Transcript Congenital Syphilis, or “It’s Really Early Syphilis, Anyway”

Congenital Syphilis
December 10, 2010
Renata Dennis, RN, MPH
Southeast AIDS Training and Education Center
(SEATEC)
Emory University
School of Medicine
Atlanta, GA 30322
Disclosure
• “I have no real or perceived vested interests
that relate to this presentation nor do I have
any relationships with pharmaceutical
companies, biomedical device manufacturers,
and/or other corporations whose products or
services are related to pertinent therapeutic
areas.”
Renata Dennis, RN, MPH, 10 December 2010
Objective
By the end of this session, participants will be able to:
• Describe the clinical manifestations of congenital
syphilis
• Discuss maternal and infant testing for congenital
syphilis
• Describe a prevention plan for congenital syphilis
4
How common are STDS in pregnant women in
the United States?
STDs
Bacterial Vaginosis
Herpes Simplex virus 2
Trichomoniasis
Chlamydia
Gonorrhea
Hepatitis B
HIV
Syphilis
Estimated Number of
Pregnant Women
1, 080,000
880,000
124,000
100,000
13,200
16,000
6,400
<1,000
CDC Fact Sheet, updated December 2007
5
*TORCH Infections in Pregnancy
T-Toxoplasmosis
O-Other Infections (HIV, Hepatitis B, Syphilis, etc.)
R-Rubella
C-Cytomegalovirus
H-Herpes Simplex
*Also known as STORCH or TORCHeS (to account for the
importance of Syphilis), plus other acronyms to emphasize a
variety of important infections.
Tolan, R., Infectious Diseases in Clinical Practice, 01/2008
Primary and secondary syphilis — Rates among women by state: United States and
outlying areas, 2008
0 .2
0 .2
0 .0
0 .0
0 .1
0 .2
0 .1
0 .5
0 .3
0 .8
0 .3
1 .1
0 .2
0 .1
0 .3
0 .4
0 .4 0 .6
1 .0
0 .6
Gu a m 1 .2
1 .8
0 .6
1 .1
0 .6 0 .5
0 .1
0 .6
0 .5
1 .2
1 .4
0 .9
3 .8
5 .6
0 .5
4 .4 7 .2
2 .0
1 3 .9
1 .1
0.0
0.0
0.2
0.0
0.0
0.5
1.3
2.7
2.3
R ate per 100,000
population
3 .8
0 .0
VT
NH
MA
RI
CT
NJ
DE
MD
DC
2 .1
<=0.2
0.21-4.0
>4.0
Pu e rto Ri c o 1 .4
Vi rg i n Is . 0 .0
Note: The total rate of P&S syphilis among women in the United States and
outlying areas (Guam, Puerto Rico, and Virgin Islands) was 1.5 per 100,000
female population.
(n= 17)
(n= 33)
(n= 4)
7
Congenital Syphilis:
Epidemiology and Pathogenesis
• Perinatal transmission of Treponema pallidum at any stage of
pregnancy or during delivery from an infected woman to her
offspring
• Drug use during pregnancy increases risk of maternal and
congenital syphilis
• Syphilis chancres make it easier to transmit and acquire HIV
infection sexually, and
• Rate of congenital syphilis 50 times greater among
infants born to HIV-infected mothers
AETC National Resource Center, Treating Opportunistic Infection Among HIV-Infected Children, 12/2004
STD Fact Sheet, www.cdc.gov/std/Syphilis/STDFact-Syphilis.htm, downloaded 12/2010
8
Congenital Syphilis:
Epidemiology and Pathogenesis, cont’d.
• The spirochete crosses the placenta and infects the
fetus; may also occur from contact with an
infectious lesion canal during delivery
• In utero sonographic findings include: hydrops,
thickened placenta, hepatomegaly, ascites
• Any woman delivering stillbirth after 20 weeks
gestation should be evaluated for syphilis
CDC Syphilis Surveillance Report, 2006;
S. Philip, Congenital Syphilis, 9/2002
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Case(s) of Congenital Syphilis ????
