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neurosyphilis (dementia paralytica, syphilitic paresis)

Syphilis of the central nervous system. Clinical manifestations: 1) slow mental deterioration a) memory loss b) impaired judgment c) irresponsibility 2) psychosis & delirium in acute presentation [4] 3) headaches 4) tremor a) hands b) lips c) tongue 5) chronic meningitis 6) cranial neuropathies 7) myelopathy (acute, subacute, or chronic dysfunction of the spinal cord, including tabes dorsalis) 8) uveitis, visual loss, or optic nerve dysfunction 9) Argyl Robertson pupil Laboratory: 1) positive serologic tests for syphilis -> serum RPR > 1:32 predictive of neurosyphilis 2) elevated serum globulin 3) lumbar puncture a) elevated cerebrospinal fluid (CSF) pressure b) positive CSF VDRL c) CSF pleocytosis, > 20 WBC/mm3 d) CSF Treponema pallidum PCR does not correlate well with CSF VDRL or CSF pleocytosis 4) in HIV positive patients CD4 count < 350/mm3 predictive of neurosypilis Complications: - seizures - stroke Management: 1) normal CSF: - treat as secondary syphilis or syphilis of unknown duration 2) abnormal CSF a) 12-24 million units/day of penicillin G b) given as 2-4 million units IV every 4 hours c) duration for 10-14 days 3) if patients are allergic to penicillin, doxycycline 200 mg BID for 28 days is as effective as penicillin [9]

Specific

tabes dorsalis

General

spinal cord disease; myelopathy (disease/disorder primarily affecting spinal cord) Tertiary Syphilis

References

  1. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 878
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
  3. Journal Watch 24(6):46, 2004 Marra CM et al, J Infect Dis 189:369, 2004 PMID: 14745693
  4. Knudsen RP et al Neurosyphilis, eMedicine http://emedicine.medscape.com/article/1169231-overview
  5. Libois A et al. HIV and syphilis: When to perform a lumbar puncture. Sex Transm Dis 2007 Mar; 34:141. PMID: 16865051
  6. Marra CM et al. Normalization of cerebrospinal fluid abnormalities after neurosyphilis therapy: Does HIV status matter? Clin Infect Dis 2004 Apr 1; 38:1001. PMID: 15034833
  7. Marra CM et al. Normalization of serum rapid plasma reagin titer predicts normalization of cerebrospinal fluid and clinical abnormalities after treatment of neurosyphilis. Clin Infect Dis 2008 Oct 1; 47:893. PMID: 18715154
  8. Ropper AH Neurosyphilis. N Engl J Med 2019; 381:1358-1363. Oct 3, 2019 PMID: 31577877 https://www.nejm.org/doi/full/10.1056/NEJMra1906228
  9. Girometti N et al. Clinical and serological outcomes in patients treated with oral doxycycline for early neurosyphilis. J Antimicrob Chemother 2021 Mar 30; [e-pub]. PMID: 33783506 https://academic.oup.com/jac/advance-article-abstract/doi/10.1093/jac/dkab100/6202984