Neurosyphilis


Article Author:
Tuan Ha
Prasanna Tadi


Article Editor:
Laurence Dubensky


Editors In Chief:
Dustin Constant
Donald Kushner


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
5/11/2019 2:31:58 PM

Introduction

Syphilis is an infectious disease caused by the spirochete bacteria Treponema pallidum subspecies pallidum (T. pallidum). It has been deemed the "great imitator" due to the multitude of symptoms it produces. The diagnosis becomes further muddled by periods of active disease and latency. The term neurosyphilis refers to an infection involving the central nervous system (CNS) and unlike primary, secondary and tertiary syphilis, can occur at any time after infection. Studies on rabbits have shown that within hours of initial infection, treponemes may be present in the cerebral spinal fluid (CSF). Additionally, the belief is that bacterial neuroinvasion occurs in all patients and it is a failure of clearance which results in the condition.[1][2] Five types of neurosyphilis exist which can be classified by either the early forms consisting of asymptomatic, meningeal, and meningovascular or the late forms of general paresis and tabes dorsalis. The latter generally occurs years or decades after initial inoculation.

Etiology

T. pallidum is a bacterial spirochete which spreads systemically within minutes of infection. It results in syphilis which is predominantly a venereal disease, but vertical transmission can also occur and more rarely blood transfusion-associated. Infection occurs via penetration of the spirochete through mucosal membranes as well as epithelial breaks in the skin. Unprotected sex is a significant risk factor for transmission, particularly in men who have sex with men (MSM), who account for about 80% of syphilis cases in the United States. Invasion of the CNS is thought to occur in most (if not all) individuals. Thus neurosyphilis can potentially occur in any patient.[3][4]

Epidemiology

With the advent of penicillin, rates of syphilis reached a nadir at the end of the 20th century but since then have steadily climbed particularly in the MSM population. Although syphilis is a reportable condition, rates of neurosyphilis in the United States are not known partially due to surveillance definitions requiring data which is often unavailable. Before antibiotics, neurosyphilis was prevalent and occurred in up to 25 to 35 percent of syphilis patients. Today, it more generally presents in HIV patients particularly in those who are either untreated, have low CD4+ counts, or detectable HIV RNA levels. Even so, the early forms of neurosyphilis are more frequent than the late forms. High-risk sexual behavior makes individuals vulnerable to syphilis as well as HIV, and thus neurosyphilis is more prevalent among individuals who are also at high-risk for HIV such as MSM.[2][5][6]

Pathophysiology

As previously mentioned, CNS infection occurs in the majority if not all of the patients with syphilis; however, spontaneous resolution can occur without an inflammatory response. Alternatively, transient or persistent meningitis can occur; in the latter case, they are deemed to have developed neurosyphilis. Neurosyphilis may be asymptomatic or persist to an early symptomatic phase, and eventually, if allowed to go untreated, a late symptomatic disease discussed further under history and physical.[4][7]

History and Physical

This article will focus on the manifestations of neurosyphilis; however, patients will likely have a history of syphilis and its associated symptoms which is discussed in StatPearls - Syphilis.

Neurosyphilis exists in five forms which may subclassify as early and late neurosyphilis.

Early Neurosyphilis

Asymptomatic (ANS)

  • Most common form and occurs before symptomatic syphilis.
  • Patients are unaware that they are affected and have no signs of neurological disease.
  • Defined by the presence of CSF abnormalities in a patient with serological evidence of syphilis but no neurological symptoms.
  • Prior to penicillin, diagnosis of ANS was significant in predicting the prognosis and outcomes of patients regarding neurological sequelae with syphilis.

 Meningeal

  • Results from diffuse inflammation of the meninges.
  • Typical meningeal symptoms include headache, nausea, vomiting, neck stiffness, photophobia, cranial nerve deficits, and possibly seizures.

Meningovascular

  • Inflammation of the meninges, as well as endarteritis causing thrombosis and infarction of cerebral tissue.
  • Early symptoms are nonspecific and include headache, nausea, vomiting, vertigo.
  • Causes a cerebral vascular syndrome and the symptoms depend on the site of thrombosis and the corresponding cerebral functions.
  • Spinal cord vessels may also be affected resulting in meningomyelitis and spastic weakness (particularly in the lower extremities), sensory loss, and muscular atrophy.

