Congenital neurosyphilis – Authors' reply
2013; Elsevier BV; Volume: 13; Issue: 6 Linguagem: Inglês
10.1016/s1473-3099(13)70123-3
ISSN1474-4457
AutoresSónia Silva, Raquel Henriques, Maria José Borrego, João Paulo Gomes, Eulália Afonso,
Tópico(s)Syphilis Diagnosis and Treatment
ResumoWe agree with Fernandes and Medina-Acosta's comments regarding the lack of specificity of CNS imaging in neurosyphilis diagnosis. Nevertheless, our case study has an interesting feature: because the results of the baby's serological tests did not suggest congenital syphilis, if the neurological signs—probably due to traumatic subdural bleeding—that prompted the ultrasound had not been apparent, the diagnosis of neurosyphilis would have been missed. Therefore, we emphasise the importance of transfontanellar ultrasound, even when results show non-specific changes, to help to diagnose cases of neurosyphilis. In this case, it led to additional examinations that confirmed our neurosyphilis suspicion, and the baby was then treated accordingly.Regarding the concerns of Fernandes and Medina-Acosta about IgM false-positives, the European Commission implementing decision (2012/506/EU) defines a laboratory-confirmed case as any case in which a reactive non-treponemal test (eg, venereal disease research laboratory test, rapid plasma reagin) of the child's serum occurs in addition to the detection of Treponema pallidum by one of the following: T pallidum-specific IgM (fluorescent treponemal antibody–absorption test, enzyme immunoassay); dark field microscopy; or direct fluorescent antibody test.1European CommissionCommission implementing decision 2012/506/EU of 8 August 2012.Official Journal of the European Union. 2012; L262: 1-57Google ScholarWe share Wright's concerns about the possibility of syphilis treatment failure in the fetus, even when recommended treatment is given to the pregnant mother. In our case, the asymptomatic pregnant woman had syphilis seroconversion in the second trimester and was given three doses of benzathine benzylpenicillin at weekly intervals, although the Portuguese protocol recommends one dose only (at 2·4 million IU).2Secção de Neonatologia da Sociedade Portuguesa de PediatriaSífilis.in: Protocolos de diagnóstico e terapêutica em infecciologia perinatal. Angelini Farmacêutica, Porto2007: 29-33Google Scholar Maternal HIV serologies were negative and no other signs of immunosuppression were identified. The three obstetric ultrasounds were described as normal.The pregnant mother and her current partner are both white and have Portuguese nationality. She had several sexual partners (not identified through this study), but no relation to Africa could be established. As the source of the infection remains unknown, the hypothetical and logical scenario described by Wright cannot be validated.The maternal syphilis infection was successfully treated and no signs of reinfection were seen. However, T pallidum survived in the fetal cerebrospinal fluid (CSF). Early CNS infection by T pallidum has been described, and some strains might have a greater propensity for neuroinvasion.3Stamm LV Global challenge of antibiotic-resistant Treponema pallidum.Antimicrob Agents Chemother. 2010; 54: 583-589Crossref PubMed Scopus (127) Google Scholar Nevertheless, T pallidum molecular subtyping was not possible because of the small amount of DNA available in the CSF sample.Penicillin is the most efficient treatment for syphilis during pregnancy, preventing congenital disease in most cases. However, our case showed that benzathine benzylpenicillin did not treat the fetus. T pallidum might be able to survive in fetal CNS because of the poor penetration of the blood–brain barrier by benzathine benzylpenicillin.3Stamm LV Global challenge of antibiotic-resistant Treponema pallidum.Antimicrob Agents Chemother. 2010; 54: 583-589Crossref PubMed Scopus (127) Google Scholar, 4Walker GJA Antibiotics for syphilis diagnosed during pregnancy.Cochrane Database Syst Rev. 2001; 3 (CD001143)PubMed Google ScholarConsidering potential causes of therapeutic failure, a careful assessment of therapeutic guidelines should be done. Further randomised clinical studies exploring different penicillin regimens during pregnancy (investigating dose, treatment duration, and formulations) will also be important. Maybe in the near future we will be able to systematically sequence the T pallidum genome from clinical isolates to identify putative neurotropic strains needing further research.We declare that we have no conflicts of interest. We agree with Fernandes and Medina-Acosta's comments regarding the lack of specificity of CNS imaging in neurosyphilis diagnosis. Nevertheless, our case study has an interesting feature: because the results of the baby's serological tests did not suggest congenital syphilis, if the neurological signs—probably due to traumatic subdural bleeding—that prompted the ultrasound had not been apparent, the diagnosis of neurosyphilis would have been missed. Therefore, we emphasise the importance of transfontanellar ultrasound, even when results show non-specific changes, to help to diagnose