Congenital Syphilis

KEY POINTS

• 1.

  Congenital syphilis is a global public health problem, particularly in the Americas where its incidence appears to be rising.

• 2.

  At birth 90% of infants are asymptomatic, the remaining 10% present a wide variety of symptoms from mild to lethal.

• 3.

  To confirm the presence of spirochete may be challenging, diagnosis will usually be based on maternal syphilis history, treponemal and non treponemal test performed (maternal and newborn’s) and the presence of symptoms.

• 4.

  Patients will be treated with aqueous/procaine penicillin if congenital syphilis is proven or probable. Possible disease may be treated with a single dose of benzathine penicillin. This might also be the case if infection is less likely.

• 5.

  Follow up is paramount to ensure infants do not develop long term complications. Follow up will consist of periodical physical examination and non treponemal serologic test.

• 6.

  Prevention is key in diminishing the burden of congenital syphilis. Screening during pregnancy is recommended. Epidemiological surveillance through notifications systems remains a cornerstone to tackle this problematic.

Introduction

Congenital syphilis is the infection of a fetus and newborn infant caused by Treponema pallidum , a bacterium from the family Spirochaetaceae. The infection was described for the first time in Europe during the 15th century by Gaspar Torella. In the Americas, the infection might have been brought by Europeans during colonization. T. pallidum was first identified in 1905 by Fritz Schaudinn, a zoologist, and Erich Hoffmann, a dermatologist. Penicillin was tested and proven to be an effective bactericidal agent against T. pallidum by John Mahoney, Richard Arnold, and A.D. Harris in 1943, and these findings provided an effective treatment for this infection.

Syphilis is seen all over the world, particularly in urban areas. The reservoir of Treponema is exclusively human, and it is transmitted by body fluids or lesions that contain high concentrations of spirochetes, leading to a systemic and chronic infection. Despite all the medical advances and the availability of an effective, affordable, and universally available treatment, congenital syphilis continues to cause considerable morbidity and mortality worldwide and is seen to evolve into various stages in patients with age ( Fig. 34.1A ). The consequences are particularly dire in infected pregnant women and newborn infants. Congenital syphilis remains a globally relevant public health problem.

Epidemiology

A large number of new cases of syphilis continue to be diagnosed each year. In 2016, 5.6 million new cases were diagnosed. The burden of congenital syphilis was estimated to be 473 per 100.000 births. The incidence of syphilis showed some improvement during the period from 2007 to 2016, but it has plateaued since then. The number of new patients may be diminishing worldwide, but the incidence seems to be rising in the Americas. In the United States, the Centers for Disease Control and Prevention (CDC) has reported an increased number of new cases since the year 2000. The frequency of new cases has increased from 11.2 to 39.7 per 100,000 inhabitants, particularly in the western parts of the United States. ^, Syphilis is seen less frequently in women than in men, but the rate of new infections has increased by 178.6% during the period from 2015 to 2019. The prevalence is higher among women aged 20 to 39 and in African American, Latino, and Native American individuals living in the United States, Alaska, or the Pacific Islands. ^, The frequency of congenital syphilis has also increased during this period (see Fig. 34.1B ).

In 2017, most parts of Latin America and the Caribbean region had reported advances in prevention of congenital syphilis; 15 out of the 17 countries in these regions reported virtual elimination of vertically transmitted syphilis (incidence <0.5 new cases per 1000 newborn infants per year). However, most of these advances have since been lost with a resurgence in the past few years. The largest rise in case load has been noted in Brazil. Studies suggest that inadequate treatment of infected mothers is an important factor. Lack of proper prenatal care, difficulties in timely diagnosis of the infection, and clinical evidence of maternal infection despite proper treatment were also found to be fundamental to determining obstetric results.