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Congenital syphilis often involves multiple organ systems of body and may be confused with many other diseases of the newborn. With lot of stress on prevention of HIV infection, little concern is being raised about the increasing number of babies born with congenital syphilis. We have encountered two such cases within a span of 5 months emphasizing that syphilis is forgotten but not yet gone.
First baby was a 26 day old female neonate, born to fifth gravida, unbooked mother with history of three abortions, admitted with complaints of excessive crying and paucity of movements of both lower limbs and left upper limb of about 20 days duration. There was no history of abnormal movements, apneic spells, or trauma. Baby maintained a posture of flexed lower limbs at hip and knee. Left elbow and both knee joints were tender. She had pallor and firm hepatosplenomegaly of 3 cm and 2 cm respectively. There were no other positive clinical findings. Her Hb was 9.7gm/dl with normochromic normocytic anaemia. TORCH titre and HIV test were negative. There was no evidence of tuberculosis in mother and baby. VDRL was reactor for both infant and mother in dilutions of 1:128 and 1:32 respectively and blood TPHA was positive for both. Kiddigram revealed metaphyseal fuzziness of distal end of both femur, metaphyseal fractures at lower end of humerus. Cerebrospinal fluid analysis was normal and VDRL and TPHA were negative. Baby and parents were treated adequately. Follow up VDRL showed a downfall titre and radiological resolution was seen after 10 months.
Second case comprised a female neonate born to booked and immunized primigravida mother at 35 weeks gestation was found to have firm hepatomegaly of 5 cm and splenomegaly of 3 cm at birth. No other clinical signs were detected. Antenatal period was uneventful. There was no history of tuberculosis in mother or close relative. VDRL in the first trimester of pregnancy was non-reactor. Her hemogram, platelet count, and liver enzymes were within normal limit. Blood culture was sterile. Torch titre and HIV test were negative. VDRL was reactor in dilutions of 1:128 and 1:32 for infant and mother respectively. TPHA was positive in both mother and child. Cerebrospinal fluid study was within normal limit and VDRL was also negative. Kiddigram showed cat bite appearance in lower end of both femur and evidence of periostitis in left humerus. Newborn was managed with Inj sodium penicillin for 14 days. Follow up VDRL titre declined and repeat X-ray after 12 months showed resolution.
The commonest effect of maternal syphilis on the fetus is probably abortion and perinatal deaths may be to the tune of around 40% if left untreated . Only 22% babies become symptomatic and manifestations appear mostly within the first few weeks of life . Splenomegaly and pseudoparalysis, which form part of diagnostic pentad, were present in these two cases . Radiological evidence of skeletal involvement has been reported in 80% cases . The disappearance of these radiological features takes nearly six to twelve months; hence such babies should be followed up for six to twelve months. A high index of suspicion is emphasized since congenital syphilis may mimic any neonatal infection. WHO has reported high rates of syphilis among pregnant women from several countries in eastern Asia . It is now believed that congenital syphilis can occur at any time in gestation, with the risk of fetal infection increasing as the stage of pregnancy advances. Therefore, STS being non-reactor in first trimester does not rule out syphilis and high-risk partners should undergo STS in the last trimester and before delivery. Follow up of the infant should be incorporated in routine paediatric care.