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Could we miss congenital neurosyphilis?
Clinical Picture
Could we miss congenital neurosyphilis? Sónia Silva, Raquel Henriques, João Paulo Gomes, Maria José Borrego, Eulália Afonso Lancet Infect Dis 2012; 12: 816 Neonatal Intensive Care Unit, Coimbra University Hospitals, Coimbra, Portugal (S Silva, R Henriques, E Afonso); and National Health Institute Doutor Ricardo Jorge, Lisbon, Portugal (J P Gomes, M J Borrego) Correspondence to: Dr Sónia Silva, Neonatal Intensive Care Unit, Coimbra University Hospitals, 3000–075 Coimbra, Portugal [email protected]
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followed by target sequencing. T pallidum was not detected in blood samples from the mother or newborn baby. The newborn baby was treated with intravenous crystalline penicillin G (50 000 IU/kg per dose every 12 h for 10 days) and had a successful outcome. 4 days after end of treatment, cerebral MRI showed a widespread subdural haemorrhage (requiring drainage) and confirmed previous brain ultrasound findings (figure C, arrows). At 6 months of age, cerebrospinal fluid PCR for T pallidum was negative. At 12 months, the child has global development delay with a Griffiths’ developmental quotient of less than 85% and spastic diplegic cerebral palsy. He is integrated in a rehabilitation programme and has had no further seizures. In view of the mother’s treatment response during pregnancy and placental antibody transfer to the neonate, neurosyphilis might have gone unnoticed because initial clinical characteristics could have been attributed to subdural haematoma. This case is intriguing because there were no signs of primary or secondary syphilis in the newborn baby, possibly because T pallidum was sequestered rapidly in the fetal CNS. Thus, a question remains as to whether or not every newborn whose mother has been treated appropriately should have transfontanellar ultrasound and lumbar puncture for highly sensitive molecular detection of T pallidum.
Portugal has the highest incidence of congenital syphilis in Europe, and employs a screening protocol during pregnancy of serological testing in every trimester and in all newborn babies whose mothers were treated during pregnancy. A pregnant woman presented with syphilis seroconversion during the second trimester. She and her partner were treated appropriately (three intramuscular doses of penicillin G; total 7·2 million IU) and had a nonreactive rapid plasma reagin (RPR) test. Maternal HIV serology was negative. The baby had a full-term vacuumassisted delivered and successful immediate resuscitation. Neonatal syphilis serology was compatible with placental transfer of maternal antibodies: the baby had a nonreactive RPR test, ELISA IgG-positivity and IgM-negativity, and much the same syphilis screening chemiluminescence immunoassay titres as his mother. However, hypotonia, seizures, and transfontanellar ultrasound findings (including abnormalities on the ventricular lining and bilateral intraventricular strand [figure A, arrow], mild ventricular dilatation, and bilateral hypoechogenic area in choroid plexus [figure B, arrow]), were suggestive of neurosyphilis. Biochemical analysis was prevented because of blood in the cerebrospinal fluid. Full neurosyphilis investigation required testing for Treponema pallidum in cerebrospinal fluid, which was done at the Portuguese National Health Institute (Lisbon, Portugal) with a real-time probe-based PCR method, and the positive result was confirmed by a nested PCR method
Conflicts of interest We declare that we have no conflicts of interest.
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www.thelancet.com/infection Vol 12 October 2012
Could we miss congenital neurosyphilis? Sónia Silva, Raquel Henriques, João Paulo Gomes, Maria José Borrego, Eulália Afonso Lancet Infect Dis 2012; 12: 816 Neonatal Intensive Care Unit, Coimbra University Hospitals, Coimbra, Portugal (S Silva, R Henriques, E Afonso); and National Health Institute Doutor Ricardo Jorge, Lisbon, Portugal (J P Gomes, M J Borrego) Correspondence to: Dr Sónia Silva, Neonatal Intensive Care Unit, Coimbra University Hospitals, 3000–075 Coimbra, Portugal [email protected]
A
816
followed by target sequencing. T pallidum was not detected in blood samples from the mother or newborn baby. The newborn baby was treated with intravenous crystalline penicillin G (50 000 IU/kg per dose every 12 h for 10 days) and had a successful outcome. 4 days after end of treatment, cerebral MRI showed a widespread subdural haemorrhage (requiring drainage) and confirmed previous brain ultrasound findings (figure C, arrows). At 6 months of age, cerebrospinal fluid PCR for T pallidum was negative. At 12 months, the child has global development delay with a Griffiths’ developmental quotient of less than 85% and spastic diplegic cerebral palsy. He is integrated in a rehabilitation programme and has had no further seizures. In view of the mother’s treatment response during pregnancy and placental antibody transfer to the neonate, neurosyphilis might have gone unnoticed because initial clinical characteristics could have been attributed to subdural haematoma. This case is intriguing because there were no signs of primary or secondary syphilis in the newborn baby, possibly because T pallidum was sequestered rapidly in the fetal CNS. Thus, a question remains as to whether or not every newborn whose mother has been treated appropriately should have transfontanellar ultrasound and lumbar puncture for highly sensitive molecular detection of T pallidum.
Portugal has the highest incidence of congenital syphilis in Europe, and employs a screening protocol during pregnancy of serological testing in every trimester and in all newborn babies whose mothers were treated during pregnancy. A pregnant woman presented with syphilis seroconversion during the second trimester. She and her partner were treated appropriately (three intramuscular doses of penicillin G; total 7·2 million IU) and had a nonreactive rapid plasma reagin (RPR) test. Maternal HIV serology was negative. The baby had a full-term vacuumassisted delivered and successful immediate resuscitation. Neonatal syphilis serology was compatible with placental transfer of maternal antibodies: the baby had a nonreactive RPR test, ELISA IgG-positivity and IgM-negativity, and much the same syphilis screening chemiluminescence immunoassay titres as his mother. However, hypotonia, seizures, and transfontanellar ultrasound findings (including abnormalities on the ventricular lining and bilateral intraventricular strand [figure A, arrow], mild ventricular dilatation, and bilateral hypoechogenic area in choroid plexus [figure B, arrow]), were suggestive of neurosyphilis. Biochemical analysis was prevented because of blood in the cerebrospinal fluid. Full neurosyphilis investigation required testing for Treponema pallidum in cerebrospinal fluid, which was done at the Portuguese National Health Institute (Lisbon, Portugal) with a real-time probe-based PCR method, and the positive result was confirmed by a nested PCR method
Conflicts of interest We declare that we have no conflicts of interest.
B
C
www.thelancet.com/infection Vol 12 October 2012