r e v b r a s o r t o p . 2017;52(6):740–742
SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Case
report
Congenital
syphilis
with
bone
lesion:
case
report
夽
Vinicius
Schott
Gameiro
∗,
Pedro
José
Labronici,
Igor
Mendes
de
Albuquerque
Rosa,
José
Angelo
de
Souza
da
Silva
DepartamentodeCirurgia,UniversidadeFederalFluminense,HospitalUniversitárioAntônioPedro,Niterói,RJ,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received8September2016
Accepted29September2016
Availableonline21October2017
Keywords:
Syphiliscongenital
Periostitis
Bonediseases
a
b
s
t
r
a
c
t
Theauthorsreportacaseofcongenitalsyphilisinanewbornwithabonelesion,resulting
inleftankleperiostitis.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora
Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Sífilis
congênita
com
lesão
óssea:
relato
de
caso
Palavras-chave:
Sífiliscongênita
Doenc¸asósseas
Periostite
r
e
s
u
m
o
Osautoresapresentamumcasodeumrecém-nascidoportadordesífiliscongênitacom
lesãoósseaqueevoluiucomperiostitenotornozeloesquerdo.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora
Ltda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Congenitalsyphilis(CS)isadiseasethatseriouslyaffects
new-borns (NB)ina multisystemicway; it can evenbefatal. It
occursthroughthehematogenoustransmissionofTreponema
pallidumthrough theplacenta ofuntreatedor inadequately
treatedpregnantwomentotheirchildren.Albeitpreventable
withadequateprenatalfollow-up,CSstillaffectsmany
new-bornsinBrazil.1
夽
StudyconductedatUniversidadeFederalFluminense,HospitalUniversitárioAntônioPedro,Niterói,RJ,Brazil.
∗ Correspondingauthor.
E-mails:drschott@bol.com.br,consultorioschott@gmail.com(V.S.Gameiro).
This article is aimed at reporting a case of CS with
bone lesion and to emphasize the importance of this
diagnosis.
Case
report
Thepatient, pregnant,21 yearsold,GIV PIAIII,residentof
SãoGonc¸alo(RJ),HIVnegativeserology,withpositiveVDRL
duringpregnancy(VDRL1:32on01/23/15andVDRL1:32on
http://dx.doi.org/10.1016/j.rboe.2017.10.002
2255-4971/©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Thisisanopenaccessarticle
rev bras ortop.2017;52(6):740–742
741
Fig.1–Anteroposteriorviewradiographsofthelegs showinglyticimageinthedistalmetaphysealregionand diffuseperiostealreactioninthelefttibia.
02/23/15).Thepatientwasnottreatedduringpregnancy.She
wasnormotensiveandnon-diabetic.
On02/23/15, shegave birth– byvaginaldelivery– to a
pretermNB(32weeks),smallforgestationalage(SGA),with
earlyrespiratorydiscomfortrequiringsupportwithanoxygen
mask.
Onthatday,theNBwasadmittedtotheneonatal
inten-sivecareunit(NICU)duetotheneedforventilatorysupport.
AfterNBscreening,whichidentifiedpositiveVDRL,treatment
forCSwasinitiatedwithcrystallinepenicillinfortendays.At
theageoffiveweeks,edemaandpainontheleftlowerlimb
uponmanipulationwereobserved;comparativeradiographs
oftheanklesandlegswererequested.Radiologicalalterations
wereobservedinthelefttibia,characterizedbyalyticimagein
thedistalmetaphysealregionwithdiffuseperiostealreaction,
extendingtothemiddlethirdofthisbone(Fig.1).
The one-month treatment control VDRL was 1:1, and
thetreatmentwithcrystalline penicillinwasreinitiated for
anothertendays.
Untilthesixthmonthoflife,thepatientwasreactivetothe
management,withoutmajoralterationsonexamination.The
patientwasdischargedat7monthsofage,withimprovement
ofsignsandsymptomsandunderoutpatientfollow-up.
On 03/12/2015, atthe age of9 months, the last control
radiographsweremade,whichshowednobonelesion(Fig.2A
andB).
Discussion
CStransmissioncanoccuratanygestationalstageorclinical
stageofmaternaldisease.Verticaltransmissiondepends
pri-Fig.2–(A)Anteroposteriorviewradiographsoftheleft
ankle,showingnobonechanges.(B)Lateralview
radiographsoftheleftankle,alsowithoutbonechanges.
