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).