A 2-month-old female was seen in our emergency department for evaluation of a congenital infection. During pregnancy, mother was routinely screened for human immunodeficiency virus (HIV) and syphilis in the first trimester and tests results were negative. Throughout the entire pregnancy, mother had regular prenatal care at scheduled visits. She presented to her obstetrician at 28 weeks gestation with generalized skin lesions on palms and soles, as well as a painless lesion in her genital area. At both the 28-week and 36-week prenatal visits, she was referred to dermatology, and mother was subsequently treated with topical hydrocortisone cream. No further workup was done. Two months after delivery, mother followed up with her primary care provider due to lack of resolution of skin lesions. At that time, a sexually transmitted infection was suspected and mother was tested for syphilis, and rapid plasma reagin (RPR) came back positive at 1:128. Infant was referred for further workup.On presentation, physical exam of the infant was significant for desquamation of the skin on the bilateral soles of her feet, pinpoint pink dots on the soles of her feet bilaterally, and a erythematous skin lesion 1 × 1 cm on her right medial knee. Mother did report that infant was not moving her left leg. Infant did not exhibit any neurological deficits on physical exam. Significant laboratory findings included slight anemia, hemoglobin of 8.9 g/dL, and hematocrit of 26.5%. Further workup for congenital infection was done including lumbar puncture. All findings in the cerebrospinal fluid in this patient were within normal limits, including normal cell count, glucose, and protein. Venereal disease research laboratory (VDRL) tests was negative as well. Long-bone radiographs were also done, which were significant for osteochondritis and periostitis. This was seen in the medial metaphysis of the proximal left tibia and distal left femur (Figure 1A), the metaphysis of the medial right proximal tibia, and in the distal left ulnar metaphysis (Figure 2A).

There is a common narrative among interns and residents. We work crazy hours. We often feel like we're in over our heads and don't know what we're doing. And yet, somehow, we are expected to be taking good care of very sick patients, among the sickest in our cities. While being a first-year intern is well understood to be overwhelming, one of the most significant challenges is rarely discussed and confronted: that our patients, especially in distressed environments, have urgent nonmedical problems that stem from systemic injustices.