Syphilis in Pediatric Age
Introduction to Syphilis in Pediatric Age
Syphilis is a sexually transmitted infection caused by the spirochete Treponema pallidum. In pediatric patients, syphilis can be classified into two main categories:
- Congenital syphilis: Acquired in utero from an infected mother
- Acquired syphilis: Occurs through sexual contact or, rarely, through nonsexual contact with infectious lesions
Pediatric syphilis, particularly congenital syphilis, remains a significant public health concern globally. It can lead to severe complications and long-term sequelae if left untreated. Understanding the epidemiology, clinical manifestations, and management of syphilis in children is crucial for pediatricians, neonatologists, and infectious disease specialists.
Epidemiology of Syphilis in Pediatric Age
The epidemiology of pediatric syphilis varies globally and is influenced by several factors:
Congenital Syphilis:
- Global incidence: Estimated 661,000 cases annually (WHO, 2016)
- Higher rates in low- and middle-income countries
- In the United States, rates have increased since 2012
- Risk factors include:
- Lack of prenatal care
- Maternal drug use
- Poverty and limited access to healthcare
Acquired Syphilis in Children:
- Less common than congenital syphilis
- Primarily affects sexually active adolescents
- Risk factors include:
- Early sexual debut
- Multiple sexual partners
- Inconsistent condom use
- History of other sexually transmitted infections
The resurgence of syphilis cases in many regions highlights the need for continued vigilance, improved prenatal screening, and comprehensive sexual health education for adolescents.
Transmission of Syphilis in Pediatric Age
Congenital Syphilis:
Transmission occurs vertically from mother to child. The risk and timing of transmission depend on several factors:
- Maternal stage of infection:
- Primary and secondary syphilis: 60-100% transmission risk
- Early latent syphilis: 40% transmission risk
- Late latent syphilis: 8% transmission risk
- Timing of maternal infection:
- Higher risk if maternal infection occurs during pregnancy
- Lower risk if maternal infection occurs before pregnancy
- Adequacy of maternal treatment
Transmission can occur at any time during pregnancy but is more common in the second and third trimesters.
Acquired Syphilis:
In children and adolescents, transmission primarily occurs through:
- Sexual contact with an infected individual
- Rarely, through nonsexual contact with infectious lesions (e.g., kissing, close physical contact)
It's important to note that any case of acquired syphilis in a pre-pubertal child should raise suspicion of sexual abuse and trigger appropriate child protection measures.
Clinical Manifestations of Syphilis in Pediatric Age
Congenital Syphilis:
Clinical manifestations can be classified based on the time of presentation:
Early Congenital Syphilis (0-2 years):
- Prematurity or low birth weight
- Hepatomegaly and splenomegaly
- Jaundice
- Anemia
- Rhinitis ("snuffles")
- Skin rash (maculopapular, vesiculobullous, or desquamative)
- Osteochondritis and pseudoparalysis
- Pneumonia alba
- Nephrotic syndrome
Late Congenital Syphilis (>2 years):
- Hutchinson's triad:
- Hutchinson's teeth (notched incisors)
- Interstitial keratitis
- Eighth nerve deafness
- Saddle nose deformity
- Saber shins
- Clutton's joints (symmetric painless swelling of knees)
- Neurosyphilis
Acquired Syphilis:
The clinical stages are similar to those in adults:
Primary Syphilis:
- Chancre: painless, indurated ulcer at the site of inoculation
- Regional lymphadenopathy
Secondary Syphilis:
- Generalized maculopapular rash, including palms and soles
- Condylomata lata
- Mucous patches
- Generalized lymphadenopathy
- Constitutional symptoms (fever, malaise, headache)
Latent Syphilis:
- Asymptomatic phase
- Positive serologic tests
Tertiary Syphilis:
- Rare in children due to long latency period
- Can include gummatous lesions, cardiovascular syphilis, and neurosyphilis
The diverse and often nonspecific clinical manifestations of syphilis in children underscore the importance of maintaining a high index of suspicion, especially in at-risk populations.
Diagnosis of Syphilis in Pediatric Age
Diagnosing syphilis in children requires a combination of clinical evaluation, serological testing, and, in some cases, direct detection methods. The approach may differ for congenital and acquired syphilis.
