Congenital syphilis in neonates: Persistent diagnostic and treatment challenges in resource-limited settings.

Despite available guidelines, congenital syphilis (CS) continues to burden low- and middle-income countries (LMICs), with failures occurring across multiple points. Two prior case reports from India described symptomatic infants with delayed diagnoses resulting from absent or ignored antenatal screening. We add five neonates identified prospectively at birth at a tertiary care centre in northern India (September 2024-January 2026), born to mothers with reactive syphilis serology. All were asymptomatic, but maternal treatment was adequate in only two cases. Neonatal RPR was reactive in one infant only. Based on CDC criteria, one neonate was classified as highly probable CS, three as possible, and one as less likely. Limited availability of aqueous crystalline penicillin necessitated benzathine penicillin use in all cases, and one infant left against medical advice. Together, these series map recurring, correctable failures across the entire CS prevention cascade in LMICs.