514 HY Kim, et al. • Early congenital syphilis presenting with skin eruption alone elevated slowly to 5.6 g/dL with albumin 4 g/dL. His parents were also recommends identification of syphilis in the mother; lack of evidence treated with benzathine penicillin G. The patient was 5 month olds of adequate maternal treatment; presence of clinical, laboratory or at the last visit and his physical examination was normal, including radiological evidence of syphilis in the infant; and comparison of neurologic examination. In addition, the baby showed a reduction in maternal and infant non-treponemal serologic titers using the same seroreactivity from 1:32 to 1:8 dilutions. Discussion test and preferably the same laboratory, as was conducted in this case13). In addition, The CDC recommends serologic VDRL testing of pregnant women during the first prenatal visit and additional serologic testing and evaluation of sexual history at 28 weeks of gestation and This 3-month-old infant presented only with skin eruption, which soon after delivery in communities in which there is a high risk of led to difficulty in diagnosis. Several physicians could not establish what congenital syphilis13). his illness was, and his symptoms were misinterpreted as adverse Congenital syphilis is a preventable and treatable disease if physicians reactions caused by DTaP vaccination. In addition, the maternal self are aware of its diverse clinical symptoms. Therefore, clinical suspicion report that she was VDRL-negative caused a further delay in diagnosis of and formal confirmation of antenatal screening results as well as a the patient. Diagnosis of early congenital syphilis is difficult because detailed maternal history provide important clues for the diagnosis of more than half of the infants are asymptomatic, and signs in sympto- congenital syphilis. matic infants may be subtle and nonspecific4). We found a report of an infant with a skin rash whose mother had adequate prenatal care, similar to our patient2). If diagnosis is missed, death may result, despite the fact that syphilis is a very easy and inexpensive disease to treat5). Congenital syphilis occurs whenT. pallidum crosses the placenta from the mother to the fetus during pregnancy or by contact with an infectious lesion during birth6). Manifestations of congenital syphilis are divided into early and late signs based on the first 2 years of life. Mucocutaneous involvement is present in as many as 70 percent of infants and may be apparent at birth or develop during the first few weeks of life6). Cutaneous findings of early congenital syphilis is classically a vesiculobullous or maculopapular rash on the palms and soles and may be associated with desquamation7). Other types of rashes such as erythema multiforme have also been reported7,8). In addition, symptoms of early congenital syphilis include fever, failure to thrive, hepatosplenomegaly, lymphadenopathy, osteochondritis, pneumonitis, and rhinitis6). Leukocytosis, Coombs- negative hemolytic anemia, thrombocytopenia, hypoproteinemia, hypoalbuminemia, hyperbilirubinemia, and elevated liver enzyme levels may be present6,9). Because these laboratory findings are difficult to identify upon physical examination, a high index of suspicion is necessarytomaketherightdiagnosisearly.Althoughacraldermatitis, vitamin or nutrient deficiency, and hand eczema might mimic this disorder, skin rash of early congenital syphilis is relatively recalcitrant to classical eczema treatment, which might be differential diagnostic point10,11). Characteristic mucocutaneous rash, presenting with erythematous maculopapular or bullous lesions, followed by desquamation involving hands and feet, are common in congenital syphilis12). For definitive diagnosis, the Centers for Disease Control (CDC) References 1. Walker GJ, Walker DG. Congenital syphilis: a continuing but neglected problem. Semin Fetal Neonatal Med 2007;12:198-206. 2. Lugo A, Sanchez S, Sanchez JL. Congenital syphilis. Pediatr Dermatol 2006;23:121-3. 3. Park HJ. Clinical observation and statistical consideration of syphilis (2000-2007). Korean J Dermatol 2008;46:1344-52. 4. Fan P, Fu M, Liao W, Luan Q, Hu X, Gao T, et al. Early congenital syphilis presented with exclusive bending pain of extremity: case report. J Dermatol 2007;34:214-6. 5. Simmank KC, Pettifor JM. Unusual presentation of congenital syphilis. Ann Trop Paediatr 2000;20:105-7. 6. Woods CR. Syphilis in children: congenital and acquired. Semin Pediatr Infect Dis 2005;16:245-57. 7. Chakraborty R, Luck S. Syphilis is on the increase: the implications for child health. Arch Dis Child 2008;93:105-9. 8. Sangtawesin V, Lertsutthiwong W, Kanjanapattanakul W, Khorana M, Horpaopan S. Outcome of maternal syphilis at Rajavithi hospital on off- springs. J Med Assoc Thai 2005;88:1519-25. 9. Chudomirova K, Mihajlova E, Ivanov I, Lasarov S, Stefanova P. Congenital syphilis: missed opportunities for prenatal intervention. Sex Transm Infect 2002;78:224-5. 10. Ferri FF. Ferri’s clinical advisor 2011. Philadelphia: Mosby Elsevier, 2010: 431-60. 11. Habif TP. Vesicular and bullous diseases. In: Habif TP, editor. Clinical dermatology. 5th ed. Edinburgh: Mosby Elsevier, 2009;635-70. 12. Azimi P. Syphilis (Treponema pallidum ). In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, editors. Nelson textbook of pediatrics. 18th ed. Philadelphia: Saunders Elsevier, 2007:1263-9. 13. From the Centers for Disease Control and Prevention. Congenital syphilis: United States, 2000. JAMA 2001;286:529-30.