Serological Testing:
- Nontreponemal tests:
- Rapid Plasma Reagin (RPR)
- Venereal Disease Research Laboratory (VDRL)
- Used for screening and monitoring treatment response
- Treponemal tests:
- Fluorescent Treponemal Antibody Absorption (FTA-ABS)
- Treponema Pallidum Particle Agglutination (TP-PA)
- Enzyme Immunoassays (EIA)
- Used for confirmation of nontreponemal test results
Diagnosis of Congenital Syphilis:
- Evaluation of maternal history and serological status
- Comparison of infant's nontreponemal titer to maternal titer
- Physical examination for signs of congenital syphilis
- Additional tests:
- Complete blood count
- Liver function tests
- Cerebrospinal fluid (CSF) analysis
- Long bone radiographs
- Ocular and auditory examinations
Diagnosis of Acquired Syphilis:
- Clinical evaluation for signs and symptoms of syphilis
- Serological testing (nontreponemal and treponemal tests)
- Direct detection methods for primary syphilis:
- Darkfield microscopy of lesion exudate
- Polymerase Chain Reaction (PCR) for T. pallidum
Special Considerations:
- Interpretation of serological tests in infants can be challenging due to passive transfer of maternal antibodies
- Serial serological testing may be necessary to differentiate between congenital infection and passively transferred maternal antibodies
- Neurosyphilis should be considered in any child with positive syphilis serology and neurological symptoms
Accurate diagnosis of syphilis in children is crucial for appropriate management and prevention of complications. Close collaboration between clinicians, microbiologists, and radiologists is often necessary for comprehensive evaluation.
Treatment of Syphilis in Pediatric Age
Treatment of syphilis in children aims to eradicate the infection, prevent transmission, and avoid complications. The choice of treatment depends on the type of syphilis (congenital vs. acquired) and the stage of the disease.
Congenital Syphilis:
Proven or Highly Probable Congenital Syphilis:
- Aqueous crystalline penicillin G: 50,000 units/kg IV every 12 hours (first 7 days of life) or every 8 hours (after 7 days of life) for 10 days
- Alternative: Procaine penicillin G 50,000 units/kg IM daily for 10 days
Possible Congenital Syphilis:
- Single dose of benzathine penicillin G 50,000 units/kg IM
- Some experts recommend the full 10-day course as for proven cases
Acquired Syphilis:
Primary, Secondary, or Early Latent Syphilis:
- Benzathine penicillin G 50,000 units/kg IM (max 2.4 million units) as a single dose
Late Latent Syphilis or Latent Syphilis of Unknown Duration:
- Benzathine penicillin G 50,000 units/kg IM (max 2.4 million units) weekly for 3 doses
Neurosyphilis:
- Aqueous crystalline penicillin G 200,000-300,000 units/kg/day IV (max 18-24 million units/day) divided every 4-6 hours for 10-14 days
Treatment in Penicillin-Allergic Patients:
- For congenital syphilis: Penicillin desensitization is recommended
- For acquired syphilis in older children:
- Doxycycline (for children ≥8 years)
- Azithromycin (limited data, not recommended for primary therapy)
Additional Considerations:
- Jarisch-Herxheimer reaction: Patients should be monitored for this reaction, especially in congenital syphilis
- Treatment of sexual partners is crucial in cases of acquired syphilis
- HIV co-infection may require more aggressive treatment and follow-up
Treatment of syphilis in children requires careful consideration of the patient's age, disease stage, and potential complications. Close follow-up is essential to ensure treatment effectiveness and to monitor for any adverse reactions.
Prevention and Follow-up of Syphilis in Pediatric Age
Prevention of Congenital Syphilis:
- Universal prenatal screening:
- First trimester or at first prenatal visit
- Repeat screening at 28-32 weeks and at delivery in high-risk populations
- Timely and adequate treatment of syphilis in pregnant women
- Partner notification and treatment
- Public health interventions to reduce syphilis in women of childbearing age
Prevention of Acquired Syphilis:
- Comprehensive sexual education for adolescents
- Promotion of safe sex practices, including condom use
- Regular STI screening for sexually active adolescents
- Prompt diagnosis and treatment of cases to prevent further transmission
Follow-up After Treatment:
Congenital Syphilis:
- Clinical evaluation at 2, 4, 6, and 12 months of age
- Serological testing:
- Nontreponemal tests at 3, 6, and 12 months of age
- Expect a fourfold decrease in titer by 6-12 months
- Seroreversion expected by 12-18 months in adequately treated cases
- Repeat CSF examination at 6 months if initial CSF was abnormal
- Long-term follow-up for neurodevelopmental assessment
- Audiologic evaluation every 6 months for the first 3 years
Acquired Syphilis:
- Clinical evaluation and serological testing at 3, 6, and 12 months after treatment
- For early syphilis, expect a fourfold decrease in nontreponemal titer within 6-12 months
- For late latent syphilis, a fourfold decrease may take 12-24 months
- Consider retreatment if:
- Clinical signs or symptoms persist or recur
- Sustained fourfold increase in nontreponemal titer
- Failure of nontreponemal titer to decrease fourfold within 6-12 months (early syphilis) or 12-24 months (late syphilis)
Special Considerations:
- HIV co-infection: More frequent monitoring may be necessary
- Neurosyphilis: Follow-up CSF examination at 6-month intervals until normal
- Adolescents: Provide counseling on prevention of future STIs
Public Health Measures:
- Mandatory reporting of syphilis cases to local health authorities
- Contact tracing and partner notification
- Community education and awareness programs
- Integration of syphilis screening in routine pediatric and adolescent care
Effective prevention and follow-up of pediatric syphilis require a comprehensive approach involving healthcare providers, public health officials, and the community. Regular monitoring and adherence to treatment guidelines are crucial for ensuring optimal outcomes and preventing complications.
