiographs of 40/44 (91%) babies were assessed independently by two radiologists for signs of congenital syphilis and the data were analysed using frequency tables. Of the 44 mothers in the study, 34 (77%) were VDRL positive and the rest were either negative or unknown. Maternal age ranged from 14 to 39 years and most (92%) had antenatal care. Fourteen of the 34 (41%) VDRL positive mothers received treatment antenatally. All mothers were asymptomatic and none had any clinical features of syphilis. In 35/44 babies, the VDRL test was positive and in nine, the test was either negative or unknown. Twenty-six of the babies had signs suggestive of congenital syphilis and in 12, (46%) long bone radiographs revealed changes compatible with the diagnosis of congenital syphilis. Radiographic abnormalities were present only in infants with VDRL titres > 1:8.

Clinical and epidemiological features of syphilis in pregnant women: the course and outcome of pregnancy

Clinical and epidemiological features of syphilis and the course and outcome of pregnancy were studied in 155 pregnant women infected with syphilis; 95 (61%) women were unemployed, 47% were unmarried. Syphilis proceeded without clinical manifestations in 121 cases (78%). Discordant results of complement fixation (Wassermann) test, precipitation test, Treponema pallidum immobilization test, and fluorescent antibody test were observed in 22 (14%) of the women. Pregnancy pathology was observed in 75 cases (48.8%) and more often appeared as anemia in 49 (31.5%), stillborn in 46 (29.8%) and toxicosis in 44 (28.4%). Fetal ultrasonic stigmas of infection were evident in 23 cases (49%). There was distension of the brain ventricle system and hepatomegaly each in 1 case (2%), transvascular infiltration of liver in 2 cases (4%), dilation of intestinal loops, gastromegaly, ventriculomegaly and petrifaction in lungs each in 1 case; ultrasonic changes in vessels of organs: of the liver in 4 cases (8%), intestines and stomach in 16 cases (32%), lungs in 4 cases (8%), kidneys in 10 cases (21%) and of the ventricular system in 9 cases (19%). Fetus development retardation was revealed in 3 cases (6%), fetal hypoxia in 1 (2%), hypohydrosis in 2 (4%) and hydropsy in 1 case (2%). The pregnancy pathology in women with syphilis was considered not pathognomonic.

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".

Incidence and clinical significance of echogenic vasculature in the basal ganglia of newborns

Cranial sonography has become the main modality of the investigation and diagnosis of a wide variety of neonatal intracranial abnormalities. Occasionally, cranial sonograms reveal basal ganglia and thalami bright echoes. It is believed that these lesions are indicative of vasculitis due to intrauterine infections, in particular with cytomegalovirus (CMV). We hypothesized that the incidence of proven neonatal intrauterine TORCH infection is low and that screening of all asymptomatic infants with bright lenticulostriate echodensities would not be cost-effective. We reviewed brain sonograms of 3700 infants, performed over a period of 3 1/2 years. Echogenic basal ganglia vasculature were observed in 75 patients (2%). Chart review performed for clinical presentation and TORCH studies showed that only one infant had confirmed intrauterine congenital infection, which was by CMV. This infant had no signs or symptoms of CMV. In addition, there were 4 patients with chromosomal anomalies among the 75 patients (5%), of these one had trisomy 13 and another-trisomy 21. Our results indicate that echogenic basal ganglia blood vessels are not an exceptional finding on cranial sonograms, and are seldom associated with intrauterine infection. We conclude that it is not cost-effective to screen infants with echogenic basal ganglia blood vessels for intrauterine infection, unless clinical suspicion exists.

[Osteoarticular involvement in parasitic diseases: bone treponematosis]

Bone and joint localizations of treponematosis vary greatly although there are many common features. Osteal and periosteal lesions are common. We report radiographic descriptions of bone and joint treponematosis, which must not go unrecognized due to the increasing incidence of these diseases.

Contribution of long-bone radiographs to the management of congenital syphilis in the newborn infant

OBJECTIVE

To determine the contribution of long-bone radiographs to the diagnosis and management of newborn infants at risk for congenital syphilis.

DESIGN

Historical cohort.

SETTING

Three large hospitals in Houston, Tex.

