To the Editors: Congenital syphilis (CS) has reemerged worldwide.1 In 2024, 39 CS cases were reported in Türkiye, with a rate of 4.2 per 100,000 live births.2 CS can occur at any time of gestation; when left undetected or untreated, it can cause long-term sequelae.1,3 We report a CS case, with dactylitis and Parrot pseudoparalysis. A 2.5-month-old male was referred to our clinic with a macrophage activation syndrome (MAS) suspicion. Two weeks prior, left middle finger edema was noted. He was hospitalized and treated for septic arthritis, and then left arm weakness occurred. A left clavicular fracture was detected, and brachial plexus injury was suspected. However, his symptoms have progressed to include tenderness to touch and loss of spontaneous movement in both arms. Due to anemia, hyperferritinemia and slightly hypofibrinogenemia, MAS was suspected and he was transferred on the fourth day. On examination, he was irritable. Muscle strength was graded as 3/5 in the right and 1/5 in the left upper extremity, while deep tendon reflexes were preserved. Generalized lymphadenopathy, painful left middle finger edema and an erythematous left ankle plaque were observed. Other systemic findings were normal. Laboratories revealed moderately elevated acute-phase reactants without hypofibrinogenemia, excluding MAS. Following a prior reactive anticytomegalovirus IgM result, he was referred to our department. The mother was questioned about prenatal infections; her pregnancy was uncomplicated and routine prenatal infectious disease screening in the first trimester was unremarkable. However, the father developed a primary penile lesion 3 months before birth and was then diagnosed with syphilis 1 month before delivery. After the father’s diagnosis, maternal Venereal Disease Research Laboratory test (VDRL) was negative; consequently, she was not treated or retested at delivery. Cytomegalovirus infection was excluded; however, the infant’s serum VDRL titer was 1/32, while mothers was 1/4. Cerebrospinal fluid (CSF) analysis was normal and CSF VDRL was negative. Ophthalmologic and audiologic assessments were unremarkable. Long-bone radiographs revealed diffuse periosteal reaction, cortical hyperostosis and intramedullary lytic–sclerotic lesions (Fig. 1). Retrospective review of maternal records revealed a reactive Treponema pallidum hemagglutination (TPHA) test performed 4 days after a nonreactive VDRL; however, this result was neither followed nor reported.FIGURE 1.: Long-bone Radiographs of the Patient. A: Anteroposterior radiograph including both upper extremities and the thorax demonstrates symmetric solid periosteal reactions (arrowheads) causing cortical hyperostosis involving the bilateral radius, ulna, humerus and the left metacarpal bones. Lytic destructive lesions are noted in the proximal metaphysis of both humeri and in the metaphysis of the left radius (open arrows). A pathologic fracture of the left clavicle is also observed (white arrow). B: Anteroposterior radiograph of the bilateral lower extremities demonstrates diffuse, symmetric solid periosteal reactions (arrowheads) resulting in cortical hyperostosis of the bilateral tibia, fibula and femur. Lytic destructive changes in the proximal metaphysis of the right tibia (open arrows) are present.Early CS was diagnosed. Crystalline penicillin G (50,000 U/kg/dose, every six hours) was administered for 10 days. Cranial and spinal magnetic resonance imaging findings were unremarkable. He was discharged after significant clinical improvement, with upper extremity muscle strength recovering to 4/5. Early CS presents various symptoms, such as hepatosplenomegaly, skeletal anomalies and intrauterine growth retardation.3 Parrot pseudoparalysis, as observed in our patient, refers to loss of extremity movement due to painful syphilitic periostitis, without neurologic defects.3,4 In our case, maternal VDRL was negative despite a positive TPHA 4 days later. This discrepancy suggests either the prozone phenomenon, seroconversion window or technical problems.3,5 Although the mother had a high risk for syphilis, her TPHA result was not incorporated into prenatal management nor was she retested at delivery or given penicillin in the context of partner therapy. Preventing CS requires a meticulous medical history of both parents, careful monitoring of prenatal syphilis screening results and partner therapy regardless of initial maternal results. ACKNOWLEDGMENTS We are thankful to Dr Hakan Kisaoğlu for admitting the case to our clinic.
Durmuş et al. (Mon,) studied this question.