Utilidad del examen de líquido cefalorraquídeo y de la radiografía de huesos largos en neonatos asintomáticos con riesgo de sífilis connatal

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Abstract

Resumen Introducción: existe limitada información sobre la utilidad del análisis del líquido cefalorraquídeo (LCR) y de la radiografía de huesos largos en la identificación de sífilis congénita en niños asintomáticos. El grupo de estudio se plantea evaluar la utilidad de dichos estudios, considerando su rendimiento y costo como política de salud. Objetivos: conocer la prevalencia de alteración en el análisis de LCR y radiografía de huesos largos en recién nacidos asintomáticos con riesgo de sífilis connatal. Material y método: se realizó un estudio tipo analítico con adquisición prospectiva en el año 2010. Se incluyeron recién nacidos de término con diagnóstico de sífilis asintomáticos. Resultados: la muestra estuvo conformada por 61 recién nacidos y sus madres. El promedio de edad materna fue de 25 años con un DE de 5,6. Los títulos maternos de VDRL estuvieron en un rango de no reactivo a 1/64 y los de sangre de cordón umbilical entre no reactivo y 1/128. Del total de embarazos, 49,2% (30/61) fueron bien controlados, considerando el mismo como cinco o más controles, 29,5% (18/61) mal controlados y 21,3% (13/61) sin control. En seis de los 61 pacientes (9,83%) se identificó consumo de cocaína o marihuana. En embarazo, se realizaron 53 punciones lumbares para estudio de LCR, de las cuales 10 fueron en blanco y 21 traumáticas (58,5%). Ningún estudio de LCR mostró alteraciones en el análisis citoquímico. Se obtuvo un único VDRL positivo en LCR, resultando de una punción traumática. Se realizaron un total de 54 radiografías de huesos largos. En una se informó periostitis. Conclusión: en los recién nacidos asintomáticos en riesgo de sífilis congénita, la baja incidencia de neurosífilis y el bajo rendimiento del estudio del LCR sumado al alto porcentaje de punciones lumbares traumáticas o en blanco ponen en duda su utilidad basada en los criterios actualmente establecidos, como método estándar de evaluación. No se obtuvo evidencia contundente para la indicación de la radiografía de huesos largos como método rutinario de evaluación en recién nacidos asintomáticos.

Translated abstract

Summary Introduction: there is limited information on the usefulness of the analysis of cerebrospinal fluid (CSF) and long bone radiography in identifying congenital syphilis in asymptomatic children. The group study attempts to assess the utility of such studies, considering their performance and cost as health policy. Objectives: to determine the prevalence of altered CSF analysis and long bone radiography in asymptomatic newborns at risk of congenital syphilis. Material and methods: we carried out an analytical and prospective study in the year 2010. It included term infants with a diagnosis asymptomatic syphilis. Results: The sample consisted of 61 newborns and their mothers. The average maternal age was 26 years, standard deviation (SD) 6,8. VDRL maternal titles ranged from nonreactive to 1/64 and in the umbilical cord blood from nonreactive to 1/128. Of all pregnancies, 49,2 % (30/61 ) were well controlled, considering the same as five or more controls, 29,5 % (18/61) poorly controlled and 21,3% (13/61) without control. In six of the 61 patients (9,83%) was identified cocaine or cannabis. In 53 newborns lumbar punctures were performed for CSF study, of which 10 were in white, and traumatic in 21 (58,5%). Neither study showed alterations in CSF cytochemical analysis. It obtained a single positive VDRL in CSF,which resulting of a traumatic puncture. There were a total of 54 long bone radiographs. Reported periostitis in only one case. Conclusion: in asymptomatic newborns at risk of congenital syphilis, the low incidence of neurosyphilis and low CSF examination performance,added to the high proportion of traumatic and white lumbar punctures question its usefulness currently based on the criteria established as a standard method of evaluation. Not obtained strong evidence for the indication of the long bone radiography as routine method assessment in asymptomatic newborns.

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Fetal syphilis: clinical and laboratory characteristics.

L Hollier, T Harstad, Diane Twickler … (2001)

To examine the pathophysiology of fetal syphilis and correlate hematologic, immunologic, and sonographic findings. Twenty-four women with untreated syphilis during pregnancy were prospectively identified. Sonography with amniocentesis and percutaneous umbilical blood sampling were performed. Darkfield examination, rabbit infectivity testing, and polymerase chain reaction for detection of Treponema pallidum were performed on amniotic fluid. Hematologic and chemical testing of fetal blood was performed using standard techniques. Fetal antitreponemal IgM was detected by Western blot assay. Maternal syphilis was treated with 2.4 to 4.8 million units of benzathine penicillin G intramuscularly. Neonatal outcomes and signs of congenital syphilis were recorded. Six women had primary, 12 had secondary, and six had early latent syphilis. Sixty-six percent of fetuses (95% confidence interval [CI] 47%, 82%) had either congenital syphilis or detection of Treponema pallidum in amniotic fluid. Sixty-six percent had hepatomegaly, including three fetuses (12.5%, 95% CI 4%, 31%) with ascites. Fetal antitreponemal IgM was detected in three cases. Abnormal liver transaminases were found in 88% (CI 69%, 96%), anemia in 26% (CI 13%, 47%), and thrombocytopenia in 35% (CI 19%, 55%). Maternal treatment was successful in 83% (CI 64%, 93%). Risk of treatment failure was significantly increased when hepatomegaly and ascites were present (P =.01). Findings with fetal syphilis are similar to those of neonatal syphilis. We hypothesize that fetal transaminase elevation occurs early in the course of infection; hematologic abnormalities and hydrops occur later. Severity of disease may be associated with risk of treatment failure.

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A review of diagnostic tests for congenital syphilis in newborns.

Daan Notermans, L Kortbeek, T Herremans (2010)

Congenital syphilis (CS) can occur when a mother is inadequately treated or not treated at all for an active Treponema pallidum infection. Symptoms of CS are often subtle and non-specific, and it is estimated that up to 60% of affected infants are asymptomatic at birth, making the diagnosis dependent on laboratory findings. Despite decades of experience with CS, problems still arise in its diagnosis because laboratory test results for children at risk for CS can be inconclusive and no single diagnostic test can be used to diagnose CS. The development of diagnostic tests such as enzyme immunoassays, immunoblotting and polymerase chain reaction (PCR) has increased the sensitivity and specificity of diagnoses, but the detection of specific IgM is currently the most sensitive serological method, and the presence of specific IgM should be considered as evidence of a congenital T. pallidum infection. Suspected cases can also be confirmed or excluded by serial post-partum tests of antibody kinetics. The authors note strongly that it is considered unethical not to treat a baby at risk of contracting CS, even without a definitive diagnosis. In this review, we describe the various microbiological methods-and their shortcomings-used in the laboratory diagnosis of CS.