PATIENTS

Eight hundred fifty-three live born infants who were evaluated for the presence of congenital syphilis.

INTERVENTION

Long-bone radiographs done as part of the diagnostic evaluation for the presence of congenital syphilis.

MAIN OUTCOME MEASURE

Changes in diagnostic classification or management decisions that were based on radiographic findings in the long bones.

RESULTS

For 450 infants, radiographic results did not affect management because clinical or historical factors were present that dictated treatment: 26 infants had clinical symptoms of congenital syphilis (65% [17] had abnormalities on radiographs); and 424 infants were born to mothers who were untreated or reinfected (5.9% [25] had abnormalities on radiographs). All of these infants required a full course of therapy regardless of radiologic findings. Born to mothers with possibly inadequate therapy (according to 1993 Centers for Disease Control and Prevention guidelines), 237 asymptomatic newborn infants were candidates for a single injection of penicillin G benzathine if the results of their evaluations were normal; of these, 2 (0.8%) had abnormal radiographic findings. Of the 166 infants born to adequately treated mothers with appropriately falling serologic titer levels, 1 (0.6%) had abnormal radiographic findings (P=.99 between groups). The results of the long-bone radiographs did not alter management for any of the 853 infants who were evaluated for congenital syphilis.

CONCLUSIONS

Long-bone radiographic findings, often abnormal in symptomatic infants, do not differentiate between active infection and past infection. The use of long-bone radiographs should be reconsidered in the routine evaluation of infants for congenital syphilis.

Skeletal lesions in early congenital syphilis (a review of 86 cases)

Early congenital syphilis is still common in Morocco, where it causes a large number of stillbirths and neonatal deaths. Over the last 16 years, we managed 86 cases of congenital syphilis in infants aged one day to four months. Multiple organs were affected in half the patients. Skeletal lesions were found in 65% of patients, Wimberger's sign in nearly 20% (17/86), and pseudoparalysis in 23%. The significance of the skeletal lesions often seen in congenital syphilis in Morocco is emphasized.

Chest radiographs of neonates with respiratory failure caused by congenital syphilis

Congenital syphilis still occurs in newborn babies and the prevalence has increased in recent years, especially in developing countries. This has led to an increase in the number of babies with congenital syphilis requiring intensive care for respiratory failure. The early recognition of this disease could lead to the institution of timely and appropriate treatment. In this study the radiological picture of syphilitic pneumonitis is described in 20 neonates admitted to our neonatal intensive care unit requiring ventilation for respiratory failure. The radiological picture of the babies with syphilis was compared to 20 babies with other causes of respiratory distress. The radiological picture in 17 babies demonstrated a coarse nodular pattern in addition to band-like opacities radiating from the hilar regions. The nodular opacities became confluent on follow-up radiographs. In 13 cases, the proximal humeri showed changes typical of congenital syphilis. Two of the three babies with syphilis who did not have the typical chest radiological picture had bony involvement visible on the chest radiograph. Both the sensitivity and specificity of radiographic diagnosis were 75% with a positive and negative predictive value of 75%. The diagnosis of congenital syphilitic pneumonitis can therefore be suspected on chest radiographs and should be included in the differential diagnosis of any baby who presents with an interstitial pattern on chest radiography.

Absence of lower extremity ossification centers in term infants with congenital syphilis

Radiologic evaluation is valuable for confirmation of congenital syphilis. Bony abnormalities are thought to be secondary to active disease or a growth response of bone to systemic illness. Anteroposterior lower extremity radiographs of 85 euthyroid term infants (> or = 38 weeks' gestation; mean weight, 3244 gm; range, 1940-4380 gm) with presumptive congenital syphilis were evaluated for the presence of the distal femoral and proximal tibial secondary ossification centers and other bony abnormalities. Both proximal tibial and distal femoral ossification centers were absent in only 9 of 85 infants with syphilis; the proximal tibial center was absent in 26 of 85 (total 30.6%; 95% confidence limits 0.2 to 0.4). This observation is significant at the p < 0.01 level by chi-square analysis with use of historical controls. Periosteal new bone formation was seen in 2 of 85 infants. Metaphyseal lucent bands were present in 21 of 85 infants, 8 of whom also had absent lower extremity ossification centers. For comparison we reviewed lower extremity radiographs from 12 term infants without congenital syphilis. Ossification centers were absent in one growth-retarded infant, and metaphyseal lucent bands were found in one infant. Although standard texts report nearly universal ossification of the distal femoral epiphysis at term, we observed delayed skeletal maturation in 30.1% of term infants with congenital syphilis. We speculate that this delay may be reflective of systemic infection.

