- Clinical presentation of one or more ulcers or chancre;
AND
- Presence of one of the following:
- Detection and confirmation of Treponema pallidum in clinical specimens (e.g., chancre, regional lymph node) by appropriate laboratory techniques, such as dark-field microscopy, direct fluorescent antibody, or nucleic acid amplification test (NAAT);
OR
- Reactive treponemal serology (regardless of non-treponemal serology reactivity) in a case with no previous history of syphilis;
OR
- Four-fold or greater increase (e.g., 1:8 to 1:32) in titre over the last known non-treponemal test
- Clinical presentation of rash, fever, malaise, lymphadenopathy, mucous lesions, condyloma latum, alopecia, meningitis, headaches, uveitis, retinitis, or recent hearing impairment;
AND
- Presence of one of the following:
- Detection and confirmation of T. pallidum in clinical specimens (e.g., chancre, regional lymph node) by appropriate laboratory techniques, such as dark-field microscopy, direct fluorescent antibody, or nucleic acid amplification test (NAAT);
OR
- Reactive treponemal serology (regardless of non-treponemal serology reactivity) in a case with no previous history of syphilis;
OR
- Four-fold or greater increase in titre over the last known non-treponemal test
Note: The possibility of a prozone reaction should be considered in individuals who are suspected of having secondary syphilis but whose non-treponemal test is non-reactive. Neurological symptoms may be present.
- No signs or symptoms of primary or secondary syphilis
and either reactive treponemal serology (regardless of non-treponemal serology reactivity)
or four-fold or greater increase in titre over the last known non-treponemal test;
AND
- Presence of one of the following within the previous 12 months:
- non-reactive serology;
OR
- signs or symptoms suggestive of primary or secondary syphilis;
OR
- sexual exposure to a partner with primary, secondary, or early latent syphilis
- No signs or symptoms of primary or secondary syphilis
AND
- Either reactive treponemal serology (regardless of non-treponemal serology reactivity) or four-fold or greater increase in titre over the last known non-treponemal test
AND
- Last known sexual activity within the previous 12 months
AND
- Presence of one of the following within the previous 12 months:
- a titre at least or greater than 1:8 at time of diagnosis;
OR
- clinical suspicion of syphilis acquisition
- No signs or symptoms of primary or secondary syphilis;
AND
- Persistently reactive treponemal serology (regardless of non-treponemal serology reactivity);
AND
- Does not meet the case definition for confirmed early latent syphilis or latent syphilis of unknown duration;
AND
- Has not been previously treated for syphilis.
- Meets the case definition for any stage of syphilis;
OR
- Reactive treponemal serology (regardless of non-treponemal serology reactivity)
AND
- Presence of one of the following:
- reactive VDRL in non-bloody cerebrospinal fluid (CSF);
OR
- clinical evidence of neurosyphilis
and either elevated CSF leukocytes
or elevated CSF protein in the absence of other known causes
- Meets the case definition for any stage of syphilis;
OR
- Reactive treponemal serology (regardless of non-treponemal serology reactivity)
AND
- Clinical diagnosis of neurosyphilis, based on compatible clinical or laboratory findings, in the absence of other known causes
Early (infectious) neurosyphilis – diagnosis of neurosyphilis within 12 months after infection (i.e., neurosyphilis coincides with primary, secondary or early latent syphilis)
Late (non-infectious) neurosyphilis – diagnosis of neurosyphilis more than 12 months after infection
- Meets the case definition for any stage of syphilis;
OR
- Reactive treponemal serology (regardless of non-treponemal serology reactivity)
AND
- Clinical presentation of uveitis, retinitis or optic neuropathy in the absence of other known causes
- Reactive treponemal serology (regardless of non-treponemal serology reactivity);
AND
- Characteristic abnormalities of the cardiovascular system, bone, skin or other tissue [4], in the absence of other known causes
Laboratory confirmation of infection in a live birth:
- Identification of
Treponema pallidum by nucleic acid detection (PCR or equivalent), fluorescent antibody or equivalent examination of material in an appropriate clinical specimen (see Laboratory comments);
OR
- Reactive serology (non-treponemal
and treponemal) from venous blood (not cord blood) in an infant or in a child
with clinical, radiographic or other laboratory evidence of congenital syphilis;1
OR
- Infant's RPR titre at least fourfold higher than the mother/birthing parent's RPR titre in samples collected during the immediate postnatal period;
OR
- Persistent positive treponemal serology in a child older than 18 months of age;
AND
- Younger than two years of age at the time of meeting the criteria
and no other suspected source of exposure.
- Does not meet criteria for "Confirmed case: Early congenital syphilis" or "Confirmed case: Late congenital syphilis";
AND
- Reactive serology (non-treponemal
and/or treponemal) from venous blood (not umbilical cord blood) in an infant or in a child whose mother/birthing parent had untreated or inadequately treated2 syphilis prior to delivery;
AND- Younger than two years of age at the time of meeting the criteria
and no other suspected source of exposure.
