Missed opportunities and near-miss diagnoses in congenital syphilis: A case series of five infants at a tertiary care centre in Nepal.

Congenital syphilis remains a preventable but underrecognized condition in Nepal, where routine antenatal screening is limited to the first visit. We report five infants with diverse clinical manifestations, including hydrops fetalis, bullous lesions, bone involvement, and persistent rhinitis. Four were classified as highly probable and one as possible congenital syphilis according to the 2021 CDC criteria. Four mothers had initially negative screening results, highlighting the possibility of infection acquired later in pregnancy. Due to penicillin unavailability, all infants received ceftriaxone despite limited supporting evidence. The cases emphasize the importance of appropriate repeat maternal testing, follow-up and treatment of seropositive mothers, systematic infant evaluation, and reliable access to penicillin.