Case 1: A 19-year-old female is diagnosed with late latent syphilis in her first trimester of pregnancy with an initial rapid plasma reagin (RPR) titer of 1:128. She is treated with weekly benzathine penicillin 2.4 million units intramuscularly for three weeks. At delivery, she reports interim sexual exposures and absent partner treatment history. What is your role as the pediatrician seeing this infant?
Case 2: A 5-week-old baby presents to his pediatrician’s office for a sick visit with a palmer planter rash and pseudoparalysis of the left upper extremity. Mother had a history of what she was told was a “false positive” syphilis screening test in her second trimester of pregnancy. No follow-up syphilis serologies were performed. What are the missed opportunities for screening and prevention on both sides of the placenta?
In 2017, the Centers for Disease Control and Prevention (CDC) released a Call to Action (https://www.cdc.gov/std/syphilis/SyphilisCalltoActionApril2017.pdf) encouraging a multimodality and multidisciplinary approach to “Stem the Tide” of syphilis nationally. Pediatricians represent a key group involved in the early identification, appropriate management and follow-up of infants with congenital syphilis (CS).
CS is a nationally reportable disease resulting from an in utero infection with Treponema pallidum. Rising rates of CS have been noted nationally concurrent with the rise of primary and secondary syphilis among females. CS cases increased 153% between 2013 and 2017, while syphilis among reproductive-age women increased 143% during the same period, according to a CDC surveillance report released today (http://bit.ly/2MLpPQG, see figure). In 2016, 26% of CS cases’ mothers received no prenatal care (Kidd S, et al. Sex Transm Dis. 2018;45:S23-S28).
Effective CS prevention and detection depend on the identification of syphilis in pregnant females. The CDC recommends syphilis screening for all pregnant females at the first prenatal visit. Females who are at high risk for syphilis (i.e., based on clinical history, sexual behavior and/or residence in a community with high syphilis prevalence) should be rescreened during the third trimester (28-32 weeks) and again at delivery (https://www.cdc.gov/std/tg2015/default.htm).
All newborns born to mothers with reactive nontreponemal and treponemal test results should be evaluated with a quantitative nontreponemal serologic test (RPR or VDRL) performed on the newborn’s serum. Commercially available IgM tests are not recommended. Infants with an abnormal physical examination consistent with CS (e.g., nonimmune hydrops, jaundice, lymphadenopathy, hepatosplenomegaly, pneumonitis, rhinitis, skin rash and pseudoparalysis of an extremity), infants born to mothers with no or inadequate therapy and infants whose mothers received therapy less than four weeks before delivery will need further evaluation, including cerebrospinal fluid evaluation, to aid in management decisions.
CS clinical manifestations at birth usually are absent (asymptomatic infection). Clinically apparent symptoms are varied when present and may result in severe illness, miscarriage, stillbirth and early infant demise. Additionally, infants may present with delayed onset of symptoms or may have initially mild CS disease, both of which can result in delayed identification and treatment. Potentially devastating long-term complications may occur in untreated infants with CS.
For all of these reasons, it is imperative that health care systems have robust processes to screen pregnant women for syphilis as described above and to ensure that maternal serologies are known prior to the neonate’s discharge from the birth hospital. At-risk newborns should be examined thoroughly for evidence of CS. A thorough assessment of the maternal lab values and, if appropriate, the newborn workup can prevent symptomless infants from being discharged without appropriate treatment and can prevent long-term morbidity.
Treatment of the mother and/or infant is based on 1) identification of syphilis in the mother; 2) adequacy of maternal treatment; 3) presence of clinical, laboratory or radiographic evidence of syphilis in the infant; and 4) comparison of maternal (at delivery) and neonatal nontreponemal serologic titers using the same test, preferably from the same laboratory.
Penicillin is the recommended treatment for both maternal and neonatal syphilis. The treatment regimen in infants depends on age and level of suspicion based on mother’s history, the infant’s exam and laboratory results. Recommended CS treatment algorithms are available in the 2018 AAP Red Book (http://bit.ly/2NQncSg) and the CDC STD Treatment Guidelines (https://www.cdc.gov/std/tg2015/congenital.htm).
Each CS case represents a sentinel event and an opportunity to evaluate and address critical deficits within the health care system. To change the story of syphilis, collaborations on both sides of the placenta in coordination with local public health need to occur. Pediatricians can play a key role in stemming the tide of CS.
Dr. McNeil is a member of the AAP Section on Infectious Diseases, and Dr. Burstein is a member of the Section on Adolescent Health.
