An infant with seizures, rash, and hepatosplenomegaly.

(See pages 451–2 for the Photo Quiz) Figure 2. Scalp of the infant, showing crusted erythematous erosion following a ruptured bullae. Figure 1. Scaly, erythematous erosions with collaretes of crust and numerous bullae covering the entire lower limbs of the neonate. Diagnosis: congenital syphilis. The infant's rapid plasma reagin test was reactive at a titer of 1:256 dilutions; a Treponema pallidum particle agglutination assay and fluorescent treponemal antibody absorption test were also reactive. A CSF sample that was obtained after the patient had received 4 days of antibiotics revealed a WBC count of 6 cells/mm 3 (7% polymorphonuclear cells, 70% lymphocytes, and 23% monocytes and macrophages), an RBC count of 32 cells/ mm 3 , a protein level of 0.43 g/L, and a glucose level of 2.2 mmol/L; a Venereal Disease Research Laboratory test was non-reactive. Long-bone radiographs and MRIs of the brain had normal findings. The patient was treated with penicillin G for 10 days. The rash (figures 1–3) had improved markedly at the time of hospital discharge, but the patient was still requiring supplemental nasogastric feeds because of a poor suck. A follow up rapid plasma reagin test that was performed 3 months after initiation of therapy was reactive at a titer of 1:8 dilutions. The mother reported a history of having a macular rash on her trunk, upper extremities, and the dorsum of her hands 1 month postpartum. During her child's hospitalization, the mother had a rapid plasma reagin test that was reactive at 1: 128 dilutions, as well as a reactive T. pallidum particle agglu-tination assay and fluorescent treponemal antibody absorption test; she received a diagnosis of secondary syphilis, with her infection clearly having been acquired during pregnancy. Approximately 60% of infants with congenital syphilis are asymptomatic at birth [1]. Early manifestations typically occur at 2–13 weeks of age but can occur at up to 2 years of age, with more than one-half of cases involving a rash [2, 3]. Der-matologic manifestations range from desquamation alone to a generalized maculopapular rash (often presenting as bright red, raised, palpable lesions that gradually fade), mucous patches, papulosquamous lesions (especially on the palms and soles), or vesicobullous lesions. Syphilitic pemphigus is a term that refers to an increasingly rare and uniquely neonatal vesicob-ullous rash that is located primarily on the palms and soles and consists of dark red papules that evolve into bullae teeming with treponemes; the bullae are …