Clutton's Joints In Congenital Syphilis
Treponema pallidum can pass from the infected mother to the fetus through the placenta. An infected mother can transmit the disease to her child even in the late stages, but in the late latent phase, there is less infectivity to the fetus. Since T. pallidum is transmitted only through the fully formed placenta which develops by the fourth month of pregnancy, the fetus is unaffected in the early period. Abortions occurring earlier during pregnancy are not attributable to syphilis. Birth of a syphilitic baby is often preceded by repeated abortions occurring at progressively later months.
The primary stage is not evident in congenital syphilis. The early manifestations are similar to those of secondary acquired syphilis. Sometimes a syphilitic infant may be clinically normal at birth. The skin lesions consist of dusky red papules with bullae containing serum or pus, most prominent in the palms and soles (“syphilitic pemphigus”). The discharge contains a large number of T. pallidum. Generalised widespread popular skin rashes are seen at times. At the mucocutaneous junctions, the papules develop into condylomata. The infant has a wasted and dehydrated appearance which is described as “old man facies”. The baby fails to thrive and becomes marasmic. Alopecia may occur. Occasionally, there may be growth of black hair called the ‘syphilitic wig’. Mucous patches may be seen on the nose, mouth, throat and larynx. Radiating fissures may form at the angles of the mouth (rhagades). Bloodstained, thick, purulent nasal discharge may block the nostrils and produce a bubbling sound during breathing termed as “syphilic snuffle”. Feeding problems may develop due to blockage of the nose.
Bony lesions develop within 6 months of birth. The ends of long bones are swollen and tender due to osteochondritis. The restriction of movement is sometimes referred to as syphilitic pseudo-paralysis. Osteochondritis clears up by six months of age, but syphilitic periosteitis persists and tends to become more marked. Subperiosteal new bone is laid down irregularly over the shaft of bones leading to thickening and deformity, eg, Sabre tibia. Due to concentric layering of new bone, the skiagram may reveal a characteristic onion peel appearance. Painless effusions in one or both knee joints. “Clutton’s joints” develop in the second decade. These are generally seen between the ages of 10 and 20 years.
Old Man Facies In congenital Syphilis
Eye lesions: These include choroiditis and retinitis which develop after the first two years of life. Invasion of the nervous system by T. pallidum during intrauterine life may lead to arrest of development of the brain.
Late non-infectious congenital syphilis: This stage sets in after the second year of life. Lesions are more common between 7 to 15 years of age but may occur at any age. Gumma may develop in the skin, mucous membranes, or viscera. The lesions resemble those of acquired syphilis. Interstitial keratitis is one of the common lesions occurring in the late congenital syphilis. This may develop at any age between 3 and 30 years or even later.
Neurological lesions: Nerve deafness develops due to involvement of the 8th cranial nerve endings and this lesion is suggestive of congenital syphilis. It presents as bilateral progressive loss of hearing which may become total. Congential neurosyphilis leads either to general paralysis of insane or tabes dorsalis, but these patients develop the disease at a younger age. Meningovascular neurosyphilis is rare. When it occurs, it presents as cranial nerve palsies. Hemianopia and hemi- or monoplegia.
Stigmata of congenital syphilis: Damage to the developing orans in utero leads to the permanent stigmata of congenital syphilis. These include localized thickening of the frontal and parietal bones of the skull due to periosteitis giving rise to frontal bossing, “hot cross bun skull” and parrot’s nodes. Saddle nose developes due to the destruction of nasal bones, high arches palate and bull dog facies are all characteristic. The permanent teeth show diagnostic abnormalities. Peg-like incisors (Huctchinson’s teeth) are diagnostic. Hutchinson’s triad is a combination of interstitial keratitis, Hutchinson’s teeth and nerve deafness.
© 2014 Funom Theophilus Makama