Late Neurosyphilis (Parenchymal)

General paresis (General paralysis of the insane, paralytic dementia)

  • Due to chronic meningoencephalitis resulting in cerebral atrophy.
  • Symptoms of paretic neurosyphilis can be further divided into early and late symptoms and can occur insidiously or suddenly.
  • Early symptoms include mood disturbances such as irritability, personality changes, changes in sleep habits, and forgetfulness.
  • Late symptoms include labile mood, memory and judgment impairment, confusion, delusions and seizures.
  • Psychiatric disease including depression, delirium, mania, and psychosis can also result.
  • Neurologically one may see pupillary abnormalities, dysarthria, and tremors.

Tabes Dorsalis

  • Results from degeneration of the posterior (dorsal) column and roots of the spinal cord and the symptoms that result reflect this.
  • Classically patients have ataxia, lightning (lancinating) pains, bladder dysfunction, paresthesias, and vision changes
  • Additional neurologic deficits include pupillary abnormalities (Argyll Robertson pupils), ocular palsies, diminished reflexes, vibratory and proprioceptive impairments, ocular palsies, and Charcot's joints.[2][8][9][8]

Evaluation

Suspicion of syphilis infection should be confirmed before or considered in conjunction with the diagnosis of neurosyphilis; syphilis is further discussed in StatPearls - Syphilis.

Diagnosis of neurosyphilis remains a challenge due to no existing standardized testing, but it is rather made on a combination of clinical and CSF analysis findings. The Center for Disease Control (CDC) states that in primary and secondary syphilis, patients often have CSF abnormalities, and thus CSF analysis is not recommended if patients are without neurological symptoms. Patients diagnosed with tertiary syphilis should, however, undergo CSF analysis before treatment and should receive a neurosyphilis regime if abnormal. In most cases a normal CSF excludes neurosyphilis.[2]

  • CSF VDRL - Highly specific and is generally accepted as diagnostic of neurosyphilis. CSF RPR is not a recommended test due to lower sensitivity.
  • CSF Treponemal tests (FTA-ABS) - Highly sensitive; however, it is nonspecific and thus more useful to rule out neurosyphilis when the pretest probability is moderate to low.
  • CSF pleocytosis (defined as greater than 5 cells/mL) - Sensitive but is nonspecific as both infectious and noninfectious causes can both result in increased cell count. Interpretation of pleocytosis is further confounded in HIV patients who may have pleocytosis independent of neurosyphilis particularly if they are not on anti-retroviral therapy.
  • CSF protein - May aid in diagnosis but neither sensitive nor specific in the diagnosis.[6][2]

Neuroimaging can be helpful in the diagnosis and management, but findings are generally nonspecific. The most common findings were frontal and temporoparietal atrophy and nonspecific white matter lesions in patients with tabes dorsalis and changes consistent with infarction in patients with the meningovascular disease.[5][2]

Reverse sequence screening is an increasingly used algorithm across US laboratories that use treponemal tests as the initial screening to identify those patients with treated, untreated, or incompletely treated syphilis. [10]Because of a lack of validation of the reverse algorithm, higher rates of false-positive results can be seen leading to difficulty in interpreting these tests and the need for second confirmatory treponemal tests.

Treatment / Management

Patients with neurosyphilis should be admitted for the initiation of antibiotics and may require inpatient treatment.

Treatment of neurosyphilis currently includes two regimens recommended by the CDC.

  • Penicillin G 3 to 4 million units intravenously every 4 hours for 10 to 14 days, or Penicillin G 24 million units as a continuous infusion for 10 to 14 days
  • Procaine penicillin G 2.4 million units intramuscularly daily plus probenecid 500mg PO four times a day for 10 to 14 days

Both are options after penicillin desensitization in those with penicillin allergies.

Ceftriaxone is another therapeutic option with the regimen being 2g IV or IM daily for 10 to 14 days.[2][6]

Patients with a high titer of secondary syphilis can develop Jarisch-Herxheimer reaction, which is an immune-mediated self-limited reaction that occurs within 2 to 24 hours of treatment and is characterized by high fever, headache, myalgias, rash.

Patients need to be followed post-treatment at 3, 6, 9, 12, and 24 months with serial non-treponemal tests. A 4-fold decline in these tests indicates successful treatment.[11]

The CDC recommends follow up CSF exam every six months until the abnormalities resolve; if CSF continues to be abnormal after two years retreatment should be considered. 

