German guidelines on the diagnosis and treatment of neurosyphilis

Abstract

Introduction In view of the importance of neurosyphilis and the difficulties encountered in diagnosing it, the S1 guideline “Neurosyphilis” has been published by the German Society for Neurology (DGN) in accordance with the stipulations of the Association of the Scientific Medical Societies in Germany (AWMF). The present article is an abridged translation of that German guideline. Main recommendations (a) Neurosyphilis can manifest as early neurosyphilis (meningitis, meningovascular neurosyphilis or syphilitic gummas) or late neurosyphilis (tabes dorsalis, general paresis). (b) The following diagnostic criteria help to establish the presence of probable neurosyphilis (always point iv, accompanied by any two of points i to iii): (i) subacute or chronic neuro-psychiatric symptoms; (ii) increased cerebrospinal fluid (CSF) cell count or signs of blood–CSF barrier disruption; (iii) positive effect of anti-neurosyphilis antibiotic therapy on clinical course and CSF findings; (iv) positive TPHA/TPPA or FTA test in serum. (c) The diagnosis of neurosyphilis is confirmed by the subsequent detection of intrathecal production of antibodies against Treponema pallidum. (d) In neurosyphilis, treatment with intravenous penicillin or ceftriaxone for 14 days is recommended. (e) The following parameters can be used to assess a therapeutic effect: clinical findings, serum VDRL, and CSF cell count. Conclusion The German guideline on the diagnosis and treatment of neurosyphilis is a practical tool to support clinicians in diagnosing and treating patients with neurosyphilis. This article is an abridged translation of this guideline (Klein MW, J.; Angstwurm, K.; Esser, S.; Hahn, K.; Matschke, M.; Scheithauer, S.; Schoefer, H.; Sturzenegger, M.; Wildemann, B. Neurosyphilis, S1-Leitlinie. Deutsche Gesellschaft für Neurologie, Leitlinien für Diagnostik und Thearpie in der Neurologie 2020).

A case of neurosyphilis with psychosis and hippocampal atrophy

“…Coinfections with HIV, chlamydia, gonococci, hepatitis B and hepatitis C can occur, so they should be ruled out. 3 …”

“…Fortunately, the prognosis of neurosyphilis has improved significantly in recent decades due to rapid and adequate antibiotic treatment. 3 It is crucial for clinicians to diagnose and treat those affected with neurosyphilis because of the potentially irreversible complications it can cause. In addition, the scientific community should create diagnostic criteria and tools that are universally acceptable.…”

“…Coinfections with HIV, chlamydia, gonococci, hepatitis B and hepatitis C can occur, so they should be ruled out. 3 The patient was given parenteral procaine penicillin, oral probenecid and steroids. Alternative antibiotic regimes that can be given include benzylpenicillin 1.8-2.4 g intravenously every 4 hours for 14 days, doxycycline 200 mg orally two times per day for 28 days, amoxicillin 2 g orally three times per day for 28 days and ceftriaxone 2 g via the parenteral route for 10-14 days.…”

“…However, the low incidence with syphilis infection suggests that spontaneous healing is possible. 3 Early neurosyphilis can present as meningitis, meningovascular syphilis or asymptomatic neurosyphilis. Late neurosyphilis can appear as paretic neurosyphilis (general paresis), dementia and tabes dorsalis characterised by sensory ataxia, peripheral neuropathy and cranial nerve lesions.…”

“…In addition, neurosyphilis may develop during any stage after the initial exposure to syphilis, often manifesting years or even decades later. However, the low incidence with syphilis infection suggests that spontaneous healing is possible 3. Early neurosyphilis can present as meningitis, meningovascular syphilis or asymptomatic neurosyphilis.…”