Neurosyphilis

 Definition: The term "neurosyphilis" refers to infection of the central nervous system (CNS)
by Treponema pallidum. Neurosyphilis can occur at any time after initial infection.

 PATHOGENESIS — Neurosyphilis begins with invasion of the cerebrospinal fluid (CSF), a process that
probably occurs shortly after acquisition of T. pallidum infection. The organism can be identified in the
CSF from approximately one-quarter of untreated patients with early syphilis

 EPIDEMIOLOGY: neurosyphilis, particularly the early forms, is most frequently seen in persons with
HIV. This association may simply reflect the fact that syphilis is most common in men who have sex
with men, many of whom have HIV, or it may reflect a true difference in susceptibility

 CLINICAL MANIFESTATIONS
Neurosyphilis can be classified into early forms and late forms. The early forms typically affect the
cerebrospinal fluid (CSF), meninges, and vasculature, while the late forms affect the brain and spinal
cord parenchyma.
 Early neurosyphilis: Subdivide into 5 subcategories; Asymptomatic neurosyphilis, symptomatic
meningitis, Ocular syphilis, Otosyphilis, Meningovascular syphilis
 Late neurosyphilis: includes General paresis, and Tabes dorsalis
 Atypical neurosyphilis

 Diagnostic criteria (from UpToDate)

-ARV: antiretroviral
drugs
-EIA: syphilis enzyme
immunoassay
-TPPA: treponema
pallidum particle
agglutination test
-FTA-ABS: fluorescent
treponemal antibody-
absorbed test
* A reactive serum EIA
should be confirmed
with a different
treponemal test.

Algorithm for diagnosis of neurosyphilis in a Algorithm for the diagnosis of

patient without HIV infection neurosyphilis in a patient with HIV
infection
  Psychiatric symptoms of Neurosyphilis

o Symptomatic meningitis: Patients with symptomatic syphilitic meningitis complain of

headache, confusion, nausea and vomiting, and stiff neck. Visual acuity may be impaired if
there is concomitant uveitis, vitreitis, retinitis, or optic neuropathy. Signs include cranial
neuropathies, particularly of the optic, facial, or auditory nerves.
Focal meningeal inflammation may lead to diffuse leptomeningitis or to syphilitic gummas,
Meningitis, brain ischemia, or gummas may cause seizures.

o Meningovascular syphilis: syphilitic meningitis can cause an infectious arteritis that may affect
any vessel in the subarachnoid space surrounding the brain or spinal cord and result in
thrombosis, ischemia, and infarction. Many patients with meningovascular syphilis have
prodromal symptoms, such as headache, dizziness, or personality changes, for days or
weeks before the onset of ischemia or stroke. These symptoms are probably due to
concomitant meningitis.

o Late (tertiary) neurosyphilis:

 General paresis (also known as general paralysis of the insane, paretic neurosyphilis,
or dementia paralytica) is a progressive dementing illness. In the early stage of disease,
general paresis is associated with symptoms of forgetfulness and personality change.
Most affected individuals experience progression of deficits in memory and judgment
leading to severe dementia. Less often, patients may develop psychiatric symptoms
such as depression, mania, or psychosis.

 Tabes dorsalis (also called locomotor ataxia) is a disease of the posterior columns of
the spinal cord and of the dorsal roots. The most frequent symptoms of tabes dorsalis
are sensory ataxia and lancinating pains. The latter are characterized by sudden, brief,
severe stabs of pain that may affect the limbs, back, or face and that may last for
minutes or days. Pupillary irregularities are among the most common signs in patients
with tabes dorsalis, and the Argyll-Robertson pupil accounts for approximately one-half
of these. Other findings seen with tabes dorsalis include absent lower extremity reflexes,
impaired vibratory and position sensation, and, less commonly, impaired touch, pain,
and optic atrophy.
 Treatment:

o Aqueous crystalline penicillin G (18 to 24 million units per day, administered as 3 to 4 million
units intravenous [IV] every four hours, or 24 million units daily as a continuous infusion) for 10
to 14 days,

or

o Procaine penicillin G (2.4 million units intramuscular [IM] once daily) plus probenecid (500 mg
orally four times a day), both for 10 to 14 days

Source:
https://www.uptodate.com/contents/neurosyphilis?search=neurosyphilis&source=search_result&selectedTitle=
1~70&usage_type=default&display_rank=1