Neurosyphilis

Abstract

PURPOSE OF REVIEW: This article focuses on the epidemiology, clinical presentation, diagnosis, and management of neurosyphilis, with an emphasis on clinically relevant issues faced by the practicing neurologist.RECENT FINDINGS: The incidence of primary and secondary syphilis, the sexually transmissible stages of infection, has been on the rise for the past 2 decades. A concerning recent trend is the surge in cases of syphilis in women and of congenital syphilis. Neurosyphilis remains a relatively common complication that can occur at any stage of syphilis. Along with meningitis, meningovascular syphilis, which has been historically described as a late presentation of neurosyphilis, now frequently occurs as a manifestation of early infection. Late forms of neurosyphilis, including tabes dorsalis and general paresis, are less prevalent in the era of widespread penicillin use. As more laboratories adopt the reverse-sequence algorithm for syphilis testing, patients with serodiscordant results (ie, a reactive serum treponemal test with a nonreactive nontreponemal test) may present an increasingly encountered diagnostic challenge for neurologists. Although the CSF Venereal Disease Research Laboratory (VDRL) remains a mainstay of diagnostic testing for neurosyphilis, using a higher titer cutoff (greater than 1:320) for the Treponema pallidum particle agglutination assay (TPPA) from the CSF may improve the utility of the TPPA as a supporting criterion for the diagnosis of neurosyphilis. Penicillin G is the treatment of choice for neurosyphilis, although ceftriaxone may be a reasonable alternative therapy. SUMMARY: A high index of suspicion and awareness of the variable clinical presentations of neurosyphilis are essential to the approach to this treatable infection. Neurologists should be mindful of the limitations of serologic testing in the diagnosis of neurosyphilis and exercise clinical judgment to determine the likelihood of the diagnosis.

The Clinical Characteristics and Serological Outcomes of Infants With Confirmed or Suspected Congenital Syphilis in Shanghai, China: A Hospital-Based Study

“…The diagnosis of congenital neurosyphilis is difficult to establish since the majority of infants with CS do not manifest any abnormalities on neurologic examination ( 31 ). Currently, central nervous system invasion by T. pallidum is usually inferred from CSF abnormalities, such as reactive VDRL, pleocytosis, and elevated protein levels ( 32 ). Although a positive VDRL in CSF is considered specific for neurosyphilis, it has limited sensitivity ( 33 – 35 ).…”

Serum Interleukin-26 is a Potential Biomarker for the Differential Diagnosis of Neurosyphilis and Syphilis at Other Stages

“… 18 Neurosyphilis can occur at any stage of syphilis, not just in tertiary syphilis, and its clinical manifestations are misleading, generating a high probability of missed detection and misdiagnosis as mental or neurological diseases during the process of initial differential diagnosis. 19 In the current diagnostic guidelines, the most important laboratory confirmation standard for neurosyphilis is positive serum syphilis antibody accompanied by cerebrospinal fluid abnormalities of pleocytosis and elevated cerebrospinal fluid protein levels or positive CSF VRDL test results. It also includes signs and symptoms of neurosyphilis with other clinical causes of such manifestations being excluded.…”

Treatment Challenges in a Severe Case of Syphilitic Myelitis With a Longitudinally Extensive Spinal Cord Lesion

“…1 The clinical presentations of neurosyphilis are varied and include meningitis, stroke (via meningovascular involvement), dementia, and myelopathy (including tabes dorsalis and meningomyelitis). 1…”

“…At any time during the course of the disease, neurosyphilis can develop as a result of the organism invading the central nervous system. 1 The clinical presentations of neurosyphilis are varied and include meningitis, stroke (via meningovascular involvement), dementia, and myelopathy (including tabes dorsalis and meningomyelitis). 1…”