Syphilis

Key Features

Essentials of Diagnosis

Congenital

• 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

Acquired

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

• History of sexual contact and a positive serologic test

General Considerations

• 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

Demographics

• 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

Clinical Findings

Symptoms and Signs

Congenital syphilis

• 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

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