Syphilis

Syphilis: Excerpt from The 5-Minute Pediatric Consult

Esther K. Chung, MD, MPH

Syphilis - BASICS

Syphilis - description

• Systemic infection caused by the spirochete Treponema pallidum
• Can be congenital or acquired
• Consider sexual abuse when syphilis is diagnosed in young children.

Syphilis - epidemiology

• Congenital syphilis is transmitted from an infected mother to her unborn or newborn baby.
• Acquired syphilis is sexually transmitted from an infected to an uninfected individual.
• Infection transmitted to the fetus at any stage of disease; during primary and secondary syphilis, rate of transmission is 60–100%
• Nasal secretions are highly infectious in congenital syphilis, and open, moist skin lesions are infectious in congenital and acquired syphilis.

Syphilis - risk factors

• Lack of prenatal care
• Maternal use of illicit drugs
• Sexual abuse
• Infection with HIV

Syphilis - DIAGNOSIS

Syphilis - signs & symptoms

• Congenital syphilis:
  • Clinical manifestations range from asymptomatic to death or stillbirth.
  • Clinical signs include periostitis, osteochondritis, persistent rhinorrhea, or maculopapular rash.
• Acquired syphilis:
  • Primary stage: Painless, indurated ulcers (chancres), single or multiple, at the site of inoculation ~3 weeks after exposure (range 10–90 days); lesions usually resolve without treatment in 3–6 weeks.
  • Secondary stage: Generalized rash, which is often maculopapular and involves the palms and soles; condyloma lata, hypertrophic papular lesions; fever, malaise, lymphadenopathy; signs appear 3–6 weeks after initial chancre and may last 2–10 weeks
  • Relapse: Symptoms of secondary syphilis may recur 1 or more times before the latent period.
  • Latent period: Untreated, illness may enter a latent stage; patients are asymptomatic, not contagious; lasts 1–40 years or more; patients seroreactive but without other evidence of disease.
    • Early latent period: 1st 4 years of latent period
    • Late latent period: Subsequent years
  • Tertiary stage: Up to 1/3 of untreated secondary syphilis cases progress to tertiary or late disease; can occur many years after the primary infection; may see gummatous changes of the skin, bone, and/or viscera, or cardiovascular syphilis
  • Neurosyphilis: CNS involvement in 3–7% of untreated cases; can develop at any stage of disease; signs include changes in mood/behavior, hyperactive reflexes, impaired memory and/or judgment, and Argyll–Robertson pupils

Syphilis - history

• Newborn/Infants:
  • Obtain a detailed prenatal history; inquire about all syphilis testing done on the mother; if mother has a history of syphilis, ensure documented treatment. The local department of health should have detailed records that include titers and treatment on all cases of syphilis.
  • Newborns should be evaluated for congenital syphilis if the mother is not adequately treated for syphilis—mother treated with nonpenicillin regimen, such as erythromycin; mother treated adequately but without a 4-fold decrease in antibody titers in early or high-titer syphilis; maternal syphilis treated <1 month (30 days) before delivery; maternal syphilis treated prior to pregnancy with insufficient follow-up to assess serologic response to treatment; maternal titer has increased 4-fold, if the infant’s titer is 4-fold greater than the mother’s titer, or if the infant is symptomatic
• Older children/adolescents:
  • Ask about possible sexual abuse in children.
  • Ask about sexual activity in adolescents, including experience, number of lifetime partners, ages of partners, history of other STDs.
  • Ask about other risk behaviors.
  • Ask about risk factors for HIV exposure.

Syphilis - physical exam

• Early congenital syphilis:
  • Low birth weight; irritability, bulging fontanel, if neurosyphilis is present
  • Alopecia (scalp and eyebrows)
  • Fissures in the lips, nares, anus; mucocutaneous lesions
  • Rhinitis (“snuffles”) may occur at 1 to several weeks of age and may be blood-tinged and purulent
  • Lymphadenopathy
  • Pneumonia: Check for tachypnea and/or respiratory distress.
  • Myocarditis
  • Hepatosplenomegaly with or without jaundice
  • Pseudoparalysis of an extremity
  • Rash: Bullous (“syphilitic pemphigus”) and/or maculopapular (“blueberry muffin”) lesions symmetrically distributed on palms, soles, and other parts of the body
  • Condyloma lata: Flat, wartlike, moist lesions around the anus/vagina, chancres
• Late congenital syphilis:
  • Bony deformities, such as short maxilla, high-arched palate, saddle nose, mulberry molars, Higoumenaki sign (enlargement of the sternoclavicular portion of the clavicle), protuberance of the mandible, saber shins, scaphoid scapulae
  • Rhagades, neurologic involvement
• Acquired syphilis:
  • Primary syphilis:
    • Chancre (painless ulcer), single, most commonly located on the genitalia, and/or
    • Painless inguinal adenopathy
  • Secondary syphilis: Flulike illness with fever, headache, sore throat, nasal discharge, generalized arthralgias and myalgias, malaise, generalized painless and mobile lymphadenopathy; hepatosplenomegaly; maculopapular rash involving the palms and soles that may involve mucous membranes; condyloma lata (moist, papular lesions); alopecia; signs of meningitis, hepatitis, nephropathy, ocular involvement

