Congenital SyphilisCongenital Syphilis

Irina Tabidze, MD, MPH Irina Tabidze, MD, MPH andand

Thad Zajdowicz, MD, MPHThad Zajdowicz, MD, MPHSTD/HIV DivisionSTD/HIV Division

Chicago Dept of Public HealthChicago Dept of Public Health

Congenital Syphilis (CS)Congenital Syphilis (CS)• Syphilis is a chronic infection caused by the

spirochete Treponema pallidum, which is of particular concern during pregnancy because of the risk of transplacental infection of the fetus.

• Congenital infection is associated with several adverse outcomes, including:-Perinatal death-Premature delivery-Low birth weight-Congenital anomalies

Modes of Transmission:Modes of Transmission:• Sexual contact.• Trans-placental passage from

infected mother.• Contact with lesion at the time

of delivery.• The risk of developing syphilis

after exposure is about 40%.

Risk Factors for CSRisk Factors for CS• Lack of or inadequate prenatal care.• Maternal substance abuse. Failure to repeat a serological test

for syphilis in the third trimester. Treatment failure. Inadequate access to Sexually

Transmitted Diseases (STD) clinics and STD outreach activities.

Epidemiology of CSEpidemiology of CS

• Incidence of CS reflects the rate of syphilis in women of childbearing age.

• Peaks in CS occur one year after peaks in P&S syphilis in women.

Congenital syphilis — Rates for Congenital syphilis — Rates for infants <1 year of age: US, 1981–infants <1 year of age: US, 1981–2002 and the Healthy People 2010 2002 and the Healthy People 2010

objectiveobjectiveRate (per 100,000 live births)

Cong. Syphilis2010 Objective

0

25

50

75

100

125

1981 83 85 87 89 91 93 95 97 99 2001

Note: The Healthy People 2010 objective for congenital syphilis is 1.0 case per 100,000 live births. The surveillance case definition for congenital syphilis changed in 1988.

Congenital syphilis — Reported cases Congenital syphilis — Reported cases for infants <1 year of age and rates for infants <1 year of age and rates of P &S syphilis among women: US, of P &S syphilis among women: US,

1970–20021970–2002

Kaufman CriteriaCDC SurveillanceDefinition

P&S rate (per 100,000 population) CS cases (in thousands)

P&S Syphilis

CongenitalSyphilis

0

4

8

12

16

20

1970 75 80 85 90 95 20000.0

1.5

3.0

4.5

6.0

7.5

Note: The surveillance case definition for congenital syphilis changed in 1988.

Syphilis in NewbornsSyphilis in Newborns• Two-thirds of live-born neonates with CS

are asymptomatic at births.• Overt infection can manifest in the fetus,

the newborn, or later in childhood.• The infant may have many or even no

signs until 6-8 weeks of life (delayed form).

• Clinical manifestations after birth are divided arbitrarily into:- Early CS (<=2 years of age) and - Late CS ( >2 years of age)

Clinical Clinical Manifestations of Manifestations of

Early CSEarly CS• Condyloma Lata• Maculopapular rash• Hepatosplenomegaly• Jaundice due to the

hepatitis• Anemia• Osteochondritis• Snuffles• Pseudoparalysis

• Lymphadenopathy• Mucous patches

Congenital SyphilisCongenital Syphilis

Congenital SyphilisCongenital Syphilis

Congenital SyphilisCongenital Syphilis

Congenital SyphilisCongenital Syphilis

Clinical Clinical Manifestations of Manifestations of

Late CSLate CS• Hutchinson’s triad

(63%): -Hutchinson’s teeth

(blunted upper incisors)

-Interstitial keratitis -VII nerve deafness• Frontal bossae (bony

prominences of the forehead) (87%)

• Saddle nose (74%)• Defect of hard pallet• Clutton’s joints

(bilateral painless swelling of knees)

• Saber chins• Short maxillas• Protruding mandible

Hutchinson’s Triad (late congenital syphilis):Interstitial keratitisTeeth abnormalitiesDeafness

Congenital SyphilisCongenital Syphilis

Congenital SyphilisCongenital Syphilis

Clutton’s JointsClutton’s Joints

Saddle NoseSaddle Nose

Sabre ShinsSabre Shins

Laboratory DiagnosisLaboratory Diagnosis• Direct visualization- Darkfield examination of exudate- Direct fluorescent antibody to T.

pallidum• Serologic testing- Nontreponemal Antibody tests (VDRL

test and RPR test)- Treponemal Antibody tests (FTA-ABS

and MHA-TP)

Interpretation of the Syphilis Interpretation of the Syphilis Serology of Mothers & their Serology of Mothers & their

InfantsInfants

Maternal syphilis with possible infant infection

+++ or -+

Recent or previous syphilis in the mother; possible infection in infant

++++

No syphilis in mother

--++

----

+

Infant

-

Infant MotherMother

Mother successfully treated for syphilis before or early in pregnancy;

+-

Interpretation

No syphilis or incubating syphilis in the mother and infant

Treponemal TestNontreponemal Test

Maternal TreatmentMaternal Treatment• Penicillin is the gold standard for

the treatment of syphilis.• Pregnant women with syphilis

should be treated with the appropriate penicillin regimen according to their stage of disease.

• Sexually Transmitted Diseases Treatment Guidelines 2002. MMWR 2002; 51 (No. RR-6): [19-23]

Treatment of InfantsTreatment of Infants

• Sexually Transmitted Diseases Treatment Guidelines 2002. MMWR 2002; 51 (No. RR-6): [26-28]

Follow-up evaluationFollow-up evaluation• Non-treponemal antibody serologic

testing should be checked at 1, 3, 6, 12 and 24 months following treatment.

• Titers should decrease four-fold by 6 months post therapy and become non-reactive by 12 to 24 months.

• Titers that show a four-fold rise or do not decrease suggest either treatment failure or re-infection.