Produção Nacional
Revisado por pares
Congenital neurosyphilis
2013; Elsevier BV; Volume: 13; Issue: 6 Linguagem: Inglês
10.1016/s1473-3099(13)70080-x
ISSN1474-4457
AutoresRegina Célia de Souza Campos Fernandes, Enrique Medina‐Acosta,
Tópico(s)Syphilis Diagnosis and Treatment
ResumoIn their Clinical Picture of treatment failure for syphilis in pregnancy, Sónia Silva and colleagues1Silva S Henriques R Gomes JP Borrego MJ Afonso E Could we miss congenital neurosyphilis?.Lancet Infect Dis. 2012; 12: 816Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar 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,2Brazilian Ministry of HealthDiretrizes para o controle da sífilis congênita. Brazilian Ministry of Health, Brasília2005Google Scholar we would like to raise some points that are discordant with the proposal made by Silva and colleagues. First, infants with congenital neurosyphilis might have CNS imaging findings similar to those reported in other intrauterine CNS infections.3Tagarro A Garcia-Alix A Alarcon A Hernanz A Quero J Congenital syphilis: beta2-microglobulin in cerebrospinal fluid and diagnosis of neurosyphilis in an affected newborn.J Perinat Med. 2005; 33: 79-82Crossref PubMed Scopus (14) Google Scholar No ultrasonographic diagnostic pattern of neurosyphilis has been described in the scientific literature, and thus ultrasonography is not recommended for the assessment of congenital syphilis. Second, much of the neurological presentation and findings in the cerebral MRI in Silva and colleagues' reported case can be best ascribed to trauma and sequelae secondary to vacuum-assisted delivery. Third, we do not view as uncommon the absence of clinical manifestations in early congenital syphilis (the terms primary and secondary syphilis are not appropriate for infants). Therefore, we see no evidence to invoke rapid sequestration of T pallidum in fetal CNS. In Brazil, 63·9–75·5% of congenital syphilis cases were asymptomatic between 1998 and 2006, and diagnosis was possible by comparative analyses of both maternal and newborn venereal disease research laboratory (VDRL) test titres.4Brazilian Ministry of HealthBoletim epidemiológico sífilis 2012. Brazilian Ministry of Health, Brasília2012Google Scholar By contrast with the Portuguese protocol, we screen every pregnant woman at delivery with the non-treponemal VDRL test, and then screen newborn babies from VDRL-positive mothers. We do not test newborn babies using ELISA IgG and IgM because IgM has about a 10% false-positive rate and a 20–40% false-negative rate.2Brazilian Ministry of HealthDiretrizes para o controle da sífilis congênita. Brazilian Ministry of Health, Brasília2005Google Scholar Fourth, the scientific literature offers two explanations for treatment failure for syphilis in pregnancy: seroconversion during the second trimester, with the possibility of secondary syphilis due to high spirochete load;5Rawstron SA Bromberg K Failure of recommended maternal therapy to prevent congenital syphilis.Sex Transm Dis. 1991; 18: 102-106Crossref PubMed Scopus (31) Google Scholar and late treatment during pregnancy, when maternal pharmacokinetics are changed because of augmented renal blood flow and a larger volume of distribution for penicillin.6Alexander JM Sheffield JS Sanchez PJ Mayfield J Wendel Jr, GD Efficacy of treatment for syphilis in pregnancy.Obstet Gynecol. 1999; 93: 5-8Crossref PubMed Scopus (152) Google Scholar We therefore disagree with the proposal of screening with transfontanellar ultrasound and lumbar puncture for T pallidum-specific PCR of every newborn baby from mothers given appropriate treatment. Treatment failure for syphilis should always be considered in mothers who undergo seroconversion during pregnancy and who are given treatment late. In these cases, babies who are negative according to non-treponemal tests should be rigorously followed up. In settings in which this follow-up is not possible, infants should be immediately investigated, with the inclusion of a cerebrospinal fluid study by VDRL or rapid plasma reagin. 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 neurosyphilis – Authors' replyWe 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. Full-Text PDF
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