CCMS Medicine Spring 2017 - 10

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Resurgent Syphilis
Causing Increased Cases of
Congenital Syphilis
BY JOHN P. MAHER, MD, MPH

[Author's caveat: The reader should be aware that a variety of
statistical measures of syphilis and congenital syphilis are referenced
throughout this article and they should not be confused with each
other. They represent the data found in various sources, and evidence
changes (particularly in the population denominator figures) in the
methodological approach of different authors over the years. - JPM]

I

nfectious syphilis is one of the most important conditions
known to medicine. However, many physicians - once past
their internships and residencies, especially if practicing in
"nice" suburban neighborhoods - never see or diagnose a case of
sexually transmitted disease (STDs) again, let alone syphilis. Thus,
they may tend to forget about it, at least in terms of having it on
the list of their top index of suspicion diagnostic categories.
But, to paraphrase the astronaut's alert message ("Houston,
we have a problem"), syphilis has again become resurgent and it is
necessary to re-emphasize Sir William Osler's dictum, namely: "He
who knows syphilis knows Medicine." (1)
Sometimes we consider such maxims as outdated, historical
references which remind us of a time before the development of
scientific clinical medicine, and especially prior to the introduction
of antibiotics. This author, for example, learned about clinical
syphilis in the 1950s at the old Kings County Hospital's
"Dermatology and Syphilology Clinic" in Brooklyn, NY, and was
fortunate enough to see a number of STD cases in his clinical
rotations and again in his internship in Rochester, NY, but then
not again until he began to focus on Public Health and Preventive
Medicine at the NYC Department of Public Health in the mid1960s.
Nevertheless, things have changed; the infectious disease
pattern has recycled. It is time, once again, to reconsider Osler's
statement, as syphilis outbreaks are being reported in many parts
of this country.

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While it is not as ancient as tuberculosis or leprosy, awareness
of infectious syphilis and its venereal transmission goes back to
the mid-15th century, where some historians blame its appearance
and spread on the return to Europe of Columbus and his crews
who are alleged to have contracted the disease in the New World.
Its name derives from an epic poem by Girolomo Fracastorius
(Syphilis, sive Morbus Gallicus), in which he attributes the
appearance of the disease as a curse from the Sun God Apollo
upon the mythical shepherd, Syphilus, for his sacrilege of offering
sacrifice to the wrong god. (2, 8)
One classical description of syphilis(3) describes venereal
syphilis as: "an acute and chronic treponemal disease characterized
clinically by a primary lesion, a secondary eruption involving skin
and mucous membranes, long periods of latency, and late lesions
of skin, bone, viscera, the central nervous system (CNS), and
the cardiovascular system." And, of increasing importance, it can
be transmitted from an infected, untreated mother to the infant
in utero or in the birth passage (in partu). (For a more current
definition, see Table I)

TABLE I:
2008-2014 Definition of Congenital Syphilis (9)
A case of CS was defined as an illness in an infant from
whom lesional, placental, umbilical cord, or autopsy materials
demonstrated Treponema pallidum by darkfield microscopy,
fluorescent antibody, or other specific stain; an infant whose
mother had untreated or inadequately treated syphilis at delivery;
or an infant or child who had a reactive treponemal test for syphilis
and any of the following: (a) evidence of CS on physical exam; (b)
evidence of CS on radiography of long bones; (c) a reactive VDRL
test of CSF; (d) an elevated CSF cell count or protein without
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