NICU

Congenital Syphilis

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Congenital Syphilis, Parrot Pseudoparalysis, Neonatal Snuffles, Congenital Syphilitic Pemphigus, Olympian Brow, Syphilitic Saddle Nose, Mulberry Molars, Higoumenakis Sign, Clutton's Joints, Saber Shin

  • See Also
  • Epidemiology
  1. Congenital Syphilis Incidence in U.S. is increasing
    1. 2012: 7.7 cases per 100,000 live births
  • Pathophysiology
  1. Transmitted transplacentally or via contact with syphilitic lesions during delivery
  • Risk Factors
  1. Children born to mothers who have sex with multiple partners
    1. Unique pocket of Syphilis is in urban women who trade crack Cocaine for sex
  • Signs
  • Early presentation (birth to 48 months)
  1. Only one third of Congenital Syphilis patients are symptomatic at birth
  2. Common
    1. Hepatosplenomegaly
    2. Morbilliform rash similar to Secondary Syphilis rash
      1. Nickels and Dimes type rash on palms and soles
    3. Fever
    4. Neurosyphilis findings in infants
      1. Bulging Fontanelle
      2. Seizures
      3. Cranial Nerve deficit
  3. Uncommon
    1. Parrot Pseudoparalysis (painful epiphysitis)
      1. Syphilis related bone Growth Plate involvement results in failure to move involved extremities
      2. Rothner (1975) Pediatrics 56(4): 604-5 [PubMed]
    2. Snuffles
      1. Rhinitis characterized by blood stained mucus
    3. Syphilitic Pemphigus
      1. Bullae on distal extremities
  4. Other findings
    1. Anemia
    2. Jaundice
    3. Thrombocytopenia
    4. Reticulocytosis
    5. Edema
  • Signs
  • Late presentation (48 months to age 20 years)
  1. Common
    1. Olympian Brow
      1. Frontal bossing or high forehead
    2. Rhagades
      1. Mouth or nose scarring
    3. Saddle nose deformity
      1. Nasal cartilage destruction with depressed nasal bridge
    4. Hutchinson's Teeth
      1. Permanent upper central incisors with peg-shape
    5. Mulberry Molars
      1. First molars (6th year molar) with extra cusps (mulberry appearance)
    6. Higoumenakis Sign
      1. Unilateral, proximal clavicular enlargement (near sternoclavicular joint)
    7. Wimberger Sign
      1. Pathognomonic, bilateral symmetric Osteomyelitis with medial tibia metaphysis pathologic Fractures
  2. Uncommon
    1. Clutton's Joints
      1. Major joint sterile effusions with symmetric distribution
    2. Saber Shins
      1. Tibial bowing
  • Labs
  1. See Syphilis
  2. Obtain Serologic Non-Treponemal Tests (VDRL or RPR)
    1. Infant and mother at birth
    2. Infant every 2-3 months until Non-Treponemal Test nonreactive
  1. Indications
    1. Findings of Congenital Syphilis on exam
    2. Suspected untreated maternal Syphilis
      1. Mother treated for Syphilis within 4 weeks prior to delivery
  2. Testing
    1. CSF for VDRL, cell count and protein
    2. Complete Blood Count with platelets
  3. Diagnostics
    1. Long Bone XRays
    2. Ophthalmology and audiology exams
  • Management
  1. Precautions
    1. Do not miss doses
      1. More than one day of treatment missed requires repeating the entire antibiotic course
  2. Diagnosis at birth to age 1 month
    1. Penicillin G Benzathine 50,000 U/Kg IM (up to 2.4 million U IM)
      1. Given every 12 hours for 7 days, then every 8 hours for an additional 3 days
    2. Alternatives
      1. Penicillin G Procaine 50,000 U/Kg IM (up to 2.4 million U IM) every 24 hours
      2. Ceftriaxone 75 mg/kg IV/IM every 24 hours for 10-14 days
        1. Risk of worsening Neonatal Jaundice and Kernicterus!
  3. Diagnosis at >1 month of age
    1. Penicillin G Benzathine 50,000 U/Kg IM (up to 2.4 million U IM)
      1. Given every 4-6 hours for 10 days (200-300k units/kg/day)
    2. Alternatives
      1. Penicillin G Procaine 50,000 U/Kg IM (up to 2.4 million U IM) every 24 hours
      2. Ceftriaxone 100 mg/kg IV/IM every 24 hours for 10-14 days
  • Resources
  1. CDC STD management booklet
    1. http://www.cdc.gov/mmwr/pdf/rr/rr5912.pdf
  • References
  1. (2019) Sanford Guide, accessed on IOS 10/29/2019
  2. Green, Cohen, Billington (2016) Crit Dec Emerg Med 30(11): 4-10
  3. (2015) MMWR Morb Mortal Wkly Rep 64(RR3):1-37 [PubMed]
  4. Mattel (2012) Am Fam Physician 86(5): 433-40 [PubMed]
  5. Woods (2009) Pediatr Infect Dis J 28(6): 536-7 [PubMed]