SCIENTIFIC
An Infant with Irritability , Periostitis , and Desquamating Rash : Suspect Syphilis
AUTHORS : Yaneri B Balar , MD 1
Jeffrey Lancaster , MD 2 Sabah Servaes , MD 1 Joseph D Lynch , MD 2
1
Department of Radiology , West Virginia University
ABSTRACT
Congenital syphilis is a re-emerging disease in the United States . This condition can be difficult to diagnose due to a wide variety of clinical presentations , variation in routine maternal syphilis screening , and continued risk of infection during pregnancy . A 4-month-old male presented to our hospital with irritability and apparent pain in his legs . His medical evaluation revealed multiple clinical signs concerning for congenital syphilis . Syphilis infection was confirmed via nontreponemal testing . He was treated with penicillin and cured . This case illustrates the diagnostic challenges in congenital syphilis , its clinical course , and treatment .
2
Department of Pediatrics , Division of Pediatric Hospital Medicine , West Virginia University
CASE PRESENTATION
A 4-month-old male in foster care presented with suspected bilateral lower extremity discomfort and decreased movement . The symptoms had been present for the last two days and the pain appeared to worsen with palpation of the legs . The caregivers reported that he did not seem to be in pain when his legs were not touched . He had been afebrile and was eating , voiding , and stooling normally .
A review of his past medical history revealed a similar pain episode that occurred during a hospital admission for bronchiolitis at age 2 months . During that admission , his hemoglobin level was 6.5 mg / dL ( reference range 9.6-12.4 mg / dL ), and he had a desquamating rash on his thighs , palms , soles , and perioral region ( Figure 1 ). The rash was diagnosed as a viral exanthem , and it resolved shortly after discharge . were not repeated during the pregnancy . His nursery course was remarkable for a five-day observation for neonatal abstinence syndrome .
Upon presentation , the patient was in no acute distress . Vital signs were normal for age . The child ’ s physical examination was unremarkable except for irritability with palpation or manipulation of his legs . There was no obvious deformity or sign of infection such as erythema or induration . Ortolani and Barlow maneuvers did not result in hip subluxation or dislocation .
Laboratory evaluation was performed and revealed a platelet count of 182,000 ( reference range : 244-529 x 1000 µ L ). Electrolytes were within normal ranges .
Aspartate aminotransferase and alanine aminotransferase were 182 U / L and 200 U / L ( reference range : 18-74 U / L and 3-45 U / L ). C-reactive protein was 29.8 mg / L ( reference range : < 8 mg / L ). Radiographs of his bilateral lower extremities revealed periosteal elevation of the femurs ( Figure 2 ). Due to the previous admission findings of anemia and desquamating rash and the prenatal history , congenital syphilis was suspected . Rapid plasma reagin test titer of 1:64 ( reference range < 1:4 ) confirmed the syphilis diagnosis .
DISCUSSION
In 2020 , the Centers for Disease Control and Prevention ( CDC ) reported the highest incidence of syphilis in a single year since 1994 . 1 The number of cases had tripled with more than 2,000 cases reported in
FIGURE 1 : Rash Present on Thigh and Soles During Prior Hospitalization
Relevant birth history included vaginal delivery at 39 weeks with APGARs of 7 and 9 . His mother ’ s pregnancy was complicated by polysubstance use disorder ( amphetamines and benzodiazepines ), gonorrhea ( which was treated and cured ), and hepatitis C . Other prenatal infectious screening tests obtained in the first trimester for human immunodeficiency virus , hepatitis B , syphilis ( via rapid plasma regain test ), Group B Streptococcus , and Chlamydia were negative . These tests
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