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Presentation

Congenital Syphilis in the U.S.: Rising Prevalence, Screening, and Early Recognition

Description

The talk highlighted the rising burden of congenital syphilis in the United States, now at a 30-year high with a roughly tenfold increase over the past 12 years. A case story illustrated how subtle maternal symptoms, such as a rash or new itching during pregnancy, can be missed, leading to severe neonatal illness after birth. The speaker emphasized that the biggest preventable problem is failure to screen pregnant people early and repeatedly, rather than treatment failure alone. Current recommendations call for syphilis screening at the first prenatal visit and, according to newer ACOG guidance, again at all three routine pregnancy time points. The causes of missed diagnosis include poverty, substance use, language and citizenship barriers, lack of access to care, low health literacy, and stigma. Most infants with congenital syphilis have no signs at birth, so absence of symptoms is not reassuring. When present, early findings may include copper-red morbilliform rash, desquamation, bullous lesions, nasal discharge, hepatosplenomegaly, jaundice, anemia, bone disease, and CNS involvement. Diagnosis relies on serology with confirmatory testing, and treatment is 10 days of IV penicillin for infants; treating maternal disease in pregnancy is highly effective at preventing transmission. Early infant treatment can also prevent many late manifestations such as Hutchinson teeth, keratitis, saber shins, saddle nose, frontal bossing, and Clutton joints. The main takeaway was to screen broadly, test any pregnant patient with rash or new pruritus, and recognize that early identification and treatment can substantially reduce harm.

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Conclusions

Congenital syphilis is rising sharply in the United States and is now at a 30-year high, making prevention an urgent public health priority.
The most common missed opportunity is failure to screen pregnant patients in time, rather than failure to treat a confirmed diagnosis.
Universal repeat syphilis screening during pregnancy, including at least three time points, is now recommended because risk-based screening misses too many cases.
Pregnant patients with any rash or new itch should be tested for syphilis because the clinical downside is low and the stakes are high.
Most infants with congenital syphilis are asymptomatic at birth, so absence of skin findings does not rule out infection.
When present, the most typical early skin eruption is a symmetric copper-red morbilliform rash, often with Biett’s collarette, but presentations can be highly variable.
Congenital syphilis can mimic many other dermatologic and systemic diseases, so clinicians should keep a broad differential when evaluating neonatal rashes or nodules.
Prompt treatment of maternal syphilis with penicillin is highly effective at preventing congenital infection and can prevent most adverse outcomes.
Treatment of infected infants with 10 days of IV penicillin is the standard of care, with close follow-up to confirm clinical and serologic improvement.
Early recognition and treatment of congenital syphilis can prevent many late sequelae, although some complications such as keratitis and skeletal deformities may still occur.

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