Congenital Syphilis
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Direct answer
Congenital syphilis is infection of the newborn by Treponema pallidum that crosses the placenta from an inadequately treated mother. It presents as early disease in the first two years or as late disease after that, and the Hutchinson triad is the classic late presentation. The diagnosis rests on maternal and infant serology, and aqueous crystalline penicillin G for 10 days is the treatment for proven or probable disease.
What you must remember
- Early disease: before about 2 years, with hepatosplenomegaly, snuffles, a copper-coloured rash on the palms and soles, and osteochondritis.
- Snuffles: a persistent, often blood-stained nasal discharge, one of the classic early signs.
- Hutchinson triad: interstitial keratitis, notched Hutchinson incisors and eighth nerve deafness, all signs of late disease.
- Other late stigmata: mulberry molars, saddle nose, frontal bossing, sabre tibia and Clutton joints, which are painless knee effusions.
- Non-treponemal tests: VDRL or RPR on infant serum, with a fourfold higher titre than the mother's suggesting infection.
- Treponemal tests: used to confirm a reactive result, since they stay positive for life after treatment or infection.
- Treatment: aqueous crystalline penicillin G for 10 days for proven or probable neonatal disease.
- Prevention: early antenatal screening and treatment of the mother, which India's PPTCT programme supports.
Staging the infection at the bedside
A 6-week-old boy has snuffles, a rash on the palms and an enlarged liver, and his mother was never screened in pregnancy. The timing of signs indicates the stage, and the stage decides how much damage is already permanent.
| Feature | Early disease | Late disease |
|---|---|---|
| Timing | Before about 2 years | After about 2 years |
| Skin | Copper-coloured rash on palms and soles | Usually absent |
| Nose | Snuffles | Usually absent |
| Bones | Osteochondritis, periostitis | Sabre tibia, Clutton joints |
| Eyes and ears | Uveitis may occur | Interstitial keratitis and deafness |
| Teeth | Usually normal | Hutchinson incisors, mulberry molars |
Early disease usually responds fully to penicillin, whereas late stigmata are permanent and cannot be reversed by treatment. The age boundary of about 2 years is the pivot of most stage-based MCQs, so the feature list must be tied to the child's age. Snuffles and rash are the earliest clues, while teeth and deafness declare themselves only years later, which is why long-term follow-up of these infants matters.
Where the exam tries to catch you
Many errors come from timing, not from the diagnosis itself.
- Trap: dismissing a well-looking neonate whose mother has reactive serology. Correct: every such infant needs full evaluation, including infant serology and, where indicated, cerebrospinal fluid examination and a long bone radiograph.
- Trap: expecting Hutchinson teeth or deafness in a newborn. Correct: these are late stigmata that appear after about 2 years, while snuffles and rash belong to early disease.
- Trap: giving a single dose of benzathine penicillin to an infant with proven disease. Correct: neonatal disease needs the full 10-day course of aqueous crystalline penicillin G.
Frequently asked questions
Which investigation helps confirm congenital syphilis in a newborn?
Non-treponemal tests such as VDRL or RPR on the infant serum are the first step, and a fourfold higher titre than the mother's suggests infection. Treponemal tests confirm a reactive result. Cerebrospinal fluid examination and a long bone radiograph are part of the evaluation in symptomatic infants.
What are the features of late congenital syphilis?
Late congenital syphilis, after about 2 years, presents with the Hutchinson triad of interstitial keratitis, notched incisors and eighth nerve deafness. Mulberry molars, saddle nose, frontal bossing, sabre tibia and Clutton joints also occur. These stigmata are permanent.
Which treatment is standard for neonatal congenital syphilis?
Aqueous crystalline penicillin G for 10 days is the standard treatment for neonatal congenital syphilis with proven or probable disease. Infants with abnormal examination or serology receive the full course. The treatment regimen is not shortened because the infant looks well.
Why is antenatal screening important for congenital syphilis?
Antenatal screening detects maternal syphilis early, so the mother can be treated before the fetus is infected. Untreated maternal infection is the main cause of congenital syphilis. India's PPTCT programme screens pregnant women for syphilis as part of its routine antenatal care.