Syphilis in Pediatric Age
- What is the causative agent of syphilis?
Treponema pallidum - What are the two main categories of syphilis in children?
Congenital syphilis and acquired syphilis - How is congenital syphilis transmitted?
Transplacental transmission from an infected mother to the fetus - What is the most common mode of transmission for acquired syphilis in children?
Sexual abuse - What is the classic triad of symptoms in early congenital syphilis?
Hutchinson's teeth, interstitial keratitis, and eighth nerve deafness - What are Hutchinson's teeth?
Peg-shaped, notched central incisors - What is the most common symptom of early congenital syphilis?
Rhinitis ("snuffles") - What is the characteristic rash of congenital syphilis?
Copper-colored, maculopapular rash on palms and soles - What bone abnormality is commonly seen in congenital syphilis?
Osteochondritis of long bones - What is the primary stage lesion of acquired syphilis called?
Chancre - How long after infection does the primary chancre typically appear?
10-90 days, average 21 days - What is the characteristic of the secondary stage rash in syphilis?
Symmetrical, non-itchy, maculopapular rash involving palms and soles - What are condylomata lata?
Highly infectious, wart-like lesions in moist areas of the body during secondary syphilis - Which laboratory test is used for initial screening of syphilis?
Non-treponemal tests: RPR (Rapid Plasma Reagin) or VDRL (Venereal Disease Research Laboratory) - What confirmatory test is used for syphilis diagnosis?
Treponemal tests: FTA-ABS (Fluorescent Treponemal Antibody Absorption) or TPPA (Treponema pallidum Particle Agglutination) - What is the preferred treatment for congenital syphilis?
Intravenous Penicillin G for 10-14 days - What is the recommended treatment for acquired syphilis in children?
Intramuscular Benzathine Penicillin G - What is the Jarisch-Herxheimer reaction in syphilis treatment?
A temporary worsening of symptoms after starting antibiotic therapy - How often should follow-up serological testing be done after treatment of congenital syphilis?
Every 3 months for the first year of life - What is neurosyphilis?
Invasion of the central nervous system by Treponema pallidum - What test is used to diagnose neurosyphilis?
CSF (Cerebrospinal Fluid) analysis - What is the most common presentation of late congenital syphilis?
Interstitial keratitis - What is Clutton's joints in congenital syphilis?
Symmetrical, painless swelling of the knees - What is the characteristic nose deformity seen in congenital syphilis?
Saddle nose - How long can the latent stage of syphilis last without treatment?
Several years to decades - What is the risk of transmission from an untreated mother to fetus during pregnancy?
70-100% - What is the recommended screening protocol for congenital syphilis?
Serological testing of all pregnant women in the first trimester and at delivery - What is the "moth-eaten" appearance in congenital syphilis?
Patchy alopecia (hair loss) on the scalp - What is Parrot's pseudoparalysis in congenital syphilis?
Painful swelling of long bones causing decreased limb movement - What is the main differential diagnosis for secondary syphilis rash in children?
Viral exanthems
Further Reading
- CDC: Congenital Syphilis - 2021 STI Treatment Guidelines
- WHO Guidelines for the Treatment of Treponema pallidum (Syphilis)
- Congenital Syphilis: A Discussion of Epidemiology, Diagnosis, Management, and Opportunities for Intervention
- American Academy of Pediatrics: Syphilis in Adolescents and Young Adults
- Syphilis in Children: Congenital and Acquired
