Congenital Syphilis Presenting as Sepsis after the Neonatal Period: When Negative Maternal Serologies are Misleading

Case RepoRtTo avoid congenital infections, serological screening during pregnancy is mandatory. 1,2,5,8Portugal, like most European countries, has implemented a universal program for pregnant women, which includes syphilis screening during both the first and third trimesters. 11,12However, false-negative results may occur. 1,6,13e report the case of an infant with congenital syphilis presenting as sepsis after the neonatal period.Notably, the infant was born to a woman whose first and third trimester syphilis screening were negative. Case DesCriptionWe present a 2-month-old male infant, born to a 30-year-old healthy mother who followed the prenatal screening according to national guidelines.All three trimesters' obstetric ultrasounds showed no abnormalities.Maternal serological screening in the first trimester introDuCtion Congenital syphilis (CS) is a global public health issue, with a rising number of cases reported worldwide, including in many highincome countries. 1The United States saw an increase of 183% reported cases between 2014 and 2018, and in 2023, the country reported the highest number of cases since 1992. [1][2]][3] The increasing rate of syphilis cases over the last decade is particularly concerning, given the rising rates among women of childbearing age, which directly correlates with the incidence of CS. 2,4,5 Among 14 European countries that reported a 25% or greater increase in overall syphilis cases in 2022, 10 also reported cases of CS in the same period. 5In fact, according to the ECDC 2022 report, the rate of CS has been increasing, with Portugal representing one of the countries with a higher number of cases (18.8 cases per 100,000 live births in 2021). 5This trend raises concerns and poses new challenges for pediatricians, who must be aware of its clinical signs.In untreated maternal infection, vertical transmission occurs in 70-100% of cases, with stillbirths accounting for one-third of these outcomes. 5Early clinical manifestations of CS include intrauterine growth restriction, skin rash, hepatosplenomegaly, copious nasal discharge, central nervous system abnormalities, and inflammation of the long bones. 2,6,7Pseudoparalysis, perirectal masses, or isolated fever are rarer presentations. 2 Although sepsis has been described as a presenting feature of CS, it is rarely recognized by the clinician at its initial presentation. [8][9][10] Awareness of CS is crucial, as most newborns (60-90%) are asymptomatic at birth and may only present clinical manifestations after the neonatal period, which can be subtle and nonspecific. 1,4,6,8arly symptomatic syphilis can be severe, with multisystem involvement, often requiring intensive care for affected patients. 8ne study reported a mortality rate of 38%.