Early congenital syphilis

Case 1 A boy was delivered at 35 weeks' gestation by standard vaginal deliv ery. His mother was a 24-year-old gravida 4, para 1 woman. Purple erythemat ous macules and diffuse vesicular eruptions of various sizes were found ext ensively over the skin. The rapid plasma reagin (RPR) titer test of the new born showed 1:16 positive and 1:32 weakly positive. There was no obvious hi story of maternal or paternal syphilitic infection; however, the mother con fessed to having sexual contact with other men, and had a history of extrau terine pregnancy and spontaneous abortion. She showed 1:8 positive and 1 :1 6 weakly positive RPR titer test. The father's RPR titer was 1:8 positive a nd Treponema pallidum hemagglutination (TPHA) test was 1:160 positive. Physical examination revealed that this 2300-g boy had a rapid respiration of 55/min. The Apgar score was eight at 1 min. The boy's temperature was 36 degreesC. He had a normal skull, and the size of the bregma was 1.2 cm x 1 .2 cm. The intranasal septum was normal with excessive excretions in the no strils. The lips were slightly red. His intraoral mucous membrane was smoot h, and his pharynx and throat were normal. His respiratory movement was sym metrical. He had sinus rhythm (135 b.p.m.) and no signs of abnormality. His breathing sound was clear with signs of effusion. The abdominal examinatio n revealed hepatosplenomegaly. There was no transudate from the umbilicus. The liver was palpable 2cm below the costal margin. The spleen was also pal pable just below the costal margin. The movement of the boy's limbs was nor mal. The fingernails had developed to the end of the fingers. The pleat dra pe of the metatarsal was less than one-third of the foot area. The boy had normal neural reflexes including rooting, sucking, and Moro reflex. Examina tion of the skin revealed a light purple color all over the body, with diff use reddish-copper maculopapules, over which there were pale vesicles about 0.5-1.2 cm in size. Part of the vesicular eruption that occurred especiall y on the palms and soles had ruptured (Figs 1-6). The majority of the body surface was involved, but mucosal involvement was not noted. Laboratory examination revealed the following values: leukocyte count, 25.9 x 10(9)/L, containing 72% neutrophils and 23% lymphocytes; red blood cell count, 4.62 x 10(12)/L; hemoglobin, 173 g/L; and platelets, 117 x 10(9)/L. The urine test, excretion test, and blood chemistries were normal. The cult ure of the vesicular fluid was negative with no bacterial growth. Roentgeno graphy was normal. The RPR titer test showed 1:6 positive and 1:32 weakly p ositive. Two weeks later, re-examination of blood routine tests showed: whi te blood cell count, 13.3 x 10(9)/L, containing 40% neutrophils and 60% lym phocytes; red blood cell count, 4.08 x 10(12)L; hemoglobin, 141 g/L; and pl atelets, 227 x 10(9)/L. According to the history, clinical manifestations, and RPR titer test, the following diagnosis was made: early congenital syphilis, premature and low weight infant. The boy was treated with procaine penicillin intravenously at 100,000 U/kg/ day for 15 days. The eruption subsided in 2 weeks. The infant was carefully followed up without recurrence of eruption, and serologic RPR tests were p erformed at 1, 2, and 3 months after the conclusion of treatment. The RPR t iter was 1:4 positive at the third month. Case 2 A 2-month-old girl presented with an acute onset of a shin eruption accompanied by fever, cough, and dyspnea. The girl had no abnormal appearan ces at full-term delivery. The girl developed an erythematous macular and p apular eruption on her palms and soles 12 days afterwards. She had been dia gnosed and treated for "dermatitis" at another hospital, but the treatment was not effective. The eruption persisted and spread to the trunk and limbs . On the 21st day, the girl developed a cough, snuffles, dyspnea, and fever . Physical examination revealed a restless infant with a temperature of 39 in verted perpendicularC. Moist rales were audible on chest auscultation. Abdo minal examination revealed hepatosplenomegaly and the existence of borboryg mus. The liver was palpable 5cm below the costal margin and 6 cm below the xiphoid. The spleen was palpable 3 cm below the costal margin. There were s ymmetrical reddish-brown macules and papules on the buttocks, palms, and so les (Figs 7-9), some with scaling and pigmentation. In some parts, the erup tion had ruptured and left a denuded area that developed extensive macerati on, ulceration, and crusting. The perioral and periorbital areas were erode d with excretions. Laboratory studies revealed the following values: serologic RPR titer, 1:12 8 positive; TPHA titer, 1:160 positive; 19s-lgM test positive. Both the RPR and TPHA tests of the parents were positive. Procaine penicillin was given intramuscularly at 100,000 U/kg/day for 10 da ys. The infant recovered quickly and the eruption cleared within 2 weeks. T he infant was followed up carefully acid RPR test results were negative 1, 2, and 3 months after treatment.