Laboratory confirmation of infection in a live birth:
- Identification of
Treponema pallidum by nucleic acid detection (PCR or equivalent), fluorescent antibody or equivalent examination of material in an appropriate clinical specimen (see Laboratory comments);
OR
- Reactive serology (non-treponemal
and treponemal) from venous blood (not cord blood) in an infant or in a child
with clinical, radiographic or other laboratory evidence of congenital syphilis;1
OR
- Infant's RPR titre at least fourfold higher than the mother/birthing parent's RPR titre in samples collected during the immediate postnatal period;
OR
- Persistent positive treponemal serology in a child older than 18 months of age;
AND
- Two or more years of age at the time of meeting the criteria and no other suspected source of exposure.
- Does not meet criteria for "Confirmed case: Early congenital syphilis" or "Confirmed case: Late congenital syphilis";
AND- Reactive serology (non-treponemal and/or treponemal) from venous blood (not umbilical cord blood) in an infant or in a child whose mother/birthing parent had untreated or inadequately treated2 syphilis prior to delivery;
AND- Two or more years of age at the time of meeting the criteria and no other suspected source of exposure.
- A fetal death that occurs after 20 weeks' gestation or in which the fetal weight is greater than 500 g;
AND- Laboratory confirmation of infection [i.e., identification of Treponema pallidum by nucleic acid detection (PCR or equivalent), fluorescent antibody or equivalent examination of material in an appropriate clinical specimen (see Laboratory comments)].
- Does not meet criteria for "Confirmed case: Syphilitic stillbirth";
AND- A fetal death that occurs after 20 weeks' gestation or in which the fetal weight is greater than 500 g where the mother/birthing parent had untreated or inadequately treated syphilis prior to delivery;
AND- No other cause of stillbirth established.
- Meets the case definition for infectious syphilis (i.e., primary, secondary or early latent)
or late latent syphilis
AND
- Presence of one of the following:
- syphilis serology conducted as part of prenatal blood screening;
OR
- known to have given birth to an infant, live or stillborn, with congenital syphilis;
OR
- clinical presentation of infectious syphilis during pregnancy
- Reactive treponemal serology (regardless of non-treponemal serology reactivity) in an individual either with no previous history of syphilis
or four-fold or greater increase in titre over the last known non-treponemal test;
AND
- Follow-up to determine staging of syphilis is not complete
In addition to venous blood samples, appropriate clinical specimens for the diagnosis of congenital syphilis include nasal secretions, skin lesions, fluid from blisters or exudative skin rashes, placenta, umbilical cord, or autopsy clinical material. Cord blood should not be used for infant testing.
Syphilis serological results can be affected by the timing of maternal/birthing parent infection. If syphilis is acquired close to delivery, maternal/birthing parent and newborn serological tests may initially be negative. Reactive syphilis serological tests in an infant can represent infant infection or trans-placental passage of antibodies. In the absence of congenital infection, antibodies are expected to decline and clear by 18 months of age. Infant non-treponemal titres at least fourfold higher than maternal/ birthing parent titres (using the same non-treponemal test) at birth supports a diagnosis of congenital syphilis. A fourfold or greater rise in infant non-treponemal titre supports a diagnosis of congenital syphilis.
Includes any evidence of congenital syphilis such as any features suggestive of congenital syphilis on radiographs of long bones; reactive cerebrospinal fluid (CSF) venereal disease research laboratory (VDRL); an elevated CSF cell count or protein (without other cause); anemia; skeletal abnormalities (e.g., osteochondritis, saber shins); hepatosplenomegaly; skin rash; condylomata lata; rhinitis (snuffles); pseudoparalysis; meningitis; ascites; interstitial keratitis; lymphadenopathy; dental abnormalities (e.g., Hutchinson's teeth, mulberry molars); sensory neural hearing loss; intrauterine growth restriction; prematurity; or any other abnormality not better explained by an alternative diagnosis.
Adequate treatment is:
- treatment with penicillin therapy appropriate for the stage of syphilis infection that was completed at least 4 weeks before delivery; and
- sufficient reduction in maternal/birthing parent non-treponemal titres; and
- no evidence of reinfection.
A lack of verbal or written confirmation of treatment should be considered "inadequate treatment." Refer to current Canadian guidelines for additional information.
BCCDC has adopted modified federal case definitions for congenital syphilis as of February 2025. Early and late congenital stages now use the same criteria except for age: late congenital diagnoses apply to children two years and over, while early diagnoses apply to children under two years. “Probable case: late congenital syphilis” has not been diagnosed in BC as of February 2025 but is now an option in clinical report forms. Any future diagnoses of “Probable case: late congenital syphilis” will appear in reporting products.
- Syphilis is a complex sexually transmitted infection that has a highly variable clinical course. Classification by a clinician with expertise in syphilis may take precedence over the above case definitions developed for surveillance purposes.
- Treponemal test includes TP-PA, EIA, CIA or equivalent serologic methods.
- Non-treponemal test includes VDRL, RPR or equivalent serologic methods.
- T. pallidum is rarely seen in these lesions and is diagnostic when present although not required to meet the surveillance case definition.
- Clinical presentation includes any evidence of congenital syphilis on physical examination (e.g., skin lesions, lymphadenopathy, hepatosplenomegaly); on radiographs of long bones; a reactive CSF-VDRL; or an elevated CSF cell count or protein in the absence of other known causes. Note that neonates may not display clinical manifestations of congenital syphilis thus may only meet laboratory criteria.
For more information on the case definition of syphilis, please refer to the
Technical Appendix of the annual STI surveillance reports.
