|Year : 2015 | Volume
| Issue : 3 | Page : 193-195
A tryst with a dysmorphic parturient with congenital syphilis
Madhuri S Kurdi1, Kaushic A Theerth1, Jagadish G Sutagatti2, Ashwini Halesh3
1 Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, India
2 Department of Radiodiagnosis, Karnataka Institute of Medical Sciences, Hubli, India
3 Department of Anaesthesiology, Narayana Hrudayalaya Hospitals, Bengaluru, Karnataka, India
|Date of Web Publication||12-Mar-2015|
Madhuri S Kurdi
Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kurdi MS, Theerth KA, Sutagatti JG, Halesh A. A tryst with a dysmorphic parturient with congenital syphilis. Indian J Anaesth 2015;59:193-5
|How to cite this URL:|
Kurdi MS, Theerth KA, Sutagatti JG, Halesh A. A tryst with a dysmorphic parturient with congenital syphilis. Indian J Anaesth [serial online] 2015 [cited 2020 Aug 4];59:193-5. Available from: http://www.ijaweb.org/text.asp?2015/59/3/193/153045
| Introduction|| |
Syphilis is a spirochetal infection classified as congenital or acquired. There are four stages of syphilis - primary, secondary, latent and late. As a disease, it has been forgotten by most anaesthesiologists. However, it has of late suddenly re-emerged.  We report here our experience of anaesthetising a seriously dysmorphic patient of late congenital syphilis.
| Case report|| |
A 35-year-old unregistered poorly communicative primigravida from a low socioeconomic, tribal community with an obstructed labour presented for an emergency caesarean section. She had a dysmorphic scarred face, short, weak body and limb contractures [Figure 1]. The attender gave a history of some swelling on the face in childhood followed by facial and limb deformities.
Examination of her face revealed nasal cartilage atrophy, absent nasal bridge and a fistula over the area, single nasal cavity, absent nasal tip, columella and septum. The nasal floor had a midline cleft up to the soft palate such that the hard palate appeared nearly absent. The soft palate appeared contracted. The upper central, lateral incisors and canines were absent [Figure 2]. The lower jaw appeared protruded. Mouth opening and neck movements were normal. Purulent discharge was seen from the right ear. The forehead appeared prominent. There was anterior bowing of both tibia. Right wrist was fixed in palmar flexion. Right foot had equino-varus deformity. Height and weight could not be measured. Remaining systems and spine appeared unremarkable. Her blood pressure (BP) was 126/84 mm of Hg, pulse rate was 110/min and haemoglobin was 12 g/dL. Electrocardiography revealed sinus tachycardia. Human immunodeficiency virus and venereal diseases research laboratory tests were negative. It was decided to administer subarachnoid block to the patient.
Equipment for tackling a difficult airway was kept ready. After intravenous preloading, subarachnoid block was administered with 1.2 ml of 0.5% hyperbaric bupivacaine and the patient in left lateral position. An upper level of sensory block up to T3 dermatome was achieved. A stillborn baby was extracted and oxytocin infusion was started. BP decreased to 70/50 mm of Hg. Intravenous fluids and increments of intravenous ephedrine were ineffective in improving the BP and dopamine drip was started. The approximate blood loss was 800 ml. She was Shifted to the (ICU) with a pulse rate of 130/min, BP 80/56 mm of Hg on dopamine support. Echocardiography was normal. The patient stabilized over the next 3 hours and dopamine was tapered off.
Post-operatively, ophthalmological examination revealed small corneal opacities in left eye. Examination of ears revealed right ear chronic suppurative otitis media with conductive deafness and bilateral sensorineural deafness. Rapid plasma reagin test was negative. Fluorescent treponemal antibody absorption (FTA-ABS) test could not be done due to non-availability.
| Discussion|| |
The classical stigmata of syphilis are Hutchinson's incisors, interstitial keratitis, 8 th nerve deafness, anterior bowing of mid portion of tibia (sabre shins), forehead prominence, otitis media, saddle nose and corneal opacities.  Gummas involving nose, septum and hard palate are characteristic of late congenital syphilis.  They can cause palatal destruction and perforation. 