Differential Diagnosis

Since it is often called the "great imitator" the differential for neurosyphilis is broad; however, the following are important considerations[5]:

  • Brain tumors/abscess
  • Subarachnoid hemorrhage
  • Herpes encephalitis
  • Electrolyte disturbances
  • Drug toxicity
  • Multiple sclerosis
  • Wernicke encephalopathy

Toxicity and Side Effect Management

The Jarisch-Herxheimer reaction is the primary side effect of treatment. It is due to the release of endotoxin from the lysing spirochetes and characteristically presents as fevers, chills, myalgias, tachycardia, headache, and vasodilation with resultant flushing and/or mild hypotension. The reaction usually occurs in the first 2 to 6 hours of antibiotic administration and resolves within 12 to 24 hours. Management is symptomatic with acetaminophen as the preferred agent.[5]

Prognosis

According to the Nation Institute of Health, the prognosis of patients presenting with neurosyphilis is mostly dependent on the type of neurosyphilis and early detection of the disease. Patients who present with asymptomatic or meningeal neurosyphilis generally return to normal health if treated adequately. Patients with meningovascular disease, general paresis or tabes dorsalis may improve but usually, do not return to their health or functional baseline. Furthermore, patients who are treated years after initial infection tend to have more poor prognoses. 

Complications

While neurosyphilis itself is a complication of syphilis, untreated neurosyphilis can result in devastating neurological sequelae including permanent paralysis, dementia, and death. Treatment should be initiated immediately as some complications may be reversible, and the success of therapy has an inverse relationship to the duration of the untreated infection.[8]

Consultations

Most patients, in whom the diagnosis of neurosyphilis is made or considered, should receive an infectious disease and neurology consult. These specialties may guide further work-up, management and monitor response to therapy.

Deterrence and Patient Education

Patients diagnosed with syphilis should receive counsel regarding disease transmission and risk reduction via safe sex practices. Pregnant patients should also have counseling on the possibility of vertical transmission. All patients should receive education on the signs and symptoms of neurosyphilis. Patients under therapy for syphilis should be informed about the need for repeat titers as a test of cure; patients who are treated for syphilis and fail to achieve a four-fold decline in non-treponemal titers within 6 to 12 months may have unrecognized neurosyphilis necessitating further work-up and more aggressive treatment. All patients diagnosed with neurosyphilis should also undergo testing for HIV. Providers should inform patients who are undergoing treatment of the Jarisch-Herxheimer reaction as a potential occurrence.[8]

Pearls and Other Issues

Neurosyphilis is a complication of syphilis that can occur at any time post-exposure infection with syphilis. With the advent of penicillin, it had reached a nadir until the 2000s when it saw a resurgence, particularly in those with high-risk behavior including the MSM and HIV population. It can be asymptomatic or result in a range of diseases which includes meningeal, meningovascular, general paresis and tabes dorsalis. Confirmation is via history and CSF studies. Penicillin is the mainstay of treatment, and confirmatory CSF studies should be performed every six months until resolution. The Jarisch-Herxheimer reaction is an expected response and treatment is supportive with acetaminophen.

Enhancing Healthcare Team Outcomes

In the diagnosis and treatment of neurosyphilis communication between providers may expedite the treatment process. Communication between the consulting provider, and specialties including infectious disease, and neurology, as well as laboratory technicians and pharmacists, helps guide management of a patient with suspected or confirmed neurosyphilis. It is critical to arrange appropriate follow-up with patients being treated for syphilis/neurosyphilis to confirm complete resolution which includes reversal of symptoms and prevention of permanent disability. As neurosyphilis is a rare diagnosis in the post-penicillin era, much of the evidence level of diagnosis and treatment pertains to syphilis. In screening tests, T. pallidum enzyme immunoassay (EIA) may be necessary for those that are low risk for rule out (Evidence level IIb). If EIA positive, before the initiation of therapy, additional and confirmatory serological tests such as VDRL/RPR should be performed (Evidence level IV).[12] In terms of treatment, guidelines from the CDC recommend parenteral penicillin G for all stages of syphilis as it has long been effective and is also the mainstay treatment of neurosyphilis (Evidence level III).[4] After commencing treatment, tests of cure via VDRL/RPR are recommended in all patients (Evidence level III). This follow-up should be performed monthly for three months, and at 6 and 12 months for early syphilis. For patients with late syphilis, this should take place every six months until negative (Evidence level IV). Due to the strong association with HIV, HIV positive patients should have repeat testing yearly (Evidence level IV). Regarding neurosyphilis, CSF studies should be tested every 6 months until negative (Evidence level IV).[12]

Neurosyphilis is best addressed via an interprofessional, multidisciplinary team approach that includes primary care physicians, infectious disease specialists, a neurologist when appropriate, pharmacists, and nurses, particularly those with specialty training in infection control. [Level V]


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Neurosyphilis - Questions

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A 25-year-old male presents complaining of a penile lesion. He states that the lesion appeared about a week ago and has been painless. He has no significant past medical history. He denies any history of similar symptoms, penile discharge, neurological symptoms including dizziness, imbalance, headaches, visual disturbances. Vital signs are stable. Physical examination shows a non-tender ulcerative lesion on the glans of the penis. If allowed to progress, what part of the spinal cord may be affected by the disease process?



