Trancranial Doppler Monitoring of Response to Therapy for Meningovascular Syphilis

Abstract

Meningovascular syphilis is now quite uncommon, but there have been increasing reports in patients immunocompromised with human immunodeficiency virus. The response of syphilis affecting the central nervous system to antibiotic therapy remains a challenge. This is an even greater challenge in patients who have underlying compromise of the immune system. The authors present a 46-year-old male with recurrent stroke who was found to have cerebrospinal fluid compatible with syphilitic involvement of the central nervous system and a cerebral arteriogram, which revealed focal narrowing of the right middle cerebral artery. The baseline transcranial Doppler study demonstrated increased mean and peak flow velocity within the right middle cerebral artery. Despite a 10-day course of intravenous penicillin, with substantial improvement in the cerebrospinal fluid results, this flow velocity elevation persisted, in a remarkably consistent pattern, over a 4-month follow-up period. Thus, the involved vessel remained patent following treatment, but no clear resolution of the stenotic lesion was observed.

The Changing Face of Neurosyphilis

“…In an HIV patient, while evidence of vasculopathy on angiography may be secondary to HIV itself, meningovascular syphilis should be excluded; a negative CSF VDRL does not necessarily exclude neurosyphilis and further testing is indicated as discussed above. In an HIV patient with neurosyphilis, while vascular abnormalities may be persistent (16,20,43), we recommend continued monitoring of the patient's vascular status, ideally with cerebral angiography, to look for progression of the vasculopathy, which may alter the management of the patient (including consideration of neurosyphilis treatment failure or relapse, which may require further evaluation and retreatment with antibiotics, and/or investigation of other treatable causes of vasculopathy).…”