Pediatric Pearls: Congenital Syphilis in Infants

The mother of a 6-month-old infant presents to her pediatrician's office. She tells you that her daughter has a fever, rash, and has recently began shedding skin on her palms and soles. During your discussion, you learn that the mother was diagnosed with syphilis during her pregnancy. 

How would you advise your patient?

(Answer and discussion on next page)

Scott T. Vergano, MD, is a pediatrician in the Department of Pediatrics, Children’s Hospital of the King’s Daughters, Norfolk Virginia.

The Research

Correspondence published in the New England Journal of Medicine and an article published in Pediatrics call attention to the epidemic of congenital syphilis in the United States in recent years. The Centers for Disease Control and Prevention (CDC) report 2022 cases of congenital syphilis as of July 29, 2021, the highest number of annual cases since 1994 and already surpassing the total number of cases from the previous year. In a separate investigation, the CDC reports on 67 infants with symptomatic congenital syphilis diagnosed after 1 month of age, from 2014 to 2018. The researchers state that these infants represent “ultimate failures” of the public health system, as their diagnoses were not made during the neonatal period and led to symptomatic disease diagnosed late.

The Takeaway

In this era of resurgence of syphilis and of congenital syphilis at epidemic levels, it is more important than ever to strictly follow CDC guidelines for screening for maternal syphilis and evaluation of the neonate exposed in utero. In addition to screening early in pregnancy, the current guidelines call for repeat maternal screening at 28 weeks' gestation and again at birth in individuals and communities at high risk. Any infant exposed to syphilis in utero needs a titer drawn after birth. If an infant was inadequately treated in utero or shows physical examination evidence of syphilis or has a titer that is 4-fold greater than the mother's titer, further evaluation in the nursery is mandatory. The authors identify multiple reasons for failure of identification of congenital syphilis in their 67 infants with symptomatic late diagnoses.

Bottom Line - Physicians may need to read and process the relevant section of the Red Book once more to ensure adequate evaluation of their patients. The epidemic of congenital syphilis can reach geographic areas that have not previously been affected. It is important for all pediatricians caring for neonates and infants to review the guidelines, advocate for appropriate maternal testing, and not discharge neonates without thorough investigation of their syphilis status.