Syphilis - tests

• Pitfalls:
  • Mothers of infants with congenital syphilis should also be tested for gonorrhea, chlamydia, HIV, and hepatitis B infection.
  • In newborns, cord blood testing may result in false-positive and false-negative results; therefore, serum from the infant is the preferred source of testing.
  • False-positive nontreponemal test (e.g., rapid plasma reagin [RPR]) results may be seen with lab error, autoimmune disease, tuberculosis, lymphoma, viral infections (including Epstein–Barr, hepatitis, varicella, HIV, and measles viruses), endocarditis, malaria, and IV drug abuse.
  • False-positive treponemal tests may be seen in other spirochetal diseases (i.e., Lyme disease, leptospirosis), and rarely in autoimmune disease (i.e., systemic lupus erythematosus) and viral infections.

Syphilis - lab

• Nontreponemal tests:
  • VDRL (Venereal Disease Research Laboratory) or RPR test to measure nonspecific antibodies
  • Used for routine screening; quantitative serum titers generally correlate with disease activity; need to confirm positive results with a treponemal antibody test. 4-fold titer change (e.g., from 1:8–1:32) necessary to document clinically significant change. Titers for different nontreponemal tests are not equivalent; therefore, must use same test (and preferably same lab) when following serial titers.
  • VDRL (not RPR) used on CSF to rule out neurosyphilis.
• Treponemal antibody tests:
  • FTA-ABS (fluorescent treponemal antibody-absorption), TPHA (Treponema pallidum hemagglutination), MHA-TP (microhemagglutination assay for T. pallidum antibodies), or EIA (enzyme immunoassay for antitreponemal IgG)
  • Treponemal tests remain positive for life once infected; not useful for measuring treatment effectiveness
• Dark-field microscopy
• CSF analysis:
  • Findings include mononuclear pleocytosis, moderately elevated protein, normal glucose
  • Should be performed in all patients with acquired syphilis of >1 year’s duration.
  • Perform on infants when congenital syphilis suspected, if the physical examination is consistent with syphilis, if infant’s titer is 4-fold greater than that of mother, if dark-field or fluorescent antibody test positive on body fluids, and on all children being treated with antibiotics for syphilis.
  • Remember that CSF protein levels in normal newborns are higher than in older children; some are as high as 150–200 mg/dL.

Syphilis - imaging

Long-bone plain films: Rule out metaphyseal osteochondritis and/or diaphyseal periostitis.

Syphilis - differencial diagnosis

• Congenital syphilis:
  • Herpes simplex virus (HSV)
  • Toxoplasmosis
  • Cytomegalovirus
  • Rubella
  • Neonatal hepatitis
  • Osteomyelitis
• Acquired syphilis:
  • Chancroid (Haemophilus ducreyi)
  • Granuloma inguinale
  • Calymmatobacterium granulomatis
  • Lymphogranuloma venereum (Chlamydia trachomatis)
  • Scabies
  • Mycotic infections
  • Genital herpes (HSV)
  • Venereal warts (human papillomavirus, HPV)
  • Viral exanthem (e.g., enteroviruses may cause a maculopapular rash involving the palms and soles)

Syphilis - TREATMENT

Syphilis - medication

• Infants <28 days of age:
  • Aqueous crystalline penicillin G (50,000 U/kg/dose) IV q12h for 1st 7 days of life, then q8h for a total of 10 days or procaine penicillin G (50,000 U/kg/dose) IM daily for 10 days
  • If >1 day of treatment is missed, restart 10-day course.
• Infants >28 days of age:
  • Aqueous crystalline penicillin G (50,000 U/kg/dose) IV q4-6h for 10 days
• Primary and secondary syphilis:
  • Benzathine penicillin G 50,000 U//kg IM (maximum, 2.4 million units), single dose
  • Doxycycline 100 mg PO b.i.d. or tetracycline 500 mg PO q.i.d. for 14 days for nonpregnant, penicillin-allergic patients
• Early latent syphilis (<1 year’s duration):
  • Benzathine penicillin G 50,000 U/kg IM (maximum, 2.4 million units), single dose
  • Doxycycline 100 mg PO b.i.d. or tetracycline 500 mg PO q.i.d. for 14 days for nonpregnant, penicillin-allergic patients
• Late latent syphilis or disease of unknown duration:
  • Benzathine penicillin G 50,000 U/kg IM (maximum 2.4 million U) weekly for 3 consecutive weeks
  • Doxycycline 100 mg PO b.i.d. or tetracycline 500 mg PO q.i.d. for 4 weeks for nonpregnant, penicillin-allergic patients
• Alternative therapy can be found at www.cdc.gov/nchstp/dstd/penicillinG.htm.