Henry VIII, King of England,
1491-1547
• Much controversy among historians
• Wives had many miscarriages and stillbirths
• The king himself had evidence of a skin
disease at 22, series of headaches at 37, open
leg ulcers that did not heal at 44, deformity
(?gummata) on right side of nose at 45, and
then, there was that temper later in life
• NO WAY TO KNOW without testing-syphilis mimics other conditions
Farella, C. What if....? Pondering Clinical Cliffhangers, Nursing Spectrum, 2002
10
Congenital Syphilis:
Clinical Symptoms and Manifestations
Three major classifications:
• Fetal effects
• Early effects
• Late effects
Damage to fetus/infant depends on the stage of
development at which the infection has taken place
and time elapsed before treatment.
A.
Maranich, TORCH Infections, downloaded 12/2010
S. Philip, Congenital Syphilis, 9/2002
11
Fetal effects
(prenatal/perinatal period)
• Miscarriage
• Stillbirth
• Neonatal death
Intrauterine and/or perinatal death in 25-40% of
cases
AETC National Resource Center, Treating Opportunistic Infection Among HIV Infected Children, 12/2004;
A. Aaranich, Torch Infections, downloaded 12/2010
12
Early effects- in up to 60% of infants
(usually evident within first 5 weeks, can take up to 2 years)
Early manifestations are varied, with multi-system involvement
• Hepatosplenomegaly- diffuse
inflammation, scarring, jaundice
• Generalized lymphadenopathy –
epitrochclear nodes
• Coombs – hemolytic anemia,
thromobocytopenia, leukopenia, leukocytosis
• Hydrops fetalis
• Pemphigus syphiliticus (vesicular bullous
eruptions of palms and soles)
• Petechial lesions
• Bony lesions, osteochondritis,
periostitis, pseudoparalysis
• Syphilitc leptomeningitis
• Mucocutaneous: rhinitis (highly
infectious), “snuffles”, mucous
patches
• Chorioretinitis, salt and pepper
fundus, glaucoma
• Maculopapular rash
• Pancreatitis
• Desquamation
S.Philip, Congenital Syphilis, 9/2002
A. Maranich, TORCH Infections, downloaded 12/2010
AETC National Resource Center, Treating Opportunistic Infection Among HIV-Children, 1/2004
13
Papulosquamos Plaques
S. Philip, Congenital Syphilis, 9/2002
14
Broken vesicles, desquamation
Condylomata around anus
Infiltration, desquamation and rhinitis
S. Philip, Congenital Syphilis, 9/2002
15
Rhinitis (snuffles), mucous patches,
damage to palate(late)
Bullae and vesicular rash on soles
Eroded papular lesions S.Philip, Congenital Syphilis,
9/2002
16
Osteochondritis of distal radius and ulna
Osteochondritis of femur and tibia metaphysis
S. Philip, Congenital Syphilis, 9/2002
17
Remember:
• Infants may be asymptomatic at birth
• And without early antibiotic treatment,
children may develop:
▫
▫
▫
▫
Brain damage
Blindness
Hearing impairment
Bone and tooth abnormalities
CDC STD Treatment Guidelines 2006
18
Late effects
(manifestations after 2 years of age)
Results primarily from chronic inflammation of bone, teeth,and CNS.
• Interstitial keratitis (inflammatory)
• Nerve deafness
• Clutton’s Joints (synositis, restricted
movement)
• Hutchinson’s triad (teeth,
intersitial keratitis, 8th nerve
deafness)
• Mental retardation
•
• Frontal bossing, saddle nose,
protruding mandible
• High arched palate
• Perioral fissures
• Higouemenaki’s sign(periosteal
rotation of clavicle, sternocleidomastoid)
• Mulberry molars
• Saber shins
• Flaring scapulas
• Rhagades (linear scars that become
• Hydrocephalus
fissured or ulcerated)
S. Philip, Congenital Syphilis, 9/2002
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Hutchinson’s teeth – peg shaped upper incisors
Frontal Bossing
S. Philip, Congenital Syphilis, 9/2002
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Saber shins: Anterior bowing of tibias
Gumma: Thin atrophic scar
S. Philip, Congenital Syphilis, 9/2002
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Diagnosis in newborns,
(difficult because of maternal antibodies)
• Confirmed if organism identified in skin lesions
• Presumptive, if present:
physical exam findings
CSF findings (positive VDRL)
Osteitis on long bone x-rays
Funisitis (“barber shop pole” umbilical cord)
Positive IgM antibody (test is hard to get done)
• Regardless of physical findings, if mother was unor inadequately treated for syphilis
AETC National Resource Center, Treating Opportunistic Infection Among HIV-Infected Children, 12/2004
A. Maranich, TORCH Infections, downloaded 12/2010
CDC 2006 STD Treatment Guidelines, downloaded 12/2010
22
Diagnosis in newborns, cont’d.
