INSIGHTS AND IMAGES

A Neonate with Unexplained Hair Loss

A
4-month-old girl presented with a 2-week history of
patchy hair loss on her scalp; parents reported that
her scalp hair began shedding while bathing. The pa-
tient had received intermittent treatment with topical gluco-
corticoids following a clinical diagnosis of neonatal occipital
alopecia, but the hair loss did not improve. Physical examina-
tion revealed patchy, irregular, “moth-eaten” patches of alo-
pecia over the entire scalp (Figure, A). No erythematous
macules with subtle scales were present on her truck,
extremities, palms, or soles. The patient did not exhibit the
characteristic syphilitic facies, but manifested abdominal
Figure. Clinical picture and radiograph result. A, “Moth-
distention with hepatomegaly and splenomegaly. eaten” patches of alopecia on the whole scalp of the patient.
Laboratory tests revealed a rapid plasma reagin titer of B, Radiographs showed cortical thickening of the humerus,
1:256, a positive antinuclear antibody of 1:320, and the ulna, and radius as well as the “onion skin” sign (white arrow).
result of Treponema pallidum hemagglutination test was
positive. Although a cerebrospinal fluid culture was
negative, the infant’s cerebrospinal fluid venereal disease transmission of treponemes to her child, which then became
research laboratory test was reactive. A test for HIV localized to the child’s hair follicle. Because T pallidum di-
antibodies was negative. Radiographs revealed cortical vides more slowly than most bacteria, maintenance of peni-
thickening of the humerus, ulna, and radius as well as the cillin levels in the blood for at least 10-14 days is necessary.
“onion skin” sign (Figure, B). Diagnosis of congenital Despite the protean nature of congenital syphilis, this is not
syphilis was made, and the patient was treated with usually associated with hair loss.4 n
intravenous penicillin G at 50 000 units/kg/dose every
8 hours for 14 days. The patient’s mother and father had
no history of any sexually transmitted disease, and they We thank Lin Pang, MD and Yang Zhao, MD, from the Pediatric
Department of Beijing Ditan Hospital, Capital Medical University.
denied any recent sexual activity or history of external
We also thank the patient and her parents.
mouth ulcers. They were referred to the dermatology
department and received a diagnosis of syphilis with a Bin Zhang, MD
positive confirmatory test for antibodies to T pallidum. The Li Wei, MD
rapid plasma reagin titer of the patient’s mother and father Lin Ma, MD
was 1:8 and 1:32, respectively. Both parents received a Department of Dermatology
single intramuscular injection of penicillin G benzathine. Beijing Children’s Hospital
Congenital syphilis is caused by transmission of the spiro- Capital Medical University (National Center for Children’s
chete T pallidum from the mother to the fetus, resulting in a Health, China), Beijing, China
multitude of clinical presentations including hepatospleno-
megaly, skeletal deformities such as osteochondritis of long References
bones, hematologic disturbances, and mucocutaneous fea-
tures such as maculopapular rash, palmar/planar bullous or 1. The Lancet. Congenital syphilis in the USA. Lancet 2018;392:1168.
desquamative dermatitis, and mucous patches; stillbirth 2. Dai S, Wang H, Lin Z. Moth-eaten alopecia in secondary syphilis. Int J
Infect Dis 2019;23:6.
may even occur.1 “Moth-eaten” alopecia has mostly been 3. Moshiri AS, Moxam A. Syphilitic alopecia. N Engl J Med 2018;379:1657.
described in conjunction with secondary syphilis.2,3 In the 4. Reddy S, Bushore D, Levy A, Skinner RB Jr. Pediatr Dermatol 2006;23:
present case, the mother’s untreated syphilis resulted in 564-6.

Supported in part by the Special Fund of the Pediatric Medical Coordinated Development
Center of Beijing Municipal Administration of Hospitals (No.XTZD20180502) and the Na-
tional Natural Science Foundation of China (No.81673042). The authors declare no con-
flicts of interest.

J Pediatr 2019;212:240.
0022-3476/$ - see front matter. ª 2019 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jpeds.2019.04.050

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