• congenital syphilis
• prenatal intervention

The changes in political, economic, and social life in the eastern European countries—that is, greater group mobility, substanial rise in travel activity, changes of the sexual behaviour are all related to the increased syphilis morbidity.^1,2 There has been a sevenfold increase in the syphilis morbidity in Bulgaria in 1999 compared with 1990—that is, 2628 v 378 diagnosed cases respectively,³ in 2000 there were 1605 cases. An increased number of syphilis patients among adults, and especially among pregnant women, reflected the growing incidence of congenital syphilis. The incidence of congenital syphilis in Bulgaria increased from one case in 1990 to 31 in 2000. This is observed as one of the most alarming trends in morbidity.

We report four infants with congenital syphilis—a 20 day old male infant, two male newborns, and a 2 month old female. The children were in quite a bad condition. They presented with disseminated maculous (case 4), erythemosquamous and haemorrhagic (case 1), bullous and papulosquamous lesions, and prematurity (cases 2 and 3), rhinitis, jaundice, oedema of the lids and abdomen (case 1, 2, and 3), and hepatosplenomegaly. Case 2 had asphyxia perinatalis, bradypnoea, bradycardia, atelectases pulmonum, hypothermia, respiratory acidosis with hypoxaemia, and neurological symptoms. Osteochondritis of the long bones on x ray was found in cases 1, 2, and 3. Patient 4 had pseudoparalysis Parrot (the roentgenogram of the upper right extremity showed typical changes in the distal metaphysis of the humerus and the proximal metaphysis of the radius). Severe anaemia, leucocytosis, thrombocytopenia, elevated erythrocyte sedimentation rate, hypoproteinaemia, hypoalbuminaemia, hyperbilirubinaemia, elevated ASAT, ALAT, and LDH were noted in cases 1, 2, 3. The TFS of patient 1 revealed features of vasculitis. The serological blood tests (VDRL, TPHA, IgM-FTA ABS, IgG-FTA ABS) were positive, but CSF tests were negative. The children were treated with penicillin successfully. The mothers of the children had positive syphilis serology; they have not been treated for syphilis.

Congenital syphilis is a serious disease, whose clinical spectrum ranges from asymptomatic infection to fulminate sepsis or death.⁴ But many cases could be prevented with early and adequate prenatal care. Pregnant mothers have to be examined routinely twice during pregnancy in the first and early third trimester as well as immediately after delivery (umbilical blood sample). Unfortunately, these rules are often not followed. The reduced or absent serological screening in pregnant mothers (as in our cases) is common. The mothers of cases 1 and 3 have not been tested at delivery. A general Lues serodiagnostic test is recommended in all newborns before they leave the obstetric departments.

Some authors found that the longest delay was the time at the laboratory⁵ as in case 1. (The mother was negative in the first trimester of pregnancy, became positive in the late third trimester, but the results came too late—after delivery.) Improved laboratory services will solve this problem.

Patients have often been treated by non-venereologists without contact tracing, like the father of case 1, and his diagnosis and therapy were not adequate. With regard to confidentiality patients often receive non-professional treatment or undergo self treatment.

Unfortunately, the difficulty in dealing with patients having a poor educational background and insufficient sexual knowledge results in the impossibility to find all the sources of infection. The parents of patient 2 did not seek medical help, although the father had penis lesion. The mother did not visit a doctor after she was pregnant. Even her labour was at home, as it was in the mother of case 4.

Another big problem is prostitution, which is not legal and cannot be controlled in our country.⁶ The mothers of patients 3 and 4 were prostitutes, who did not seek medical assistance at all.

More than half of our patients are unable to indicate the name or address of the contacts (the father of case 1 and the mothers of cases 2, 3, 4), thus demonstrating the high frequency of occasional sexual contacts and the lack of protective measures.

The government health system has existed in Bulgaria for more than 50 years but social and economic changes require a new insurance system and new approaches concerning STDs. The system for notification of STD patients should be improved in order to ensure a higher confidentiality. The reported cases also emphasise the necessity of cooperation between dermatologists, obstetricians, neonatologists, and paediatricians.