Congenital syphilitic skeletal manifestations in a premature infant revisited

Increasing rates of congenital syphilis have been reported in recent years despite the availability of adequate therapy. In our perinatal-neonatal center, approximately 1.5% of newborns have reactive serologic tests for syphilis. Untreated or partly treated maternal syphilis can adversely affect neonatal outcome since the treponeme can cross the placenta at any time during pregnancy. As a result of hematogenous placental transmission, neonatal manifestations are usually systemic and similar to the secondary stage of syphilis, and include hepatosplenomegaly, jaundice, neurosyphilis, and skeletal changes. A case of early congenital syphilis in an extremely premature infant with primary skeletal involvement is presented.

Fetal syphilis: correlation of sonographic findings and rabbit infectivity testing of amniotic fluid

Fetal syphilis is the presumed diagnosis when the sonographic findings of fetal hydrops are found in the presence of maternal syphilis. In the absence of fetal hydrops, the diagnosis of fetal infection is difficult. We hypothesized that intra-amniotic infection would be accompanied by anatomic placental and fetal abnormalities that could be detected by ultrasonography. Rabbit infectivity testing (RIT), intratesticular inoculation of rabbits with amniotic fluid, can be used to confirm intra-amniotic infection with Treponema pallidum. Twenty-one gravidas with untreated early (primary, secondary, and early latent) syphilis underwent sonography and amniocentesis for RIT at 24 weeks of gestation or later. Antenatal sonographic findings were compared to their amniotic fluid RIT results. Hepatomegaly was significantly (P < 0.01) associated with amniotic fluid infection detected by RIT. Antenatal detection of hepatomegaly, which is probably the initial sonographic manifestation of hydrops fetalis, may ultimately identify the fetus affected with congenital syphilis.

Are long bone radiographs necessary in neonates suspected of having congenital syphilis?

The frequency of appendicular bone abnormalities was prospectively evaluated in 93 newborns suspected of having congenital syphilis. The evaluation of each newborn included prenatal history, physical examination, serologic tests, and long bone radiography, which was performed during the first week after birth. In all patients, results of at least one serologic test for syphilis were positive or proof of syphilis was found at autopsy. In 75 patients (81%), the long bone radiographs were normal. The nonspecific finding of lucent metaphyseal bands was the most common abnormality on long bone radiographs; only five newborns had more specific changes of syphilis in the metaphyses and periosteal reaction. In view of the low frequency of relatively specific radiographic findings in the long bones, the authors recommend that long bone radiography not be a part of the routine evaluation of full-term newborns suspected of having congenital syphilis.

An unusual constellation of sonographic findings associated with congenital syphilis

Sonography of a fetus, later proved to have congenital syphilis, revealed hepatosplenomegaly, noncontinuous gastrointestinal tract obstruction, and placentomegaly. This unusual constellation of sonographic findings should raise suspicion of syphilis infection of the fetus.

Long-bone radiographic abnormalities as a sign of active congenital syphilis in asymptomatic newborns

Metaphyseal abnormalities are present in greater than 90% of infants with symptomatic congenital syphilis. The incidence of these lesions in asymptomatic newborns in the present epidemic is not known. To determine the incidence of bone lesions at birth in asymptomatic congenital syphilis, long-bone films were obtained for all babies born during a 9-month period with a positive perinatal serology. Of 2544 newborns, 61 had a positive maternal serology and 40 also had a positive cord serology. Two symptomatic babies had abnormal radiographs and 12 of 59 asymptomatic newborns had metaphyseal changes consistent with congenital syphilis. It is concluded that long-bone radiographs are abnormal in approximately 20% of asymptomatic newborns with positive perinatal treponemal serology. With the increasing incidence of congenital syphilis, radiologic studies should be included in the assessment of all newborns with a positive serology. Indeed, those patients with any sign of active disease should be carefully followed because even treated infants remain at some risk for developing the late sequelae of congenital syphilis.

