Case report:
A 32-year-old primipara female was referred to our hospital for painless delivery. Prenatal history included one prior spontaneous miscarriage in a year ago. The patient had a history of smoking, which she had stopped after the discovery of pregnancy. She had a history of panic disorder and bipolar disorder, for which she was on medication. However, she self-interrupted her medication and hospital visits after discovering her pregnancy. Pregnancy was spontaneous and was managed at a primary care facility. The initial screening test performed at 12 weeks of gestation was negative for rapid plasma reagin (RPR) and TP antibodies. No abnormalities were observed in other laboratory results. At 22 weeks of gestation, she developed vulvovaginal and vaginal itching, which was diagnosed as vulvovaginal candidiasis by vaginal culture and treated with oxenazole vaginal suppositories. She was referred to our hospital at 33 weeks of pregnancy, which has a comprehensive perinatal mother and childcare centre, because she wanted to have a painless delivery. Thereafter, the patient continued antenatal care at the hospital. She had persistent vulvar itching and white tinea versicolor discharge. She continued the treatment for vulvar candidiasis with an oxazol vaginal suppository, but the treatment was refractory. At the time of her visit at 37 weeks and 2 days of pregnancy, painless induration and ulcerative lesions were observed on the vulva, and a blood test was performed on the suspicion of syphilis. Early in the morning of the next day, 37 weeks and 3 days after conception, she developed fever and pain during urination and was urgently admitted to the hospital on the same day.
On admission, the patient had a fever of 37.5°C. On examination, rice-sized erythematous plaques were observed on the palms, along with pale oedematous erythematous plaques with infiltrates on the right forearm and trunk, and numerous rice-sized painless ulcerative lesions on the vulva (Figure1). Internal examination revealed no bleeding or water breakage, and the cervix was closed. Uterine tenderness was not observed. Blood tests revealed a white blood cell count of 9000/µl (84.6% neutrophils); C-reactive protein (CRP), 10.47 mg/dl; PT, 13 s, and APTT, 64 s. Cardiotocography (CTG) findings on admission were 145 bpm at baseline, moderate baseline fibrillation, transient tachycardia, no transient bradycardia, and no uterine contractions. Transabdominal ultrasonography showed that the foetus was growing at a rate equivalent to the number of weeks. None of the findings were suggestive of congenital syphilis, such as obvious foetal hepatomegaly, ascites, foetal oedema, or placental thickening.
Based on positive RPR and TP antibodies, along with clinical symptoms, such as painless ulceration of the vulva and a generalized rose rash, she was diagnosed with second-stage syphilis. Subsequent detailed interviews revealed that her husband had used a sex establishment at around 15 weeks of gestation, and also had sexual intercourse with her during the same time. The patient’s husband was treated with oral benzylpenicillin. After discussing the treatment plan with the Department of Infectious Diseases, the patient was treated for neurosyphilis with 4 million units of penicillin G six times a day for 10 days. The patient was in full-term labour at the time of treatment initiation. No Jarisch-Herxheimer reaction was observed. Although the generalized rosacea and vulvar hard chancre had resolved, the blood tests were positive for RPR and TP quantitative tests (RPR: 11.58 R.U. and TP antibody: 188.5 COI). No specific guidelines have been established for the mode of delivery in cases of syphilis diagnosed in the third trimester of pregnancy. Since the patient remained positive for RPR and TP antibodies, and the risk of peripartum infection could not be assessed, we opted for a caesarean section. An emergency caesarean section was performed under spinal anaesthesia at 38 weeks and 3 days of gestation due to the onset of labour pain. A girl child weighing 2908 g, with an Apgar score of 8/9 and an umbilical artery blood pH of 7.280, was delivered. The first cry was rather weak, and prompt resuscitation was initiated. Since spontaneous respiration was weak, Continuous Postive Airway Pressure (CPAP) and oxygen were administered, after which the respiratory condition improved. Based on the maternal condition, the patient was admitted to the NICU for close examination and treatment of congenital syphilis. Blood test at birth showed a negative RPR of 0.49 R.U., positive TP antibody of 18.3 COI, and FTA-Abs-IgM of less than 5. Although there were no findings suggestive of congenital syphilis on physical examination, a dose of 50, 000 U/kg/dose of penicillin G was started after birth to prevent congenital syphilis. Vital signs of the new-born remained stable after the start of treatment. No obvious signs of infection were observed, and penicillin G administration was terminated on the 10th day of life. Early congenital syphilis test was negative, and the patient was discharged on the 19th day of life.
The mother continued postoperative penicillin G infusion until postoperative day 5, after which she was discharged. The patient is currently receiving treatment on an outpatient basis. Histopathological examination of the placenta revealed necrotizing funisitis (Figure 2). In addition, immunohistochemical staining for TP antibodies showed slightly positive organisms (Figure 2).