In This Issue
Resurgence of an Old Scourge
by Pat Scheans, DNP, NNP-BC
Oregon has much to be proud of in the healthcare of its citizens. We are pioneers in health insurance coverage, support of death with dignity, and medical marijuana regulation. Currently, we are standing out in another health-related statistic: syphilis infection. In the last five years, there has been a 22% national increase in the rate of primary and secondary syphilis among women, many of them of childbearing age. But, we Oregonians are overachievers, and it’s a little embarrassing in this case. There has been a 1900% increase in syphilis over the last decade in Oregon. Congenital syphilis was steadily on the decline until the last five years when the national rate increased 38%, and for the first time in a long while, we are seeing cases of congenital syphilis in our community [1, 2]. The numbers are small, but they are doubling annually. (No surprise, we are above the national average for rise in cases of gonorrhea, as well).
The Centers for Disease Control and Prevention (CDC) consider congenital syphilis a sentinel event because it shows failure of our public health and healthcare systems. In order to protect newborns, we must prevent syphilis among women of reproductive age and their male partners, and detect and treat perinatal transmission. Oregon law already requires that all suspected syphilis cases be reported to the local health authority within ONE business day . A statewide intervention has been launched to increase public awareness of the need for screening and treatment called “SyphAware” (http://www.syphaware.org/).
All this brouhaha is caused by a little organism named Treponema pallidum. This spirochete bacterium can cross transplacentally to the fetus and wreak havoc. Up to 40% of fetuses/babies will be stillborn or die from the infection if maternal syphilis goes untreated.
Since only severe cases of congenital syphilis are clinically apparent at birth there is a need for early detection and treatment. Recommendations call for increased screening for syphilis in pregnancy during this epidemic in Oregon, and should include testing three times: the first prenatal visit, the beginning of the third trimester and in labor/delivery. Maternal serologic status must be documented at least once during pregnancy, and preferably again at delivery if at risk .
Syphilis has different stages, and has been called “the great imitator” because its symptomatology may come and go, and can resemble other conditions (such as changes in vision). Symptoms can be missed since the lesions are often painless, leading to transmission/acquisition without knowing it .
All neonates of mothers with reactive nontreponemal test (rapid plasma regain [RPR] or venereal disease research laboratory [VDRL]) and treponemal (specific antibody testing) test results should have serum RPR or VDRL testing. Umbilical cord blood and Wharton’s jelly can yield a false-negative result .
As with other perinatally acquired illnesses like hepatitis B, newborns bear an inordinate share of complications. Congenital syphilis can manifest as syphilitic rhinitis ("snuffles"), nasal bridge anomaly (“saddle nose”), rash, jaundice, hepatosplenomegaly, long bone x-ray findings and cerebrospinal fluid (CSF) findings. Long term complications may include notched incisors (“Hutchinson’s incisors”), corneal inflammation, deafness and seizures. There was a recent report of brief resolved unexplained event (BRUE) related to congenital neurosyphilis .
Evaluation and treatment of newborns is, not surprisingly, very cautious due to the devastation that congenital syphilis can cause. For instance, the Centers for Disease Control and Prevention (CDC) recommends that asymptomatic newborns with even possible congenital syphilis (defined as mother untreated, inadequately treated, undocumented treatment, treated with a nonpenicillin G regimen or treated less than four weeks before delivery) include:
- CSF analysis for VDRL, cell count, and protein
- CBC, differential, and platelet count
- Long-bone x-ray
- Aqueous crystalline penicillin G 100,000–150,000 units/kg/day, administered as 50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days
- Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days (ouch!)
- Benzathine penicillin G 50,000 units/kg/dose IM in a single dose
Careful follow up with serial testing is necessary, and consideration of consultation with a pediatric infectious disease specialist is prudent. The CDC also recommends that newborns at risk for congenital syphilis should receive a full evaluation and testing for HIV .
As always, an ounce of prevention is worth a pound of cure.
Condom use: every time - no matter what. There is room for improvement on this front - condoms don’t completely prevent syphilis transmission, and there are various suppositions about why condom use has declined recently.
People at risk for acquiring syphilis should be tested for syphilis at least annually, and as often as four times a year if they have multiple partners. Studies have shown that even if the number of people being screened regularly was unable to be improved, that increasing screening of those that are currently screened once a year to four times a year would cause large reductions in syphilis transmission .
This article highlights the importance of surveillance for and treatment of this well-known, yet long-lingering infectious agent. Syphilis is purported to have been brought from Europe to the New World by Christopher Columbus and his sailors . Now, centuries later it continues to cause pain and suffering. Nowadays, the laboratory tests for syphilis are readily available, and a new rapid test appears to make this even easier. Treatment is nothing fancy, just little old penicillin, the first antibiotic ever developed. However, therapy must be thorough (both partners; missing a dose necessitates re-starting the course), and there have been drug shortages at times, necessitating other antibiotic regimes . Here’s to hoping that the current epidemic is controlled so that Oregon’s notoriety returns to something we can be proud of.
- Oregon Health Authority. (undated). Sexually transmitted disease (STD). Retrieved from http://public.health.oregon.gov/DiseasesConditions/HIVSTDViralHepatitis/SexuallyTransmittedDisease/Pages/index.aspx
- Oregon Health Authority. (11/2015). Syphilis in Oregon. Retrieved from https://public.health.oregon.gov/DiseasesConditions/CommunicableDisease/DiseaseSurveillanceData/STD/Documents/9984-STD-Syphilis-Final.pdf
- Centers for Disease Control and Prevention. (November 13, 2015). Increase in incidence of congenital syphilis — United States, 2012-2014. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6444a3.htm
- Centers for Disease Control and Prevention. (June 4, 2015). 2015 Sexually transmitted diseases treatment guidelines: Congenital syphilis. Retrieved from https://www.cdc.gov/std/tg2015/congenital.htm
- Triemstra, J., Reno, K., Chohlas-Wood, R., & Nash, C. (2017). A brief resolved unexplained event and congenital neurosyphilis. Pediatric Annals, 46(2), e61-e64. DOI: 10.3928/19382359-20170118-02
- Harvard University Library Open Collections Program. (2017). Contagion: Historical views of diseases and epidemics. Retrieved from http://ocp.hul.harvard.edu/contagion/syphilis.html
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