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dok_zlo — 28.07.2024

A baby boy was noted to have hepatomegaly on the first day of life. Owing to fetal distress, his 29-year-old mother had delivered by cesarean section at 31 weeks’ gestation. On physical examination, the liver was enlarged (Panel A, with the area outlined with a skin marker). There were no skin lesions, lymphadenopathy, or splenomegaly. Laboratory tests were notable for thrombocytopenia and an elevated alkaline phosphatase level. Abdominal ultrasonography revealed a normally echogenic liver extending below the right kidney. A rapid plasma reagin (RPR) titer was 1:128, and a fluorescent treponemal-antibody absorption test was positive. Polymerase-chain-reaction assays of cerebrospinal fluid and nasal secretions were positive for Treponema pallidum. A diagnosis of congenital syphilis was made. Subsequent radiographs of the baby’s legs showed periostitis (Panel B, white arrow) and alternating dense and radiolucent bands (Panel B, yellow arrows) in the distal femur, a finding known as a “celery stalk” appearance. Erosion at the medial aspect of the proximal tibial metaphysis (Wimberger sign) was also observed (Panel B, asterisk). The baby’s asymptomatic mother had an RPR titer of 1:128. Screening for syphilis had not been included in her routine prenatal testing. The newborn was treated with intravenous benzylpenicillin, and his mother received a dose of intramuscular benzathine penicillin G. Two weeks after the completion of treatment, the baby’s RPR was 1:32. At a 6-month check-up, he was developmentally normal.
Simone S. Schueller, M.D., Ph.D., and Tobias Strunk, M.D., Ph.D.
Published July 24, 2024
N Engl J Med 2024;391:356
DOI: 10.1056/NEJMicm2314716
VOL. 391 NO. 4

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