Congenital syphillis ppt use in OBG And MSN
Download as PPTX, PDF0 likes2,396 views
Congenital syphilis is a severe infection transmitted from mother to fetus that can cause stillbirth or life-threatening complications in infants. Without treatment, half of infected fetuses die in utero or shortly after birth from complications like pneumonia or bleeding in the lungs. It is diagnosed through tests detecting the syphilis bacterium or antibodies in the infant's blood or spinal fluid. Treatment with intravenous or intramuscular penicillin is highly effective but must be given to the newborn if the mother was not adequately treated during pregnancy or is at high risk of transmitting the infection. With proper treatment, outcomes are good but untreated infants may develop late complications affecting the bones, teeth, eyes or brain.
Congenital syphillis ppt use in OBG And MSN
- 2. Congenital syphilis • Severe, disabling, and often life-threatening infection seen in infants • About half of all infected fetuses die shortly before or after birth
- 3. Pathophysiology CS • Trans placental transmission • Transmission rate:~ 60 - 100% • With early onset disease, manifestations result from trans placental spirochetemia and are analogous to secondary stage of acquired syphilis • CS does not have a primary stage
- 4. Clinical Manifestations • Intra-uterine: -Placenta -Fetus • Post-natal: - Early - Late
- 5. Intra-uterine: Placenta • The placenta is typically large and edematous • Characteristic placental findings include: - Hydrops placentalis - Chronic villitis - Perivillous fibrous proliferation - Normoblastemia - Necrotizing funisitis - Acute chorioamnionitis - Plasma cell deciduitis
- 6. Intra-uterine: Fetus • Depends on stage of development at time of infection & duration of untreated infection • Initially characterized by placental involvement and hepatic dysfunction (e.g., abnormal LFT), followed by amniotic fluid infection, hematologic abnormalities, ascites, and hydrops • Stillbirth / Neonatal death
- 7. Intra-uterine: Fetus • >24 weeks gestation: 66 % of fetuses have either congenital syphilis or T.Pallidum detected in amniotic fluid • Intrauterine death: 25 % of affected • Perinatal mortality: 25-30 %, if untreated
- 8. Post-Natal • Among survivors, manifestations been divided into: Early stage = First 2 years Late stage = After 2 years • Inflammatory changes do not occur in the fetus until after first trimester → organogenesis is unaffected • Nevertheless, all organ systems may be involved
- 9. Early SIGNS & SYMPTOMS- Asymptomatic • Occurs between 0 - 2 years • If asymptomatic : - Identified on routine prenatal screening - If not identified and treated, these newborns develop poor feeding and rhinorrhea ➨ Earliest signs of CS may be poor feeding and snuffles (i.e., syphilitic rhinitis)
- 10. Symptomatic Early SIGNS & SYMPTOMS- If Symptomatic: • Variable • Appear within 1st 5 weeks of life • Stillborn/ Premature • Failure to gain weight or FTT • Fever / Irritability • Severe congenital pneumonia
- 11. Symptomatic Early SIGNS & SYMPTOMS- • Most striking lesions affect the mucocutaneous tissues and bones: - Mucous patches - Rhinitis =snuffle - Condylomatous lesions ➨ ➨ highly characteristic features of mucous membrane involvement in CS
- 12. Symptomatic Early SIGNS & SYMPTOMS- • Snuffles → Followed quickly by diffuse maculopapular desquamative rash that involves extensive sloughing of the epithelium, on the palms & soles and around the mouth & anus • When chronic → “Saddle Nose” • Lesions & nasal fluid: highly infectious
- 13. Symptomatic Early CS • Bullous skin disease known as “pemphigus syphiliticus” ➲ Early rash -- small blisters on the palms and soles → Ulcerated ➲ Later rash -- copper-colored, flat or bumpy rash on the face, palms, and soles
- 14. Symptomatic Early CS • Other early manifestations include hepatosplenomegaly (100%), jaundice, anemia • Metaphyseal dystrophy and periostitis often are noted on radiographs at birth +/_ Pseudoparalysis
- 15. Congenital syphilis - early evidence of infection - bullae and vesicular rash
- 16. Multiple, punched out, pale, blistered lesions, with associated desquamation of palms & plantars
- 17. Intraoral mucous patches & facial skin lesions
- 18. Secondary lesions on feet Lesions first appeared during 4th week
- 19. Late-onset CS • Develop from scarring related to early infection • Can be prevented by treatment within first 3 months • Can appear as late as 40 years after
