Congenital Syphilis Scenarios

Question 1

Proven or highly probable congenital syphilis (3)

Answer 1

Any neonate with:
1. An abnormal physical exam that is consistent with congenital syphilis
OR
2. Serum quantitiative nontreponemal (VDRL, RPR) serologic titer that is fourfold higher than the mother’s titer
OR
3. A positive darkfield test or PCR of lesions or body fluid(s)

Question 2

Recommended evaluation for proven or highly probable congenital syphilis (3)

Answer 2

1. CSF analysis for VDRL cell count and protein**
2. CBC with differential and platelets
3. Other tests as clinically indicated (ex: long-bone radiographs, chest radiograph, LFTs, neuroimagine, opthalmologic exam and auditory brain stem response)

Question 3

Treatment for proven or highly probable congenital syphilis (2)

Answer 3

1. Aqueous crystalline penicillin G (100,000-150,000 units/kg/day) administered as 50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days

OR

2. Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days

Question 4

Possible congenital syphilis (3)

Answer 4

Any neonate who has a normal physical examination and a serum quantitative nontreponemal serologic titer equal to or less than fourfold the maternal titer and one of the following:
1. mother was not treated, inadequately treated, or has no documentation of having received treatment
OR
2. mother was treated with erythromycin or a regimen other than those recommended in these guideline (i.e.., a nonpenicillin G regimen)
OR
3. Mother received recommended treatment <4 weeks before delivery

Question 5

Recommended evaluation for possible congenital syphilis (4)

Answer 5

1. CSF analysis for VDRL cell count and protein**
2. CBC with differential and platelets
3. Long bone radiographs
4. A complete evaluation is not necessary if 10 days of parenteral therapy is administered, although such evaluations might be useful

Question 6

Recommended treatment for possible congenital syphilis (3)

Answer 6

• With this child, really think about treating with 10 days parenteral antibiotics
  1. Aqueous crystalline penicillin G (100,000-150,000 units/kg/day) administered as 50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days

OR

2. Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days

OR

3. Benzathine penicillin G 50,000 units/kg/dose IM in a single dose

Question 7

Congenital Syphilis Less Likely (3)

Answer 7

1. Any neonate who has a normal physical examination and a serum quantitative nontreponemal serologic titer equal to or less than fourfold the maternal titer and both of the following are true:
2. Mother was treated during pregnancy, treatment was appropriate for the stage of infection and treatment was administered >4 weeks before delivery
3. Mother has no evidence of reinfection or relapse

Question 8

Recommended Evaluation Congenital Syphilis Less Likely (2)

Answer 8

1. No evaluation is recommended
2. Here, you just want to watch the baby very well at every visit - look for lymphadenopathy, skin rash, jaundice, oral region, hepatosplenomegaly, etc.

Question 9

Recommended Regimen for Congenital Syphilis Less Likely (2)

Answer 9

1. Benzathine penicillin G 50,000 units/kg/dose IM in a single dose
2. Another approach involves not treating the infant,
   - Close serologic follow up every 2-3 months for 6 months for infants whose mother’s non-treponemal titers decreased at least fourfold after appropriate therapy for early syphilis
   - Or remained stable for low-titer, latent syphilis

Question 10

Follow-up of congenital syphilis (4)

Answer 10

1. Follow-up examinations if treated for congenital syphilis after the neonatal period – every 3 months until the test becomes nonreactive or the titer has decreased
2. If the titers increase at any point for more than 2 weeks or do not decrease fourfold after 12-18 months, the infant or child should be evaluated through CSF examination, treated with a 10 day course of parenteral penicillin G and managed in consultation with an expert
3. If positive at birth but titers are low, closely watch over the next couple of months that the titers are dropping
4. Treponemal tests are not used as the results are qualitative and persist after treatment