Purpose or Case Report: Congenital syphilis (CS) results from transplacental or intrapartum infection by the spirochete bacterium Treponema pallidum. After a nadir in 2005, its incidence has been rising since 2013, currently affecting 48.5 infants per 100,000 live births; this represents a nearly 300% increase since 2015. However, CS remains infrequent, and may not receive appropriate consideration in the differential diagnosis. We report such a case in which the differential diagnosis was not initially entertained. Recognition of the imaging findings of this congenital infection by the pediatric radiologist can be critical in the timely management of this condition.

Case: A 4-month old boy had wrist swelling noted by his grandmother who took him to the local ED where he was found to have a right distal radial fracture. The infant was transferred to our tertiary referral pediatric institution with concern for non-accidental trauma. Skeletal survey at our institution demonstrated multiple variable-shaped and sized lytic lesions in bilateral femurs, tibias, right fibula, bilateral humeri, radii, ulnas, right scapula and multiple vertebrae. Suggested differential diagnosis included metastatic disease, LCH, leukemia or infantile myofibromatosis, which prompted oncological evalution. CS was added late to the differential diagnosis. Further questioning then revealed that patient's mother had had syphilis during pregnancy with unknown treatment history. Further physical examination revealed multiple skin lesions and mucosal ulcers, rash, and blisters. Patient's treponemal Ig G was positive and he was treated with penicillin with RPR(Rapid Plasma Reagin) titer follow-up.

CS has a high fetal or perinatal mortality rate approaching 40%. However, most live infected newborns are asymptomatic. The common clinical presentation includes fever, rash, rhinitis, hepatosplenomegaly, anemia, jaundice and elevated liver enzymes. The common skeletal findings include periosteal reaction, metaphyseal lucent bands, widespread metaphyseal erosions; particularly characteristic (although not specific) is the Wimberger sign, which irefers to the bilateral destruction of the proximal medial tibial metaphyses with sparing of a few medial millimeters (Laval-Jeantet collar). Differential diagnosis of CS includes osteomyelitis, neuroblastoma/metastases, leukemia, infantile fibromatosis, NAT. Characteristic radiographic and clinical lesions will be presented with discussion of differential diagnoses.
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