Congenital syphilis is a vertical infection of the fetus by Treponema pallidum during pregnancy, almost entirely preventable through prenatal screening and timely maternal treatment. The United States recorded 3,761 cases in 2022 — a tenfold rise from 2012 and the highest count in three decades, with 282 stillbirths and infant deaths attributed to it.
Congenital syphilis (ICD-10: A50) is infection of a fetus or newborn with Treponema pallidum acquired transplacentally from an untreated or inadequately treated pregnant person, or rarely through direct contact with a maternal genital lesion at delivery. Treponemes can cross the placenta from approximately gestational week 14 onward, with transmission risk depending on maternal stage: 70-100% in primary or secondary maternal syphilis, 40-83% in early latent, and 10% in late latent. Outcomes range from spontaneous abortion (which can occur as early as the second trimester) and stillbirth (up to 40% of cases in untreated maternal infection) through neonatal death, early congenital syphilis (multisystem disease in the first two years), and late congenital syphilis (recognized after age two, often presenting in school age or adolescence with characteristic stigmata). The pathophysiology is direct treponemal invasion of fetal tissues plus immune-mediated injury from chronic spirochete dissemination, producing the classic targets — placenta, liver, bone, central nervous system, eye, ear, and mucocutaneous surfaces.
The key symptoms of Congenital Syphilis are: Persistent rhinitis with white or blood-tinged mucus ("snuffles") from week 1 to 3 months — a treponeme-laden discharge highly infectious to caregivers and often the earliest visible sign., Hepatosplenomegaly with elevated transaminases and direct hyperbilirubinemia, sometimes producing visible jaundice in the first week of life., Maculopapular or vesicobullous rash on the palms, soles, and face, sometimes desquamating — distinct from neonatal physiologic peeling., Generalized lymphadenopathy, particularly epitrochlear (above the elbow), which is uncommon in other neonatal conditions., Painful pseudoparalysis of Parrot — the infant refuses to move an arm or leg due to syphilitic osteochondritis at the metaphysis, sometimes mistaken for fracture or birth trauma., Periostitis and metaphyseal lucencies on long-bone radiographs (Wegner sign, Wimberger sign), present in 60-80% of symptomatic newborns., Failure to thrive, irritability, and low birth weight — nonspecific but common in symptomatic infants..
Diagnosis combines maternal serology and history, infant clinical findings, paired infant serology, lumbar puncture, long-bone radiographs, and placental examination, all interpreted against CDC case definitions. The first step is identifying maternal syphilis through routine prenatal RPR or treponemal screening at three time points (first prenatal visit, third trimester, and delivery); the test is mandatory in many US states for any birth, fetal demise after 20 weeks, or stillbirth. When maternal infection is confirmed, every infant born to a syphilis-seropositive mother is evaluated whether they appear well or sick. The CDC algorithm sorts infants into four scenarios based on maternal treatment adequacy and timing, infant nontreponemal titer compared to the mother's, and the presence of clinical or radiographic findings. A confirmed case requires demonstration of T. pallidum by dark-field microscopy or PCR from a lesion, placenta, or autopsy tissue. A presumed case is supported by an infant nontreponemal titer fourfold higher than the mother's, suggestive clinical findings, or a reactive infant IgM by FTA-ABS. Lumbar puncture with CSF VDRL, white cell count, and protein detects asymptomatic neurosyphilis. Long-bone radiographs identify metaphyseal lucencies, periostitis, and Wegner or Wimberger signs in 60-80% of symptomatic newborns. Placental histopathology shows characteristic disproportionately enlarged, pale placenta with necrotizing funisitis. Ophthalmologic examination at birth and audiologic brainstem response testing detect ocular and otic involvement that can otherwise be silent. Late congenital syphilis is diagnosed by clinical recognition of stigmata plus reactive treponemal serology — by adolescence, RPR is often non-reactive in untreated cases.
With timely identification and full penicillin treatment, prognosis is excellent — over 95% of treated infants achieve serologic cure, and asymptomatic infants typically have no long-term sequelae. Symptomatic newborns with hepatosplenomegaly, rash, and bony lesions respond clinically within weeks, with lab abnormalities normalizing over 3-6 months. The dominant determinants of long-term outcome are how early treatment is started and the extent of existing organ damage at presentation: hearing loss from eighth-nerve involvement is partly reversible if treated within weeks of onset but irreversible if longstanding; interstitial keratitis can be controlled with topical steroids and treatment of active syphilis but corneal scarring may persist; neurodevelopmental delay correlates with extent of antenatal CNS infection and is mitigated but not eliminated by treatment. Stillbirth and neonatal death remain the worst outcomes — 8-15% of US 2022 cases in CDC data. Late congenital syphilis stigmata (Hutchinson teeth, saddle nose, saber shin, frontal bossing) are structural and do not regress with treatment, though they no longer progress. Reinfection of the child later in life is possible if behavioral risk factors emerge in adolescence or adulthood.
Pediatric infectious disease consultation is required for any infant with confirmed or probable congenital syphilis, abnormal CSF, abnormal long-bone radiographs, or maternal treatment inadequacy. Neonatologists manage symptomatic newborns; ophthalmology, audiology, neurology, and developmental pediatrics provide long-term follow-up. Late congenital syphilis warrants pediatric ID plus involvement of dental, ENT, and orthopedics for stigmata management.
Find specialists →Clinical signs of early congenital syphilis (rash, snuffles, hepatosplenomegaly) resolve over 1-4 weeks of treatment. Bone lesions on radiograph normalize over 3-6 months. Nontreponemal titer (RPR) should drop fourfold by 3 months and become non-reactive by 6-12 months in successfully treated infants. Treponemal tests may remain positive for years or for life regardless of cure. Long-term ophthalmologic and audiologic monitoring extends through adolescence.
No specific restrictions. Developmental motor milestones should be tracked closely in the first 2 years to identify any delay related to early congenital syphilis or its treatment.
Seek a tertiary care center with neonatology, pediatric infectious disease, and a coordinated congenital infection clinic. Ask whether the center follows the CDC 2021 algorithm with all four scenarios, has pediatric audiology and ophthalmology onsite, and offers long-term follow-up through adolescence. Local public health departments coordinate community follow-up and partner notification.
Medically reviewed by AIHealz Medical Editorial Board · May 13, 2026
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