Case Report: Congenital syphilis presenting with respiratory symptoms in an infant.

Background: Congenital syphilis is preventable but has diverse clinical manifestations. Although rhinitis or respiratory symptoms may be among the initial complaints, symptomatic congenital syphilis may already present with overt multisystem disease involving the skin, liver, hematologic system, lungs, skeleton, kidneys, and central nervous system. We report a male infant aged 1 month and 18 days who presented with nasal congestion and rhinorrhea. Initial examination and investigations revealed diffuse desquamation involving the axillae, buttocks, perineum, palms, and soles, together with clustered rashes. Additional findings included abdominal distension, hepatomegaly, pallor, anemia, thrombocytopenia, systemic inflammation, liver dysfunction, proteinuria and hematuria, pneumonia, long-bone periosteal proliferation, and cerebrospinal fluid abnormalities. Maternal history revealed untreated syphilis before and during pregnancy. The infant tested positive by the Treponema pallidum particle agglutination assay (TPPA), with a toluidine red unheated serum test (TRUST) titer of 1:512. These findings supported early congenital syphilis with multisystem involvement. He received intravenous penicillin G sodium at 50,000 U/kg per dose every 6 h for 14 days, together with supportive care. During treatment, he developed a fever consistent with a Jarisch-Herxheimer reaction. Clinical and laboratory abnormalities improved, and serial testing showed a progressive decline in the non-treponemal titer. Conclusion: Congenital syphilis should be considered promptly when rhinitis or respiratory symptoms coexist with desquamating lesions, hepatomegaly or hepatopathy, anemia, thrombocytopenia, or other systemic abnormalities. Complete physical examination and review of maternal serology are especially important when prenatal care or transfer of maternal medical information has been incomplete. Early recognition, penicillin treatment, and structured follow-up are essential to prevent late sequelae.