Syphilis - FOLLOW UP

Syphilis - disposition

Syphilis - issues for referral

All cases should be reported to the local department of (public) health.

Syphilis - prognosis

• The prognosis is better the earlier syphilis is detected and treated.
• Following appropriate therapy, the disease is usually totally arrested.
• With late findings of syphilis involving the nervous system and/or cardiovascular system, there may not be clinical improvement.
• Untreated infection in the neonate progresses to neurosyphilis within 1 year.
• Osteochondritis and periostitis in the newborn are usually self-limited and heal in the 1st 6 months of life.
• Hemolytic anemia seen in congenital syphilis may persist for weeks.

Syphilis - complications

• Stillbirth or spontaneous abortion
• Perinatal death in 40% of pregnancies in mothers with untreated early syphilis
• Hydrops fetalis
• Prematurity
• Nephrosis
• Failure to thrive
• Disseminated intravascular coagulation
• Pseudoparalysis of Parrot: Paralysis of one of the limbs of an infant affected by congenital syphilis; usually unilateral
• Acute syphilitic leptomeningitis
• Cranial nerve palsies
• Interstitial keratitis—5–20 years after birth
• Cerebral infarction
• Seizure disorder, mental retardation
• Rhagades: Cluster of scars radiating around the mouth
• Mulberry molars: Maldevelopment of the cusps in the 1st molars
• Clutton joints: Painless arthritis of the knees and, rarely, other joints
• Hutchinson triad: Hutchinson teeth (notched upper central incisors), interstitial keratitis, eighth-nerve deafness
• Saber shins: Anterior bowing of the midportion of the tibia

Syphilis - patient monitoring

• Congenital syphilis:
  • Clinical follow-up and serial nontreponemal serologic testing every 2–3 months until titer decreases 4-fold or test is nonreactive
  • After adequate treatment, nontreponemal tests should be nonreactive after 6 months; infants with a history of abnormal CSF findings need serial CSF analyses every 6 months until CSF is normal.
  • Treated infants, follow-up at 1, 2, 4, 6, and 12 months of age; serologic tests should be performed 2, 4, 6, and 12 months after therapy until they become nonreactive or the titer has decreased 4-fold.
  • If titers have not shown a decline by 6–12 months, require re-evaluation and treatment.
• Primary and secondary syphilis:
  • Clinical follow-up and serial nontreponemal titers at 6 and 12 months after treatment (more often, if at high risk for reinfection or treatment failure): Nontreponemal titers should drop 4-fold within 6 months of treatment of primary or secondary syphilis, and within 12–24 months after treatment of latent or tertiary syphilis.

Syphilis - bibliography

1. Centers for Disease Control and Prevention. Congenital syphilis: United States, 2002. MMWR Morb Mortal Wkly Rep. 2004;53:716–719.
2. Centers for Disease Control and Prevention. Primary and secondary syphilis: United States, 2003–2004. MMWR Morb Mortal Wkly Rep. 2006;55:269–273.
3. Ferran M, Martin-Ezquerra G, Vicente A, et al. Picture of the month. Acquired secondary syphilis. Arch Pediatr Adolesc Med. 2007;161(2):199–200.
4. Hyman EL. Syphilis. Pediatr Rev. 2006;27:37–39.

Syphilis - CODES

Syphilis - icd9

079.9 Syphilis

Syphilis - FAQ

• Q: Can an infant have congenital syphilis if the mother had a negative RPR during pregnancy?
• A: A mother with a negative RPR during pregnancy may have acquired syphilis late in pregnancy and transmitted it to her fetus. If the mother was not tested at delivery, then the diagnosis may have been missed.
• Q: What is the prozone phenomenon?
• A: When a nontreponemal test is falsely negative due to high concentrations of antibody to T. pallidum; diluting the serum will result in positive test results.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Syphilis

• Back to disease: Syphilis: Introduction
• Next Book Extract About Syphilis: Surveys relating to Syphilis
• More Book Extracts: All Online Books for Syphilis

More Medical Textbooks Online about Syphilis

Review other book chapters online related to Syphilis:

Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

 » Next page: Surveys relating to Syphilis

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Surveys relating to Syphilis
• Ask Question about Syphilis

Tools & Services:

• Bookmark this page
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

Enter your search terms Submit search form
Search The Web Search wrongdiagnosis.com

Common Health Mistakes

Symptom
Checker

Search Specialists by State and City