Major M.P. Vora, M.B.B.S., D.V.D.
Indian Medical Record
A monthly journal of Public Health, Tropical Medicine & Surgery etc.
Volume LXXXVI, Number – 2 of February 1966
This article was solely contributed to Indian Medical Record
Congenital syphilis can be prevented and the method of its prevention is well known. It hinges on, firstly the protection of mothers from syphilitic infection, secondly the diagnosis of syphilis early in pregnancy, at least by the seventh month, and thirdly, on the energetic prenatal treatment of the syphilitic mother with penicillin. Yet, and, indeed, it is very unfortunate a number of syphilitic babies are born every year and still a great number of pregnancies end in either abortion, miscarriage or still-birth.
Importance of preventing transmission of infection to mothers will be obvious when one remembers the fact that in most cases the father has contracted syphilis and ha passed on the infection to the mother, who then gives birth to a syphilitic infant. The mother of a syphilitic child is herself always syphilitic. The prevention of infection of mother is possible, first, by detecting promptly every case of infectious syphilis and instituting equally promptly thorough treatment for all cases that have contracted syphilis, second by discouraging marriages until clean bill of health has been given, and, third, by postponing or preventing conception, if already married, until all evidence of disease has disappeared. If conception has already taken place, early diagnosis and treatment of the mother is indicated.
The early diagnosis of syphilis in pregnant women can be made easily by taking a careful history and having recourse to the serologic test for syphilis (STS), as a routine. Blood test during the 5 th and the 7 th month of pregnancy can spot out cases which acquire syphilis following conception. Since the clinical characters of syphilis in pregnancy are either modified or masked, physical examination alone cannot be depended on to detect the disease. From this point of view, the imperative need of a routine STS in pregnant women at every antenatal clinic, will be realised.
The chief aim of the treatment of syphilis in the pregnant women is to prevent infection of the foetus and try to cure, if possible, the mother of her syphilis. The experience has amply shown and confirmed that the antisyphilitic treatment (AST) given to the pregnant women during her pregnancy can eliminate the chances of infection to the foetus. But, it may not necessarily and always result in cure of the mother. Unless the syphilitic woman receives an adequate treatment during her pregnancy, the chances of her passing on the disease to her unborn baby are substantially great. The aim should be not only to safeguard the foetus but also to cure the mother of her disease. The treatment should occupy the least possible time and should be completed well in advance of the date of delivery. To get optimum results the treatment should be instituted as early as possible during the pregnancy. Now with penicillin in use, treatment schedule is considerably shortened and simplified. It can be started even in the third trimester of pregnancy and even then good results as far as the foetus is concerned, are obtained. Injections of procain penicillin-G are arranged in such a way that the delivery of the infant is immediately preceded by at least ten daily I.M. injections of 600,000 units each. The earlier the diagnosis is made; sufficient time is there at one’s disposal to carry out adequate treatment. A later diagnosis leaves inadequate time to complete the schedule of treatment and to have its effect on the foetus. The pregnant women should be treated early and intensively so as to secure a healthy baby. Generally this objective can be realised by means of penicillin therapy. There are very few instances of intolerance or reaction to this treatment.
Early detection and treatment of congenital syphilis:-
The task of the physician does not end with the adoption of preventive measures. It is further necessary to keep under close observation the newborn and examine it at regular intervals till he is satisfied that it has escaped infection; for, the possibility of its having syphilis is difficult to rule out, especially during the first few weeks of its birth. Syphilitic infants born of treated mothers or off springs of parents who have long-standing or latent syphilis often do not show evidence of inherited syphilis at birth, during infancy and childhood may develop manifestations of syphilis later in life. Just as in adult syphilis, the longer the infection, the harder it is to eradicate the disease from the body, so greater is the likelihood of there being permanent damage, in the congenital syphilis. By early and adequate treatment of congenital syphilis, it is possible to a great extent to prevent the development of the syphilitic stigmata, late lesions and their sequelae. Because of the desirability of prevention of late lesions and sequelae such as perforation of the palate, saddle-shaped nose, interstitial keratitis and nerve deafness, the diagnosis of congenital syphilis ought to be attempted as soon after the birth as possible and treatment instituted. This can only be done by repeated and careful physical examination, quantitative serologic tests for syphilis, C.S.F. study and x-ray examination of the long bones if necessary.
A positive STS soon after the birth does not necessarily mean that the infant has syphilis. Positivity may be due to the reagin present in mother’s blood; hence AST of the infant on this account will not be justified. Subsequent serologic tests must reveal an increasing amount of reagin in the infant’s blood. Positive STS after the second month is considered as conclusive evidence of infection. If the STS show progressive decline in the amount of reagin or become negative, it is a proof that the infant is probably free from infection. However, the STS should be repeated at third month, sixth month, 1 st year, 2 nd year, at puberty and early adolescence as a measure of precaution. If all of them are negative probably there is no infection. It is necessary that children born of syphilitic parents or suspected or inherited syphilis should be kept under close observation till they reach an adult age.
The therapeutic test or AST on suspicion, though often used by some physicians, is not sound scientifically and should not be resorted to ordinarily. It should only be used as a diagnostic procedure when all other and more accurate methods of diagnosis have failed to establish diagnosis and one still feels convinced of its existence. Otherwise it merely masks the disease and diverts one’s attention from realities.