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Which is false about Argyll Robertson pupil?



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A 45-year-old male presents to the clinic for a pre-employment check-up. He has a history of diabetes mellitus and hypertension. He has no active complaints; however, on physical examination, the provider finds that his pupils are bilaterally small and constricted mainly when the patient focuses but do not constrict in the presence of light. His visual acuity is 20/20 in both eyes with corrective vision. What is the most likely diagnosis?



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A 30-year-old female 20 weeks pregnant by last menstrual period presents to clinic for a prenatal checkup. Routine prenatal labs show a positive RPR, confirmatory tests are positive. If left untreated, what symptom is the patient at risk of developing?



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A 65 year old female from Thailand has had 18 months of inappropriate behavior and progressive memory loss. She has had delusions, tremors, dysarthria, myoclonus, and gait disturbance. CSF shows protein of 180 mg/dL, lymphocytic pleocytosis, and positive VDRL. What is the most likely diagnosis?



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A 31-year-old male presents with right-sided weakness for the last 8 hours. He denies any vision deficits, speech abnormalities, or numbness; however, he does endorse intermittent headaches. He has no past medical history except that he was tested for sexually transmitted infections a few years ago and had a VDRL positive test for which he was treated accordingly but had no further follow up. He denies any history of coronary artery disease, hypertension, diabetes. CT brain is negative of bleed, CT angiogram shows varying degrees stenosis of cerebral arteries. Cerebral spinal fluid studies show pleocytosis, negative gram stain, elevated protein. What is the most likely cause of his symptoms?



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A 54-year-old male presents to the emergency department for a 1-week history of ataxia. He states he recently began having trouble with his balance. He denies any weakness, numbness, problems with his bowel or bladder control, as well as speech difficulty. His medical history is significant for hypertension, hyperlipidemia, and congestive heart failure. He consumes alcohol socially and smokes marijuana occasionally. He is married and works as a plumber. He states that he is sexually active with both women and men, and admits to not always using protection. He also reports a recent trip to Nicaragua for vacation. His vital signs are BP 143/90, HR 77, RR 16, SpO2 98% on RA. His physical exam is significant for a positive Romberg's test and a pupil that constricts when focusing on near objects but does not constrict to bright light. Which of the following puts him most at risk for his current medical condition?



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Neurosyphilis - References

References

Collart P,Franceschini P,Durel P, Experimental rabbit syphilis. The British journal of venereal diseases. 1971 Dec;     [PubMed]
Ghanem KG, REVIEW: Neurosyphilis: A historical perspective and review. CNS neuroscience     [PubMed]
Patton ME,Su JR,Nelson R,Weinstock H, Primary and secondary syphilis--United States, 2005-2013. MMWR. Morbidity and mortality weekly report. 2014 May 9;     [PubMed]
Brown DL,Frank JE, Diagnosis and management of syphilis. American family physician. 2003 Jul 15;     [PubMed]
Hobbs E,Vera JH,Marks M,Barritt AW,Ridha BH,Lawrence D, Neurosyphilis in patients with HIV. Practical neurology. 2018 Jun;     [PubMed]
Tuddenham S,Ghanem KG, Neurosyphilis: Knowledge Gaps and Controversies. Sexually transmitted diseases. 2018 Mar;     [PubMed]
Berger JR,Dean D, Neurosyphilis. Handbook of clinical neurology. 2014;     [PubMed]
Lewis DA,Young H, Syphilis. Sexually transmitted infections. 2006 Dec;     [PubMed]
Marra CM, Neurosyphilis. Continuum (Minneapolis, Minn.). 2015 Dec;     [PubMed]
Forrestel AK,Kovarik CL,Katz KA, Sexually Acquired Syphilis. Part 1: Historical aspects, microbiology, epidemiology, and clinical manifestations. Journal of the American Academy of Dermatology. 2019 Apr 12     [PubMed]
Cohen SE,Klausner JD,Engelman J,Philip S, Syphilis in the modern era: an update for physicians. Infectious disease clinics of North America. 2013 Dec     [PubMed]
Clement ME,Okeke NL,Hicks CB, Treatment of syphilis: a systematic review. JAMA. 2014 Nov 12     [PubMed]

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