Linear areas of echogenicity in the thalami and basal ganglia of neonates: an expanded association. Work in progress

A retrospective review of 2,320 neonatal cranial sonograms obtained in 1,324 patients identified 25 patients with areas of echogenicity in their thalami and basal ganglia that were of a linear or branching linear distribution. Four of these patients had cytomegalovirus infection. Other major diagnoses encountered included Down syndrome, trisomy 13 syndrome, neonatal asphyxia, non-immune hydrops, and fetal alcohol syndrome. Results of the study suggest a broader etiologic basis for linear areas of echogenicity in the basal ganglia and thalami of children than has previously been reported. These patients warrant complete screening for possible in utero infection and perhaps also chromosomal analysis.

The skeletal manifestations of congenital syphilis. A review of 197 cases

In a retrospective review of 302 clinically suspected cases of congenital syphilis, bone changes were found in 197. The skeletal manifestations were periostitis (102 cases), osteitis (20), and metaphyseal changes (71). Combinations of more than one lesion were found in 61. Pseudoparalysis was a presenting sign in 34 infants; 12 of these were found to have had pathological fractures and four had dactylitis. Complete radiological healing without residual changes was seen in all 59 cases that were recalled for review. The orthopaedic surgeon should consider the diagnosis of congenital syphilis when destructive lesions of bone are seen in an infant.

Bone scintigraphy in latent congenital syphilis

A 26-year-old man with congenital syphilis presented with increased periosteal uptake of Tc-99m MDP during bone scintigraphy. In addition, bowing of the tibias and apparent shortening of the tibias were seen on the bone scan. Corresponding abnormalities were noted on roentgenography of the lower extremities.

Early congenital syphilis: clinico-radiologic features in 202 patients

Venereal syphilis is highly prevalent among women of child-bearing age in Zambia. It is estimated to contribute 25-30% of the perinatal mortality rate of 50 per 1,000 births at the University Teaching Hospital in Lusaka. Because of multisystem involvement, early congenital syphilis, the offshoot of maternal syphilis, has varied criteria for its diagnosis. Therefore, in an attempt to draw guidelines for an easier and more reliable diagnosis, the authors analyzed the clinico-radiologic features of congenital syphilis in 202 patients. Although all infants were under the age of six months, there were several significant differences in the manifestations of the disease among neonates and the postneonates. The younger infants had a higher incidence of jaundice and mortality, whereas joint swellings, skin rash, snuffles, anemia, and periosteal reaction visible in x-rays of long bones were typical findings among the older group. The radiologic changes were seen in greater than 95% of patients in both groups. About 84% of mothers had attended prenatal clinics, but less than 20% of the women had been tested for syphilis. Since early congenital syphilis is common in many parts of the world and since all serologic tests have limitations, awareness of appropriate diagnostic criteria is recommended for all medical personnel.

Skeletal scintigraphy in congenital syphilis

Two infants with congenital syphilis are described. Both had bone scans, the one showing significant changes in a focal lesion, while the other was unremarkable. Radiographic changes were evident at the time of the scan in the second infant, but only became apparent later in the first case. The possible cause for this discrepancy is discussed.

Child abuse

Child abuse is common in most, if not all, Western nations; it probably occurs worldwide. It may be a major factor in the increase in violence throughout much of the world. Radiologists who treat children should think of the possibility of abuse whenever they diagnose a fracture, intracranial bleed, or visceral injury, especially when the history is not compatible with their findings. Metaphyseal "corner" fractures in infants usually are caused by abuse. Less than 20% of abused children, however, present injuries that can be recognized by radiologic techniques. Consequently normal roentgenograms, nuclear medicine scans, ultrasound studies, and computed tomograms do not exclude child abuse.

Osseous manifestations in congenital syphilis: a study of 55 cases

Radiology plays an important role in the early diagnosis of congenital syphilis. Osseous manifestations in 55 cases of congenital syphilis have been analysed and their radiological appearances described. In addition to the common findings of metaphysitis, periostitis and osteitis of the long bones, unusual involvement of the skull, mandible, nasal septum, scapulae and short bones of the hands and feet was observed.