- 20. Late-onset CS • Manifestations include neurosyphilis and involvement of teeth, bones, eyes, and 8th cranial nerve • E.g.: Frontal bossing, short maxilla, high palatal arch, Hutchinson triad, saddle nose, and perioral fissure (Rhagades = bacterial infection of skin lesions )
- 21. Hutchinson triad 1. Deafness (10 – 40 years) 2. Hutchinson’s teeth = centrally notched, widely-spaced peg-shaped upper central incisors 3. Interstitial Keratitis → blindness (5-20 years)
- 22. Notched incisors known as Hutchinson’s teeth
- 23. Moribund newborn with CS Oral / skin lesions and saddle nose
- 24. Metaphyseal osteomyelitis Radiolucent distal radius & ulna with cupping distal ulna
- 25. Osteochondritis of femur & tibia
- 26. 1-m-old . Classical Wimberger's sign of destructive metaphysitis involving medial aspects of distal femora and proximal tibae
- 27. “Saber shins” = Osteoperiostitis Tibia
- 29. Possible Complications • Blindness • Deafness • Facial deformity • Neurological problems
- 30. Labs Definitive diagnosis: 1. By direct visualization of spirochetes using dark field microscopy 2. Or direct fluorescent antibody tests of lesion exudate or tissue (Placenta/UC) -Helpful early in the disease, prior to development of seroreactivity
- 31. Serologic tests - Presumptive diagnosis can be made using - Nontreponemal ( False + in medical conditions) - Treponemal (False+ in other spirochetal Diseases) → So use of only one type is insufficient - If nontreponemal test is +→ confirmatory testing is performed with a specific treponemal test
- 32. Nontreponemal test • VDRL (Venereal Disease Research Laboratory) • RPR (Rapid plasma reagin) • ART (Automated reagin test)
- 33. Nontreponemal test - Used for screening (sensitive but not specific) - Inexpensive, performed rapidly, and provide quantitative results → helpful indicators of disease activity & monitor treatment response - Measures Ab directed against lipoidal Ag from T. Pallidum, Ab interaction with host tissues or both - Nonspecific Ab develop 4-8 weeks following infection
- 34. Nontreponemal test • False negative - Early primary S - Latent acquired S - Late CS - Prozone phenomenon • False Positive - Viral infection ( EBV, Hepatitis, Varicela, Measles) - Lymphoma - TB - Malaria - Endocarditis - CT diseases - Pregnancy - IV drugs - Wharton Jelly contamination in cord samples
- 35. Nontreponemal test • Any reactive NT test must be confirmed by Treponemal test to exclude false positive • Treatment should not be delayed if symptomatic or at high risk of infection • Monitor: - Sustained 4 fold ↓NT test titer after treatment → Adequate treatment - Sustained ↑: Re-infection or relapse
- 36. Nontreponemal test Newborn Dilemma • Testing of newborn often is problematic because IgG antibody may be a reflection of maternal rather than infant infection • Unless NT titer is much higher in baby than in mother → f/u serology over 1st 6 months of life, when maternal IgG is lost, would be required to make a diagnosis i.e. Loosing precious time in treatment initiation
- 37. Treponemal Specific Test • T pallidum immobilization (TPI) • Fluorescent treponemal antibody absorption (FTA-ABS) • Microhemagglutination assay for antibodies to T pallidum (MHA-TP)
- 38. Treponemal Specific Test • Confirm + nontreponemal reaginic test • Remain positive for life i.e. Result do not correlate with disease activity and tests are not quantified • False + reactions: → Other spirochetal diseases (e.g., yaws, pinta, leptospirosis, rat-bite fever, relapsing fever, Lyme disease
- 39. Cerebrospinal Fluid Analysis • CSF VDRL • Could be negative and still develop signs of neurosyphilis →Therefore, all those with presumptive CS should be treated • A nonquantitative VDRL test is the only serologic test that should be performed on CSF Other test like FTA-ABS are less specific on CSF samples
- 40. CBC • CS characterized by anemia, thrombocytopenia, and either leukopenia or leukocytosis • Evidence of Coombs-negative hemolytic anemia or a leukemoid reaction may be present
- 41. Imaging Studies • CXR: - Syphilitic pneumonia is common in CS - Fluffy diffuse infiltrate “pneumonia alba”
- 42. Imaging Studies • Long bone radiography – 95% of symptomatic infants and 20% of asymptomatic – Multiple sites of osteochondritis at wrists, elbows, ankles and knees and periostitis of long bones – The lower extremities almost always affected
- 43. Imaging Studies • Neuroradiography: - Findings nonspecific - May mimic herpes simplex virus - MRI may reveal cerebral hypertrophy and hyperintensity in the temporal lobes
- 44. CDC Newborn Evaluation • The diagnosis of CS is complicated by the trans placental transfer of maternal nontreponemal and treponemal IgG Abs to fetus ➨ Making interpretation of reactive serologic tests for CS difficult
