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Description
A 2-month-old girl (born in Italy from Rumanian parents) was admitted to our paediatric emergency department because of fever and painful mobilisation of the left arm. Copper-red maculopapular lesions on face and hands were noted; the mother presented a similar lesion on the thumb of the right hand (figure 1). Palms and soles showed erythema and desquamation with dry scaling. Severe hepatosplenomegaly was present. X-ray was performed and epiphysial detachment of the left humerus was detected (figure 2). Congenital syphilis was suspected due to the presence of infant bone lesion and the same rash in the baby and in the mother. Serologic screening was performed in the child and revealed reactive Venereal Disease Research Laboratory (VDRL) titre (1:64) and Treponema pallidum haemagglutination (TPHA) (1/5120). Fluorescent Treponemal antibody-absorption (FTA-ABS) and specific IgM on blood were positive too. VDRL, TPHA, FTA-ABS and specific IgM on cerebrospinal fluid were negative. The diagnosis of congenital syphilis was made and the infant was treated with aqueous penicillin G, 50 000 U/kg per dose every 12 h during the first 7 days and every 8 h till day 14. An indepth medical history revealed that the father had a diagnosis of syphilis 7 months before her birth. The mother, a primigravida HIV negative woman with secondary syphilis, had two false-negative VDRL titres during pregnancy, due to prozone phenomenon. This is documented in immuno-compromised states (ie, pregnancy, HIV infection) and occurs in very high antibody titers, due to an inappropriate ratio of antibody versus antigen.1,–,3 To prevent this phenomenon the serum should be diluted up to 1:16.3
Copper-red maculopapular lesions on the child’s face and right hand (arrows). A similar lesion is visible on the thumb of the mother’s left hand (arrow head).
Left arm x-ray showing epiphysial detachment of the distal end of the humerus (arrow).
Learning points
Congenital syphilis is still a major public health problem. This report highlights that syphilis may go undetected in pregnant women, also in developed countries.
Gynaecologists and obstetricians have to be vigilant and to perform repeated serology checks during pregnancy especially if risk factors are present.
Congenital syphilis is a deadly yet curable disease. Paediatricians should consider congenital syphilis in any infant with suspicious clinical findings, despite maternal serologic status (prozone phenomenon), in order to perform early diagnosis and appropriate treatment.
Footnotes
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Competing interests None.
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Patient consent Obtained.