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Key Features

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Essentials of Diagnosis
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Congenital

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  • All types: history of untreated maternal syphilis, a positive serologic test or a positive darkfield examination

  • Newborn: hepatosplenomegaly, characteristic radiographic bone changes, anemia, increased nucleated red cells, thrombocytopenia, abnormal spinal fluid, jaundice, edema

  • Young infant (3–12 weeks): snuffles, maculopapular skin rash, mucocutaneous lesions, pseudoparalysis (in addition to radiographic bone changes)

  • Children: stigmata of early congenital syphilis, interstitial keratitis, saber shins, gummas of nose and palate

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Acquired

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  • Chancre of genitals, lip, or anus in child or adolescent

  • History of sexual contact and a positive serologic test

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General Considerations
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  • Caused by a spirochete, Treponema pallidum

  • In the acquired form, the disease is transmitted by sexual contact

  • Primary syphilis is characterized by the presence of an indurated painless chancre, which heals in 7–10 days

  • A secondary eruption involving the skin and mucous membranes appears in 4–6 weeks

  • After a long latency period, late lesions of tertiary syphilis involve the eyes, skin, bones, viscera, CNS, and cardiovascular system

  • Congenital syphilis results from transplacental infection

    • May result in stillbirth or produce illness in the newborn, in early infancy, or later in childhood

    • Syphilis occurring in the newborn and young infant is comparable to secondary disease in the adult but is more severe and maybe life-threatening

    • Late congenital syphilis (developing in childhood) is comparable to tertiary disease

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Demographics
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  • Incidence of primary and secondary syphilis is increasing in the United States particularly among gay men

  • In 2012, 15,667 new cases of primary and secondary syphilis, 322 cases of congenital syphilis (< 1 year) and nearly 50,000 total cases were reported

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Clinical Findings

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Symptoms and Signs
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Congenital syphilis
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  • Newborns

    • Most newborns are asymptomatic; symptoms develop within weeks to months

    • When clinical signs are present, consist of jaundice, anemia with or without thrombocytopenia, increase in nucleated red blood cells, hepatosplenomegaly, and edema

    • Overt signs of meningitis (bulging fontanelle or opisthotonos) may be present, but subclinical infection with CSF abnormalities is more common

  • Young infants (3–12 weeks)

    • Infant may appear normal for the first few weeks of life only to develop mucocutaneous lesions and pseudoparalysis of the arms or legs

    • Shotty lymphadenopathy may be felt

    • Hepatomegaly is universal, with splenomegaly in 50% of patients

    • Anemia has been reported as the only presenting manifestation of congenital syphilis in this age group

    • "Snuffles" (syphilitic rhinitis), characterized by a profuse mucopurulent discharge, are present in 15–25% of patients

    • A syphilitic rash is common on the palms and soles but may occur anywhere on the body

      • Rash consists of bright red, raised maculopapular lesions that gradually fade

      • Occasionally rash is vesicular or bullous

      • Moist lesions occur at the mucocutaneous junctions (nose, mouth, anus, and genitals) and lead to fissuring and bleeding

  • Children

    • Bilateral interstitial keratitis (at age 6–12 years) is characterized by photophobia, increased lacrimation, and vascularization of ...

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