Once a case of congenital syphilis is diagnosed, the investigation of the mother and the other members of the family must not be neglected.
Congenital syphilis and acquired syphilis in adults do not differ very much and consequently the principles governing their treatment are more or less the same. It is therefore, necessary to make clear the distinction between early and late stages of congenital syphilis. During the first two years of infection of the infant, there is a strong tendency for lesions of the skin such as buttocks, palms and soles, mucous membrane, and muco-cutaneous junctions. Such lesions when present in a clinically recognizable form, are typical of early congenital syphilis and are similar to those lesions occurring in the acquired early secondary syphilis. Early congenital syphilis, in contrast to early acquired syphilis, shows severe toxicity snuffles, wasting, irregular fever, marked constitutional disturbances, concomittent lesions of the viscera such as the liver, kidneys, bones and has a very high rate of mortality. This highly toxic character of early congenital syphilis is probably due to the wide-spread nature of the infection, which is acquired in utero and has existed for some time before the child is born or due to the want of sufficient extra-uterine time for the infant to mobilize body’s defensive system or both. Risk of death is very high during this period.
If the infant, unrecognised as syphilitic and untreated, survives first few months, an opportunity is provided to build up natural body defenses. It enters the period of latency of several years’ duration and develops lesions of eye, bone, middle ear and the nervous system. All manifestations after puberty are of the tertiary or gummatous type and the risk of death is comparatively negligible; late congenital syphilis may show great diversity from almost asymptomatic to gross clinical pictures. Saddle-nose, saber-tibia, corneal scarring or opacities, Hutchinson’s incisers, nerve deafness, rhagades, Clutton’s joints and nodular or gummatous lesions of the skin etc are common manifestations.
The aim of the treatment in the early congenital syphilis is two-fold; the actual preservation of life and asymptomatic clinical and biological cure i.e. radical cure of the infection, if possible. Both these objectives can be accomplished usually. In the late congenital syphilis, on the contrary, the radical cure is probably no longer possible. The aim of the treatment therefore, is symptomatic relief like healing of lesions, arrest of the progress of the disease and finally maintenance of good health. In other words, one aspires for symptomatic and clinical cure.
The principles of treatment of early congenital syphilis are the same as those in early acquired syphilis. Treatment should be as far as possible in adequate dosage, at regular intervals over an adequate period. Inadequate or irregular treatment, especially in the early stage, is often harmful in the long run. A minimum dose of 200,000 units per lb body weight or 400,000 units per Kg. body weight, of procain penicillin-G, evenly spread over a period of 10 days, is recommended. An infant weighing 7 1/2 lbs would require minimum of 1-5 mega units in ten days. Children have been found to tolerate remarkably well even large dosage; a total of 2.4 to 4.5 mega units of penicillin have been given in 15 days. However, a careful watch must be kept during the first 48 hours. Of course, when inter-current disturbances are present or intolerance is suspected, the continuity of the treatment may have to be interrupted in consultation with an expert pediatrics’ advice. In severe cases where the lesions are marked or where the infant is very young and poor in health, the treatment at the beginning must be very cautious. Generally speaking the chances of therapeutic shock are greater in infants than in adults. Intolerance to drugs in infants and children is very difficult to detect unless one keeps a very close watch on the general health of the child. During the period of penicillin administration, failure to gain weight is not uncommon; this is rapidly made up after the completion of the course. The first dose should be half the average initial dose for an infant and must follow penicillin sensitivity test. It is better to give one injection of aqueous procain penicillin than multiple injections of crystalline penicillin per day. Once the gross lesions have disappeared and the condition of the child is improved, an adequate dose may be instituted. The improvement in the condition of the syphilitic infant is often remarkable. Toxic reactions are not very common.
The principles of treatment of the late genital syphilis are the same as those in the late acquired syphilis. The aim is symptomatic relief, maintenance of good health, and minimization of invalidism, relatively little emphasis being placed on the serologic reversal or restitution of anatomical abnormality. The treatment need not be intensive and continuous but individualized cautions, leisurely, interrupted and prolonged. With slight modification of dosage and drugs, the same outline of treatment as that in adults may be worked out. A minimum of 9 mega units of penicillin in addition to one or two bismuth courses may be required over a long period. In some cases, courses may have to be repeated. The affections of the cardiovascular and nervous systems are very much less common in the late congenital syphilis than in the late acquired syphilis. The experience shows that AST does not influence the course of either interstitial keratitis or nerve deafness. For this, steroid hormones locally in keratitis and systemically in deafness are indicated. The outlook is worse in cases of congenital neurosyphilis which occurs insidiously at the time of puberty. The prolonged treatment and follow-up should be the rule. Low titre fluctuating serologic positivity is not uncommon in these cases.
A fact which is forgotten too often in the treatment of syphilis, both acquired and inherited, is that the disappearance of signs of syphilis does not mean cure of the disease. The minimum amount of treatment over a certain period has to be completed and cure has to be measured by the results of repeated physical examinations and serologic responses. The STS should be repeated at suitable intervals and the spinal fluid should be examined as a routine at the end of six months after the completion of treatment of early congenital syphilis. In some cases it may be necessary to prolong the follow-up to two years.
It is better to prevent congenital syphilis than treat it. Congenital syphilis should be diagnosed early and treated adequately.