The current patient had gaps in the nose and hard palate with a history of some swelling in that area in childhood, thus suggesting erosion by gummas [Figure 2]. Hutchinson's incisors that are characteristic of late congenital syphilis could not be made out because the upper jaw teeth were missing. Maxillary maldevelopment with bulldog face, otitis media, neural deafness, bowing of legs and corneal opacities all supported our clinical diagnosis of congenital syphilis.
The standard serological testing may be negative when patients are treated appropriately, but the FTA-ABS test is positive.  Our patient was probably a treated case and non-infective.
There is little specific advice available on the anaesthetic management of patients with syphilis.  A case of a 73-year-old lady with congenital pharyngo-laryngeal syphilis with a potentially difficult intubation during the induction of general anaesthesia has been reported.  Craniofacial abnormalities such as frontal bossing, depressed nasal bridge and maxillary hypoplasia can lead to difficulty in mask ventilation, glottis opening visualisation and intubation.  The anatomical features of our patient like short stature, nasal and hard palate abnormalities and protruding lower jaw alerted us to potential problems in airway management and general anaesthesia. Epidural anaesthesia would have permitted titration of local anaesthetic to achieve the desired sensory level of blockade, but her anatomical problems, anxiety and discomfort would have made it difficult for her to remain positioned for epidural placement. Spinal anaesthesia is another preferred technique for emergency caesarean section. Some authors have demonstrated that within commonly encountered ranges in parturient of age between 20 and 42 years, height between 146.9 and 174 cm, weight between 55.5 and 136.4 kg, body mass index between 19.2 and 50 kg/m 2 and vertebral column length between 49.6 and 67 cm, the patient variables of age, height, weight, body mass index and vertebral column length do not correlate with the spread of sensory blockade.  However, in situations of uncommonly short stature, the spinal anaesthetic dosing must be adjusted.  Our patient was of very short stature and her exact height was not measurable because of her limb deformities. Furthermore, we could not measure the height pre-operatively due to patient non-cooperation and our ignorance regarding height measurement in patients with limb disabilities. Post-operatively, we found out that surrogate methods like 'demispan' can estimate height in patients with mobility disorders.  According to demispan, our patient's height measured was 118.15 cm. Dosage recommendations according to height are not very clear in parturients. We chose a volume of 1.2 ml and the patient had sensory blockade up to T3 and prolonged hypotension probably because of sympathetic blockade or the oxytocin.
| Conclusion|| |
Syphilis can lead to gross dysmorphism and pose challenges in anaesthetic management including airway and positioning problems. In a short statured dysmorphic parturient with contractures, problems in height measurement and dose estimation of subarachnoid local anaesthetic can arise. Hence, every practising anaesthesiologist must be well-versed with various methods of height measurement and be able to suitably tailor local anaesthetic dosage.
| References|| |
Oswal S, Lyons G. Syphilis in pregnancy. Continuing education in anaesthesia. Crit Care Pain 2008;8:224-7. Available from: http://www.ceaccp.oxfordjournals.org/.[Last accessed on 2014 Jul 12].
Singhal P, Patel P, Marfatia YS. A case of congenital syphilis with Hutchinson's triad. Indian J Sex Transm Dis 2011;32:34-6.
Caserta JM. Congenital syphilis. In: Porter RS, Kaplan JL, editors. The Merck Manual for Health Care Professionals. USA: Merck Sharp and Dohme Corporation. Available from: http://www.merckmanuals.com/./congenital-syphilis.html. [Last accessed on 2014 Feb 24].
Lacy PD, Alderson DJ, Parker AJ. Late congenital syphilis of the larynx and pharynx presenting at endotracheal intubation. J Laryngol Otol 1994;108:688-9.
Saxena KN, Kapoor D, Taneja B, Maini L, Hora S. Anaesthetic management of caeserean section in an achondroplastic dwarf. Indian J Anaesth 2008;52:844-8.
Norris MC. Patient variables and the subarachnoid spread of hyperbaric bupivacaine in the term parturient. Anesthesiology 1990;72:478-82.
Harten JM, Boyne I, Hannah P, Varveris D, Brown A. Effects of a height and weight adjusted dose of local anaesthetic for spinal anaesthesia for elective Caesarean section. Anaesthesia 2005;60:348-53.
Hickson M, Frost G. A comparison of three methods for estimating height in the acutely ill elderly population. J Hum Nutr Diet 2003;16:13-20.
[Figure 1], [Figure 2]