Syphilis Congenital Syphilis. Part V

Congenital Syphilis Irina Tabidze, MD, MPH and Thad Zajdowicz, MD, MPH STD/HIV Division Chicago Dept of Public Health 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: • 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 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 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 infants <1 year of age: US, 1981–2002 and the Healthy People 2010 objective Rate (per 100,000 live births) 125 100 Cong. Syphilis 2010 Objective 75 50 25 0 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 for infants <1 year of age and rates of P &S syphilis among women: US, 1970–2002 P&S rate (per 100,000 population) 20 16 12 CS cases (in thousands) 7.5 6.0 4.5 Kaufman Criteria CDC Surveillance Definition P&S Syphilis 8 4 0 1970 3.0 Congenital Syphilis 75 80 85 90 95 2000 1.5 0.0 Note: The surveillance case definition for congenital syphilis changed in 1988. Syphilis 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 Manifestations of Early CS • • • • • • • • Condyloma Lata Maculopapular rash Hepatosplenomegaly Jaundice due to the hepatitis Anemia Osteochondritis Snuffles Pseudoparalysis • Lymphadenopathy • Mucous patches Congenital Syphilis Congenital Syphilis Congenital Syphilis Congenital Syphilis Clinical Manifestations of Late 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 Congenital Syphilis Hutchinson’s Triad (late congenital syphilis): Interstitial keratitis Teeth abnormalities Deafness Congenital Syphilis Clutton’s Joints Saddle Nose Sabre Shins Laboratory 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 Serology of Mothers & their Infants Nontreponemal Test Mother Infant Treponemal Test Mother Infant - Interpretation No syphilis or incubating syphilis in the mother and infant + + + + or - + + No syphilis in mother Maternal syphilis with possible infant infection Recent or previous syphilis in the mother; possible infection in infant + + + + - - + + Mother successfully treated for syphilis before or early in pregnancy; Maternal 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 Infants • Sexually Transmitted Diseases Treatment Guidelines 2002. MMWR 2002; 51 (No. RR-6): [26-28] Follow-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.