The Utility of Cerebrospinal Fluid Analysis in Guiding Management of Infants Exposed to Syphilis in Utero

Syphilis is re-emerging, with recent increases in congenital infections. While cerebrospinal fluid (CSF) evaluation can inform management, specimen collection requires technical skill and the interpretation of indices is nuanced. We sought to understand the practical value of CSF indices as an evaluation tool among neonates exposed to syphilis in utero.

We performed chart reviews of infants <30 days old born to birthing parents with syphilis infection, delivered between January 2000 and October 2020. Syphilis evaluation and treatment information for birthing parents and infants were abstracted. Infants were categorized per the Centers for Disease Control and Prevention congenital syphilis (CS) scenarios. CSF indices and other evaluation test results were described by scenario.

One hundred nine infants met the inclusion criteria. The overall lumbar puncture success rate was 59.7%. Among scenario 2 infants, 45.2% received 10 days of intravenous therapy due to an unsuccessful, uninterpretable or incomplete CSF evaluation. All infants with proven or highly probable CS (scenario 1) had ≥1 CSF abnormality compared with 35.1% of infants with possible CS (scenario 2; P = 0.0009; the Fisher exact test). All abnormal CSF results, inclusive of scenario 1 and 2 infants, had an elevated protein (≥119 mg/dL). Among those with elevated protein, 72.2% had either an abnormal Venereal Disease Research Laboratory, white blood cell counts (≥20 white blood cell counts/mm 3 ) or both. Among scenario 2 infants, 16.6% were indicated for intravenous therapy according to a non-CSF test result.

Several practice changes can be considered: a stepwise evaluation starting with less invasive procedures, prioritizing protein when CSF volume is low and implementing strategies to optimize successful CSF collection.