Congenital Syphilis: Complicating an already complex adoption process

Background: With the number of adoptions on the rise both nationally and internationally, screening and subsequent treatment of congenital infections is of particular importance. Among the congenital infections in adoptees, detection of syphilis is particularly difficult, as most affected babies are asymptomatic, especially during infancy. We present the story of an apparently asymptomatic orphan whose VDRL returned positive on a routine adoption screen. Methods & Materials: An 11 month old girl was brought to the pediatric outpatient following VDRL positivity. Maternal and birth details were not known. Following take-over by a nongovernmental organization at an approximate age of 5 months, she did not have any history of failure to gain weight, repeated infections, skin lesions, jaundice or bleeding manifestations. On evaluation, she was found to be thriving well and developmentally appropriate for age. General physical examination revealed frontal bossing. There was no lymphadenopathy, rash, rhinitis, condyloma lata or mucocutaneous involvement. Abdominal examination revealed hepatosplenomegaly. Other systemic examination was normal. Results: Following a non-treponemal VDRL test seropositivity, a treponemal testmicroheamagglutination test for Treponema pallidum (MHA-TP) was also positive. Blood counts were suggestive of iron deficiency anemia, and there was no thrombocytopenia. Urine examination was normal. Serological tests for HIV were negative. CSF analysis yielded normal sugar, protein and chloride levels. No bacteria were seen on dark field microscopy, cultures were sterile and CSF VDRL test was negative. Radiological evaluation revealed hot-cross bun appearance of the skull with destructive changes, and dental abnormalities consistent with early Hutchinson’s teeth. Distortion product oto-acoustic emissions were absent bilaterally, and were suggestive of moderate hearing loss. There was no evidence of interstitial keratitis, chorioretinitis or glaucoma on ophthalmological evaluation. She was treated with Crystalline Penicillin 50,000 units/kg body weight intravenously 6th hourly for 14 days. She has been adopted by a loving family, and is otherwise asymptomatic on follow-up. Conclusion: Although uncommon, congenital syphilis can complicate an already complex adoption process. Infected infants are generally not detected during this period since the disease is most commonly asymptomatic during infancy. This case reiterates the importance of early screening and timely initiation of appropriate treatment which could enhance outcomes in potential adoptees.