Title of Case(s)

A baby with painful bones

Background

Congenital syphilis, although nowadays uncommon thanks to screening in pregnancy, should be considered in young infants with periostitis or fractures, especially if accompanied by other symptoms.

Case Presentation Summary

A 2-month-old girl, born at term following induction of labour for reduced growth velocity, was taken to her local Emergency Department (ED) with swollen wrist. A plain radiograph showed a fracture. The patient was investigated for Non-Accidental Injury (NAI): a skeletal survey showed periosteal reaction in all long bones and 2 more fractures. She was investigated for metabolic disorder and the family were referred to social services for suspected inflicted injuries. The child returned 1 month later with fever, rash, coryza, hepatosplenomegaly. Following a full septic screen she was treated on IV Ceftriaxone, with resolution of fever. Screening test for syphilis antibody was positive, therefore the patient was transferred to our paediatric infectious disease department for further investigations which showed:

Of note, maternal VDRL in first trimester was negative. The child received IV Penicillin G for 2 weeks. By the end of treatment her inflammatory markers started rising again and Xray of long bones showed new periosteal reaction, so Ceftriaxone and Clindamycin was recommenced. However an MRI full body showed that the symmetrical periosteal changes were consistent with avid healing process.

Key Learning Points

Presence of fractures in non-ambulating infants should raise the suspicion of NAI. However, when these are accompanied by osteitis, fever, rash and hepatosplenomegaly, congenital syphilis should be considered.

Repeating imaging too early in the course of the disease can lead to misinterpretation of changes reflecting normal healing process.

There are no studies of the optimal duration of treatment for severe bony syphilis.