• Use combination of physical, radiologic, serologic,
and direct microscopic (darkfield microscopy,
flourescent antibody test of a sample)results, as
standard serologic tests detect only IgG
• All infants born to mothers with reactive
nontreponemal and treponemal test should be
evaluated with a quantitative nontreponemal test,
e.g., slide test, rapid plasma reagin (RPR)
AETC National Resource Center, Treating Opportunistic Infection Among HIV-Infected Children, 12/2004
CDC 2006 Sexually Transmitted Diseases Treatment Guidelines, downloaded 12/2010
23
Diagnosis in newborns, cont’d.
•If infant’s titer higher than mother’s  congenital infection
•If decreasing titer in infant  passive transfer of antibodies,
should disappear by 3-4 months of age.
•Persistently reactive VDRL, with rising titer  active infection
Remember:
•A sustained 4-fold decrease in titer of nontreponemal test after
treatment indicates adequate therapy
•A 4-fold titer increase after treatment suggests re-infection or
relapse.
S. Philip, Congenital Syphilis, 9/2002
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Syphilis Diagnosis: A Review
Serologic tests are the principal means for diagnosis:
1) Nontreponemal test: VDRL, RPR
2) Treponemal tests: TPI, FTA-ABS, MHA-TP
S. Philip, Congenital Syphilis, 9/2002
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Testing for Syphilis
switching tests can cause confusing (VDRL versus RPR)—use the same test to
compare and track progress
Nontreponemal:
VDRL, RPR
• Quantitative results correlate
with disease activity, therefore,
this is a helpful screening
test; these tests are sensitive,
but not specific
• Titers rise when disease is
active, fall when treatment is
adequate
• In congenital infection, these
tests become non-reactive
within a few months of
adequate treatment
Treponemal:
TPI, FTA-Abs, MHA-TP
• Used as a confirmatory test
• Treponemal antibody titers
become positive soon after
initial infection and usually
remain positive for life, even
with adequate therapy
• Antibody titers do not correlate
with disease activity, and are
not quantified
S. Philip, Congenital Syphilis, 9/2002
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Treatment for Congenital Syphilis
(Dependent upon clinical scenario)
• Aqueous crystalline penicillin G: 100,000-150,000 units/kg/day, administered
as 50 units/kg/dose IV every 12 hours during the first 7 days of life and every 8
hours thereafter for 10 days
OR
• Procaine penicillin G: 50,000 units/kg/dose IM in a single daily dose for 10
days
OR
• Benzathine penicillin G: 50,000 units/kg/dose IM in a single dose
• Dosage varies for older infants and children
• Other drugs are an option if there is a penicillin allergy (although
desensitization may be possible)
If >1 day of therapy is missed, the entire course should be restarted
CDC 2006 STD Treatment Guidelines
27
Close follow-up of infants:
 Should have careful follow-up examination at , 2, 4, 6, and 12 months of age.
Serologic non-treponemal tests: 3, 6, 12 months, and end of treatment
(or until non-reactive)
Non-treponemal Ab titers decline by 3 months of age, and should be non-reactive by
6 months, if infant was not infected. (Transplacentally acquired antibodies.)
If persistent, stable titers, consider retreatment.
Congenital neurosyphilis- CSF exam at 6 month intervals until normal.
S. Philip, Congenital Syphilis, 9/2002
Some questions for you:
• When does your agency test pregnant women for
syphilis? Is one time per pregnancy enough?
• When do you treat pregnant women? Does this
change if she has HIV?
• Do you ask about a history of syphilis on intake?
Remember: some people don’t realize you can be re-infected.
29
A Final Word (from the CDC):
“No infant or mother should leave the hospital
unless the maternal serologic status has been
documented at least once during pregnancy,
and at delivery in communities and populations
in which the risk for congenital syphilis is high.”
Added editorial note: The same goes for HIV.
CDC 2006 STD Treatment Guidelines
30
CDC MMWR STD Guidelines, 2006*
http://www.cdc.gov/std/treatment/2006/congenital-syphilis.htm
http://www.cdc.gov/std/treatment/2006/n5511.pdf
*New guidelines are expected any day!