cases of neurosyphilis. In this case, it led to additional examinations that confirmed our neurosyphilis suspicion, and the baby was then treated accordingly. Regarding the concerns of Fernandes and Medina-Acosta about IgM false-positives, the European Commission implementing decision (2012/506/EU) defines a laboratory-confirmed case as any case in which a reactive non-treponemal test (eg, venereal disease research laboratory test, rapid plasma reagin) of the child's serum occurs in addition to the detection of Treponema pallidum by one of the following: T pallidum-specific IgM (fluorescent treponemal antibody–absorption test, enzyme immunoassay); dark field microscopy; or direct fluorescent antibody test.1European CommissionCommission implementing decision 2012/506/EU of 8 August 2012.Official Journal of the European Union. 2012; L262: 1-57Google Scholar We share Wright's concerns about the possibility of syphilis treatment failure in the fetus, even when recommended treatment is given to the pregnant mother. In our case, the asymptomatic pregnant woman had syphilis seroconversion in the second trimester and was given three doses of benzathine benzylpenicillin at weekly intervals, although the Portuguese protocol recommends one dose only (at 2·4 million IU).2Secção de Neonatologia da Sociedade Portuguesa de PediatriaSífilis.in: Protocolos de diagnóstico e terapêutica em infecciologia perinatal. Angelini Farmacêutica, Porto2007: 29-33Google Scholar Maternal HIV serologies were negative and no other signs of immunosuppression were identified. The three obstetric ultrasounds were described as normal. The pregnant mother and her current partner are both white and have Portuguese nationality. She had several sexual partners (not identified through this study), but no relation to Africa could be established. As the source of the infection remains unknown, the hypothetical and logical scenario described by Wright cannot be validated. The maternal syphilis infection was successfully treated and no signs of reinfection were seen. However, T pallidum survived in the fetal cerebrospinal fluid (CSF). Early CNS infection by T pallidum has been described, and some strains might have a greater propensity for neuroinvasion.3Stamm LV Global challenge of antibiotic-resistant Treponema pallidum.Antimicrob Agents Chemother. 2010; 54: 583-589Crossref PubMed Scopus (127) Google Scholar Nevertheless, T pallidum molecular subtyping was not possible because of the small amount of DNA available in the CSF sample. Penicillin is the most efficient treatment for syphilis during pregnancy, preventing congenital disease in most cases. However, our case showed that benzathine benzylpenicillin did not treat the fetus. T pallidum might be able to survive in fetal CNS because of the poor penetration of the blood–brain barrier by benzathine benzylpenicillin.3Stamm LV Global challenge of antibiotic-resistant Treponema pallidum.Antimicrob Agents Chemother. 2010; 54: 583-589Crossref PubMed Scopus (127) Google Scholar, 4Walker GJA Antibiotics for syphilis diagnosed during pregnancy.Cochrane Database Syst Rev. 2001; 3 (CD001143)PubMed Google Scholar Considering potential causes of therapeutic failure, a careful assessment of therapeutic guidelines should be done. Further randomised clinical studies exploring different penicillin regimens during pregnancy (investigating dose, treatment duration, and formulations) will also be important. Maybe in the near future we will be able to systematically sequence the T pallidum genome from clinical isolates to identify putative neurotropic strains needing further research. We declare that we have no conflicts of interest. Could we miss congenital neurosyphilis?Portugal has the highest incidence of congenital syphilis in Europe, and employs a screening protocol during pregnancy of serological testing in every trimester and in all newborn babies whose mothers were treated during pregnancy. Full-Text PDF Congenital neurosyphilisSónia Silva and colleagues1 describe a case of a Portuguese pregnant mother whose syphilis serology became positive during pregnancy. She was treated during the second trimester with 2·4 million IU of benzathine benzylpenicillin, given intramuscularly, three times at weekly intervals. The mother's serology became negative during treatment, but the newborn child was discovered to have neurosyphilis on the basis of clinical and sonographic findings, with treponemal sequences detected in the cerebrospinal fluid by PCR. Full-Text PDF Congenital neurosyphilisIn their Clinical Picture of treatment failure for syphilis in pregnancy, Sónia Silva and colleagues1 posed the question of whether or not every newborn baby whose mother has been treated appropriately should be investigated by transfontanellar ultrasound and lumbar puncture for Treponema pallidum-specific PCR. In view of the Brazilian guidelines for diagnosis and treatment of maternal and congenital syphilis,2 we would like to raise some points that are discordant with the proposal made by Silva and colleagues. Full-Text PDF
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