Congenital syphilis still occurs in newborn babies and the prevalence has increased in recent years, especially in developing countries. This has led to an increase in the number of babies with congenital syphilis requiring intensive care for respiratory failure. The early recognition of this disease could lead to the institution of timely and appropriate treatment. In this study the radiological picture of syphilitic pneumonitis is described in 20 neonates admitted to our neonatal intensive care unit requiring ventilation for respiratory failure. The radiological picture of the babies with syphilis was compared to 20 babies with other causes of respiratory distress. The radiological picture in 17 babies demonstrated a coarse nodular pattern in addition to band-like opacities radiating from the hilar regions. The nodular opacities became confluent on follow-up radiographs. In 13 cases, the proximal humeri showed changes typical of congenital syphilis. Two of the three babies with syphilis who did not have the typical chest radiological picture had bony involvement visible on the chest radiograph. Both the sensitivity and specificity of radiographic diagnosis were 75% with a positive and negative predictive value of 75%. The diagnosis of congenital syphilitic pneumonitis can therefore be suspected on chest radiographs and should be included in the differential diagnosis of any baby who presents with an interstitial pattern on chest radiography.