marilyontwofactors:thestageofsyphilisinthemotherand
thedurationoffetalexposureinuterus.1
CS is more likely to occur in cases of inadequate
pre-natal care. It is also morelikely to occur in the following
cases:motherwithprimarysyphilis;presenceofanymaternal
illness of unknown duration; high maternal titers in
non-treponemalplasmatests(VDRL≥1:16)duringtreatment(or
atdelivery);smallintervalsbetweentreatmentanddelivery
(<4weeks);anduntreatedsyphilis.2
CScanbeclassifiedasearly(diagnosedupto2yearsofage)
andlate(afterthisperiod).ThemaincharacteristicsofearlyCS
includeprematurity,lowbirthweight,hepatomegalywithor
withoutsplenomegaly,cutaneouslesions,limb
pseudoparal-ysis,respiratorydistress,jaundice,anemia,andgeneralized
lymphadenopathy.Furthermore,osteitisandosteochondritis
arealsonoteworthy;theypresentcharacteristiclesionsina
radiologicalstudy(asinthepresentcase).1Laboratory
abnor-malitiesincludeanemia,thrombocytopenia,andleukocytosis
orleukopenia.Inthecaseofthepresentpatient,thepresence
ofamotherwithuntreatedsyphilisduringpregnancy
associ-atedwithclinicalmanifestationsintheNBweresufficientto
establishthediagnosisofCS.LateCSischaracterizedbysaber
shindeformityofthetibia,Clutton’sjoints,frontalbossing,
saddlenose,deformeduppermedialincisorteeth
(Hutchin-son’steeth),neurologicaldeafness,anddifficultyinlearning.1
SomeauthorsbelievethatCScouldbeprimarilyreduced
byimprovingprenatalcareinthehigh-riskpopulationandby
refining casereportinginordertocontrolsyphilisinfection
inthecommunity.3Furthermore,notificationofthepartners
ofpregnantwomenwithsyphilishasbeenassociatedwitha
markedimprovementpregnancyoutcome.4
ItisalsoknownthattheannualnumberofdeathsduetoCS
competeswiththatofdeathscausedbyverticaltransmission
ofhumanimmunodeficiency virus (HIV).5 Sincehealthcare
systemsareincreasinglyinvestinginthe preventionof
ver-ticalHIVtransmission,itisinexplicablethatthispracticehas
notbeenadoptedforsyphilis,sincethecostofpreventingCS
bytraditionalscreeningismuchlowerthanthatofpreventing
742
rev bras ortop.2017;52(6):740–742Ahighlevelofdoubtisnecessary;theorthopedistshould
considerthepossibilityofCSwheneverimagesshow
destruc-tivebone lesions.7 It hasalsobeen demonstrated that the
radiographsoflongboneswereabnormalin20%ofthe
asymp-tomaticNBs withpositiveperinatal treponemalserology.8,9
Bone lesions commonly affect the tibia and other long
bonesofthebody,generallybeingmultipleandsymmetrical.
Thelesionscanbeclassifiedasosteochondritis,
osteomyeli-tis, and osteoperiostitis.10 In cases of bone fractures and
lyticbonelesionsinNBs,intrauterineinfections,especially
syphilis,shouldalwaysbeinvestigatedaspossiblecauses.10
Bone involvement can be very painful, causing the child
torefuse tomove aextremity, a finding knownas Parrot’s
pseudoparalysis.10
Thus,consideringtherecentincreaseintheincidenceof
CSandthepossibleconsequencesofthisdiseasefortheNB,
themedicalteaminvolvedinthetreatmentofNBshouldbe
awareoftheclinicalmanifestationsandthesilentsignsofthis
disease.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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1. Diretrizesparacontroledasífiliscongênita:manualde bolso/MinistériodaSaúde,SecretariadeVigilânciaemSaúde, ProgramaNacionaldeDST/Aids.2a
ed.Brasília:Ministérioda Saúde;2006.
2.SaloojeeH,VelaphiS,GogaY,AfadapaN,SteenR,LincettoO. Thepreventionandmanagementofcongenitalsyphilis:an overviewandrecommendations.BullWorldHealthOrg. 2004;82(6):424–30.
3.MascolaL,PelosiR,BlountJH,BinkinNJ,AlexanderCE,Cates WJr.Congenitalsyphilis.Whyisitstilloccurring?JAMA. 1984;252(13):1719–22.
4.SchmidG.Economicandprogrammaticaspectsofcongenital syphilisprevention.BullWorldHealthOrg.2004;82(6): 402–9.
5.SchmidGP,StonerBP,HawkesS,BroutetN.Theneedand planforglobaleliminationofcongenitalsyphilis.SexTransm Dis.2007;347Suppl.:S5–10.
6.WalkerDG,WalkerGJ.Forgottenbutnotgone:thecontinuing scourgeofcongenitalsyphilis.LancetInfectDis.
2002;2(7):432–6.
7.RasoolMN,GovenderS.Theskeletalmanifestationsof congenitalsyphilis.Areviewof197cases.JBoneJointSurgBr. 1989;71(5):752–5.
8.Atenc¸ãoàsaúdedorecém-nascido:guiaparaosprofissionais
desaúde.MinistériodaSaúde,SecretariadeAtenc¸ãoàSaúde,
DepartamentodeAc¸õesProgramáticaseEstratégicas.
Brasília:MinistériodaSaúde;2011.
9.BrionLP,ManuliM,RaiB,KreschMJ,PavlovH,GlaserJ. Long-boneradiographicabnormalitiesasasignofactive congenitalsyphilisinasymptomaticnewborns.Pediatrics. 1991;88(5):1037–40.
