The clinical and laboratory features of neurosyphilis in HIV-infected patients

Abstract

Neurosyphilis (NS) is an important component of central nervous system diseases among HIV-infected patients. However, its characteristics are not very clear. A retrospective analysis of clinical and laboratory findings was performed in 92 NS patients with HIV infection from a tertiary hospital in Shanghai, China. The patients had a median age of 38 years and a median CD4 count of 198 cells/μL. In all, 44.6% (41/92) were diagnosed as asymptomatic NS (ANS), 23.9% (22/92) as syphilitic meningitis, 17.4% (16/92) as cerebrovascular NS, and 14.1% (13/92) as parenchymal syphilis. A quarter of patients (23/92) complicated with ocular syphilis (OS), 60.9% (14/23) of which were ANS. The serum tolulized red unheated serum test (TRUST) titers were ≤1:8 in 15 patients (16.3%), 1:16–1:128 in 51 patients (55.4%), and ≥1:256 in 26 patients (28.3%). Sixty-nine patients (75.0%) had both cerebrospinal fluid (CSF) TRUST and Treponema pallidum particle assay reactive. CSF pleocytosis and protein elevation were found in 58.7% and 53.3% of patients, respectively. Syphilitic meningitis was more likely to present with CSF pleocytosis than ANS (P = .001), cerebrovascular NS (P < .001), and parenchymal NS (P < .001). The proportion of patients with CSF elevated protein was lower in ANS group than that in syphilitic meningitis (P = .003), cerebrovascular NS (P = .001), and parenchymal NS groups (P = .025), and was higher in sero-TRUST titers ≤1:8 group than that in 1:16–1:128 (P = .01) and 1:256–1:1024 groups (P = .005).This study revealed that ANS was the most common clinical type of NS in HIV-infected patients, which should be considered in HIV and syphilis co-infection patients without neurologic symptoms, especially in those with OS. Different patterns of NS might have different CSF features which may also vary with sero-TRUST titers.

Neuroimaging findings of cerebral syphilitic gumma

“…The main neuroimaging manifestations include diffuse cerebral atrophy followed by cerebral infarction (13). However, neurosyphilis may also be asymptomatic, which frequently leads to a lack of diagnosis (14). Cerebral syphilitic gumma is a rare manifestation of advanced meningovascular syphilis that has presented following the introduction of penicillin and usually occurs 10–30 years after contracting syphilis (12).…”

German guidelines on the diagnosis and treatment of neurosyphilis

“…Ocular (posterior uveitis or panuveitis) and otological (hearing loss, vestibular failures) manifestations of syphilis are possible at any stage, but are found more frequently in patients with meningovascular neurosyphilis [ 13 ]. Ocular manifestations appear to be particularly common in HIV-positive persons and in asymptomatic neurosyphilis [ 14 ].…”

“…In 110 patients with symptomatic neurosyphilis and 154 patients with asymptomatic neurosyphilis, the CSF cell count was found to be increased in 82.7 and 81.2% of cases, respectively, and the CSF protein in 68.1% versus 28.6% [ 34 ]. In the case of simultaneous HIV infection, pleocytosis was found in only 58.7% of 92 patients, while CSF protein was elevated in 53.3% [ 14 ]. However, the significance of small increases in CSF cell count in patients with HIV is limited with regard to the diagnosis of neurosyphilis, as pleocytosis is often found in patients whose only infection is HIV [ 3 ].…”

“…In meningitic neurosyphilis, there is often an increase in the number of cells, although this does not appear to be the case in later stages [ 14 ]. In meningovascular neurosyphilis, CSF protein is particularly high [ 14 ]. Of note, an increased total CSF protein is a non-specific parameter.…”

“…In HIV patients with latent asymptomatic neurosyphilis the CD4 cell count in is usually reduced [ 36 ]. In a study by Wang et al the CD4 cell count was < 200/μl in most patients with latent asymptomatic neurosyphilis [ 14 ]. In patients with proven syphilis and HIV co-infection, CSF examination should also be considered in the event of a positive treponeme-specific seroreaction if advanced immunodeficiency (cell count < 200/μl) is present [ 5 ].…”