Congenital Syphilis

Clinical History: A 29-year-old G1P0 female with poor prenatal care who birthed a 29-week infant via vaginal delivery. The infant had a weak cry, minimal respiratory effort, and an Apgar of 6 at one minute and 8 at five minutes. The baby was intubated and sent to the NICU.

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Figure 1: Anterior-posterior projection of bilateral lower extremities - widespread osseous deformities are shown involving the epiphyseal-metaphyseal junctions and long bone cortices

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Figure 2: Anterior-posterior bone survey - osseous deformities also involving the upper extremities

Image Findings: Figure 1, AP Bilateral Lower Extremities: Diaphyseal periostitis with new bone formation is noted symmetrically and bilaterally in the lateral portions of the tibia, fibula, and femur. Osteochondritis at the epiphyseal-metaphyseal junctions of the tubular bones, highlighted by widening of the calcification zone, serrations, and osseous irregularities. The alternating regions of lucid and sclerotic lines are known as the celery stalk sign, and are suggestive of osteochondritis. Medial erosion of the proximal tibia, known as the Wimberger sign, is not appreciated on this radiograph.

Figure 2, AP Supine Bone Survey: Diffuse periostitis and osteochondritis is shown in the tubular bones of the upper extremities.

Diagnosis: Congenital Syphilis

Discussion: Congenital syphilis is most often caused by transplacental transmission of the spirochete Treponema Pallidum and is almost exclusively seen in mothers with minimal prenatal care. For diagnosis, the United States Center for Disease Control and Prevention requires physical, laboratory, or radiographic signs of congenital syphilis or history of birth from a mother with poorly controlled syphilis. Bony abnormalities typically include osteochondritis, diaphyseal osteomyelitis, and periostitis.

The mother had a known diagnosis of syphilis and was non-adherent to her penicillin treatment, thus prompting radiographic workup.

The bony deformities usually regress within months and may appear later in childhood or adolescence as gummatous or non-gummatous osteomyelitis most commonly affecting the skull and tibia. Nasal bone and mandible destruction may lead to the classic saddle-nose and Hutchinson’s teeth deformities.

Resources: [1] Centers for Disease Control and Prevention. Congenital syphilis (Treponema pallidum) case definition, 1996. http://www.cdc.gov: Congenital Syphilis Case Definition

[2] Resnick, D. and Kransdorf, M. "Chapter 55 - Osteomyelitis, Septic Arthritis, and Soft Tissue Infection: Organisms." Bone and Joint Imaging. 3rd ed. Elsevier, 2005. 767-70.

Comeron Ghobadi, Mohammed Imran Quraishi, MD, and Kayiguvwe Kragha, MD,
University of Louisville Health Science Center
Department of Diagnostic Radiology