- 45. CDC Newborn Evaluation Evaluation should include: 1. Maternal H/O syphilis including tx type & adequacy before and during the pregnancy 2. P/E of newborn 3. Quantitative NT & T tests 4. CBC, long bone x-rays, CSF (VDRL, cell count, protein), and CXR and/or LFT 5. Pathologic examination of placenta or umbilical cord using specific fluorescent antitreponemal antibody staining
- 46. CDC Newborn Evaluation • A presumptive diagnosis, which results in tx, is made if baby has + serologic test and any of following: 1. Compatible findings on P/E 2. CSF abn. (+ VDRL, ↑ WBC, or ↑protein) 3. Osteitis on x-ray long bones 4. Placentitis 5. NT test 4x > than maternal 6. Positive FTA-ABS-19S IgM antibody
- 47. Treatment • IV Penicillin G is the drug of choice for all stages of syphilis including CS • Infants: - 100,000 - 150,000 U/kg/d IV Q12 x 7 d. then Q 8 to complete 10 days - Or Procaine Penicillin G 50,000 U/kg/d IM once for 10 days (adequate CSF conc. may not be achieved)
- 48. Treatment • Indications: 1. If newborn meets any of criteria 2. If mother was treated < 4 weeks prior to delivery 3. If mother treated with other than penicillin 4. If maternal titers suggest inadequate response to treatment before or early in pregnancy
- 49. Syphilis In Pregnancy • In communities in which risk for CS is high → serologic testing and a sexual history also should be obtained at 28 weeks gestation and at delivery • Treat all pregnant patients with penicillin, regardless of the stage of pregnancy
- 50. Syphilis In Pregnancy • 3 doses of benzathine penicillin (2.4 million U IM at 1-week intervals) • No proven alternative treatment for patient allergic to penicillin i.e. Erythromycin for patient allergic to penicillin is not reliable treatment for fetus
- 51. Evaluation and Treatment of Infants During the First Month of Life The following scenarios describe the evaluation and treatment of infants for congenital syphilis
- 52. Scenario 1 Infants with proven or highly probable disease and • Abnormal P/E consistent with CS • Serum quantitative NT titer 4x > mother’s titer or • + darkfield or fl. ab. test of body fluids
- 53. Scenario 1 Infants with proven or highly probable disease and Recommended Evaluation • CSF analysis for VDRL, cell count & protein • CBC w. diff.& PL count • Other tests as clinically indicated ( long-bone x- rays, CXR, LFT, HUS, ophthalmologic exam, and BAER) Recommended Regimens • Aqueous crystalline penicillin G 50,000 U/kg/dose IV Q 12 hrs. first 7 DOL and Q 8 hrs thereafter for a total of 10 days OR • Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days
- 54. Scenario 2 Normal P/E & serum quantitive NT titer ≤ 4 x maternal titer • Mother not / inadequately treated, or no documentation • Mother was treated with erythromycin or other nonpenicillin regimen or • Mother received treatment < 4 weeks before delivery
- 55. Scenario 2 Normal P/E & serum quantitive NT titer ≤ 4 x maternal titer Recommended Evaluation • CSF analysis for VDRL, cell count, and protein • CBC w. diff. and PLT count • Long-bone X-rays Recommended Regimens • Aqueous cryst. penicillin G 50,000 u./kg/dose IV Q 12 hrs during the 1st 7 DOL and Q 8 hrs thereafter for a total of 10 days OR • Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days OR • Benzathine penicillin G 50,000 units/kg/dose IM in a single dose
- 56. Scenario 3 Normal P/E & serum quantitive NT titer ≤ 4 x maternal titer • Mother was treated during pregnancy, tx. was appropriate for the stage of infection, and treatment was administered > 4 weeks before delivery….. and • Mother has no evidence of reinfection or relapse
- 57. Scenario 3 Normal P/E & serum quantitive NT titer ≤ 4 x maternal titer Recommended Evaluation ⇩ No evaluation required Recommended Regimen ⇩ Benzathine penicillin G 50,000 units/kg/dose IM in a single dose
- 58. Scenario 4 Normal P/E & serum quantitive NT titer ≤ 4 x maternal titer • Mother’s treatment was adequate before pregnancy…. and • Mother’s NT titer remained low and stable before, during pregnancy and at delivery (VDRL <1:2; RPR <1:4)
- 59. Scenario 4 Normal P/E & serum quantitive NT titer ≤ 4 x maternal titer Recommended Evaluation ⇩ No evaluation required Recommended Regimen ⇩ No treatment required
- 60. Outlook (Prognosis) • Infected early in pregnancy ➨ stillborn • Treatment of expectant mother ↓ risk of CS • Babies who become infected when passing through birth canal have better outlook • Death from CS is usually through pulmonary hemorrhage