The value of radiography in perinatal deaths

A prospective study of 100 consecutive stillbirths/perinatal deaths was performed by routine radiography and subsequent autopsy. The object of the study was to correlate the clinical and the autopsy causes of death with any abnormal radiographic findings. A prime objective was to study the incidence of major skeletal abnormalities in the series and to ascertain if routine radiography could be used to detect abnormalities that might require genetic counselling. No skeletal abnormalities or dysplasias were detected that did not have obvious external stigmata. The use of routine radiography on undeformed stillbirths is not recommended.

Congenital syphilis: an unusual presentation

Congenital syphilis was discovered in a neonate with the unusual radiographic presentation of unilateral involvement of three bones showing lytic lesions and periostitis. Congenital syphilis should be considered in a newborn infant with these radiographic manifestations, especially when a suggestive history is obtained.

[Congenital syphilis, intrauterine radiologic diagnosis]

The present work includes six cases of congenital syphilis that were diagnosed radiologically before birth in patients with positive syphilitic reactions who had not been given treatment during gestation. The x-ray diagnosis was mainly based on lesions of diaphyses and metaphyses of the long bones of the fetal skeleton that were identified in lateral projection of x-ray plates of the maternal abdomen. In all cases reported, x-ray plates were taken in the immediate post-partum period with confirmation of the bony lesions and at the same time, of the laboratory tests including blood picture and liver function test in 5 cases. Autopsy was practiced in one case.

[Congenital syphilis (author's transl)]

Authors present a study on eleven patients affected with congenital syphillis treated during the last six years. All of them presented bone lesions in one or more locations. Familiar antecedents, mechanism of infection, clinical symptoms and radiological findings are analized, emphasizing the importance of prophylaxis and early treatment with procaine penicillin in a dosage of 50,000 U./Kg. day for at least ten days.

The unusual case: persistence of metaphyseal changes in penicillin treated congenital syphilis

A case of congenital syphilis is described in which the diagnosis was not made until the age of 9 and with persistance of metaphyseal changes in spite of prolonged penicillin treatment.

Unusual bone involvement in congenital syphilis mimicking the battered child syndrome

Congenital syphilis is re-emerging in modern society. The pediatric radiologist may contribute to its early diagnosis. A case of unusual bone involvement with fracture of the olecranon and facial bone lesions is described; the condition had to be differentiated from the "battered child syndrome". The problem of congenital syphilis as an infectious disease versus bone dystrophy is also discussed.

[Early congenital syphilis (7 cases observed in Bangui Hospital Central African Empire) (author's transl)]

In an infant of good condition, skin changes, anemia, hepato-splenomegalia and more over radiological osseous changes are symptoms of great value which are to be confirmed by a serological test of the baby and its mother. Treatment is very effective but it would be better to protect the foetus by an early detection and treatment of the syphilitic pregnant woman.

Congenital syphilitic hepatitis: a radionuclide study

A two-month-old girl with congenital syphilitic hepatitis had bizarre liver scintigraphic features showing diminished hepatic uptake of radiocolloid with accentuated pulmonary and bone marrow accumulation. These features were reversible following penicillin therapy and to our knowledge are previously undescribed manifestations of this multisystemic disease.

Focal osseous lesions in congenital lues

Five babies, aged between one to three months presented with clinical and serological evidence of syphilis. In addition to the usual periosteal and metaphyseal bone lesions of lues, areas of focal lucencies and sequestra were present. The association of sequestra in focal diaphyseal erosions may represent a non-dystrophic manifestation of the disease. The lesions were attributed to the syphilitic process. Trivial trauma to disorganised metaphyses, dystrophic changes and possibly focal osteomyelitis account for the spectrum of bone lesions in congenital syphilis. No tubular bone appears immune to these processes.

Congenital syphilitic osteitis of scapulae and ribs

A newborn with congenital syphilis presented radiographically with a lack of ossification of the medial portions of several ribs and massive sclerosis and decalcification of scapulae. The uniqueness of syphilitic scapular and rib involvement is discussed. The infant also went on to develop skin lesions which appeared following penicillin therapy and also developed an extrahepatic biliary atresia.