Prognosis of general paresis after treatment

The prevalence of asymptomatic neurosyphilis among HIV-negative serofast patients in China: A meta-analysis

Introduction

Neurosyphilis can occur at any stage of syphilis. After treatment, 30%-40% of syphilis patients remained serofast. But the prevalence of asymptomatic neurosyphilis (ANS) among serofast syphilis patients remains unclear. Untimely treatment or improper management for ANS may result in neurological complications. So we perform the meta-analysis to evaluate the prevalence of ANS cases among HIV-negative serofast syphilis patients for exploring their relationship and addressing their clinical management.

Methods

We searched CNKI, Wan Fang, VIP, CBMdisc, PubMed, Embase and Medline from January 1^st 1990 to September 22^nd 2020 for both English and Chinese records. We strictly restrict the eligibility criteria. STROBE was used for reporting quality assessment. We examined forest plots and conducted both fix-effects and random-effects to estimate prevalence by R version 3.6.2/R studio 1.2.1335 statistical software packages META version 4.9–9. If appropriate, between-study heterogeneity was examined using the I² statistic and subgroup analysis.

Results

Of 77 screened records, 5 were included. The pooled prevalence of ANS among HIV-negative serofast syphilis patients was 13% (95% CI 3%-23%; I² = 93% P<0.01, 417 people). The prevalence of ANS for the verified ANS classification definition was 3% (95% CI 0%-7%; I² = 67% P = 0.08, two studies, 189 people), and 21% (95% CI 6%-36%; I² = 86% P<0.01, three studies, 228 people) for the likely ANS classification. The prevalence of ANS among the serofast syphilis patients who were followed up for one year was 29% (95% CI 22%-36%; I² = 0% P = 0.5, two studies, 167 people) and 5% (95% CI 0%-13%; I² = 79% P = 0.03, two studies, 144 people) for two years. The prevalence in the studies from different geographical subgroups was as follows: 9% (95% CI 0%-19%; I² = 82% P<0.01, three studies, 169 people) in South-central China, 6% (95% CI 1%-10%; one study, 106 people) in East China, and 30% (95% CI 23%-38%; one study, 142 people) in North China.

Conclusion

This meta-analysis showed a high estimated prevalence of ANS in HIV-negative serofast syphilis patients, the prevalence of ANS among patients diagnosed with the verified ANS case definition is much lower than that for the likely ANS classification. It may be necessary to carry out nontreponemal test, protein test and leukocyte count for cerebrospinal fluid (CSF) in treated serofast patients for better clinical management to avoid neurological complications. The case classification definition of ANS is a key factor to evaluate the prevalence. Geographical heterogeneity needs more studies to detect. In future we need better-design studies to explore relationship between ANS and serofast status.

Medial temporal lobe atrophy as a predictor of poor cognitive outcomes in general paresis

BACKGROUND

The effect of penicillin therapy on clinical outcomes vary among patients with general paresis (GP). We sought to explore biomarkers that might serve as predictors of clinical outcomes in GP and identify patients requiring early intervention.

METHODS

Thirty-five inpatients with GP were recruited. Each GP patient underwent comprehensive neuropsychological, neuroimaging and laboratory assessments before receiving penicillin therapy, and returned for follow-up evaluations after 6 months. The visual rating of medial temporal lobe atrophy (MTA) and the Fazekas scale was used to analyze the neuroimaging abnormalities.

RESULTS

MTA scores were correlated with the pre-treatment cognitive scores and change in Mini Mental State Examination scores. GP patients with a Clinical Dementia Rating Scale (CDR) ≤1 or MTA scores ≤2 achieved significant improvement in neuropsychological test scores, as compared with patients with CDR >1 or MTA scores >2. Fazekas scale scores correlated with the pre-treatment attention scores. Significant improvements in cognitive test scores were observed in GP patients with normalization of serum rapid plasma regain (RPR) titers, but not those without normalization of RPR titers.

CONCLUSIONS

Severe MTA may serve as a predictor of poor cognitive outcome and an indicator of severe cognitive impairment in GP patients. Thus, early interventions for improving cognitive function may be considered for GP patients with severe MTA. White matter hyperintensities may associated with attention impairment. Serum RPR titer may serve as a sensitive indicator of therapeutic effect in GP.

Neurocognitive changes in tertiary neurosyphilis: a retrospective chart review

CONTEXT

Since the beginning of the new millennium, prevalence of syphilis has re-increased and is once again, a major public health problem. Neurosyphilis is the extension of syphilitic infection to the nervous system. It is considered by many as a cause of reversible dementia, when treated early. However, scarce data exist on the evolution of cognitive and behavioral impairments in patients affected by tertiary neurosyphilis.

OBJECTIVES

The aim of this study was to explore the cognitive and behavioral changes in a cohort of patients diagnosed with neurosyphilis.

DESIGN

A retrospective study based on systematized chart review between 2000 and 2012 in a large neurological tertiary care facility.

OUTCOME MEASURE

Clinical evaluations by treating physicians.

RESULTS

Eighteen patients were identified with tertiary neurosyphilis. Out of this group, only two had systematic neuropsychological follow-up despite physician reports of significant and persistent cognitive and psychiatric changes. For these two cases, only slight improvements were noted in memory and executive skills while improvements in attention were marked. None of our patients had previous psychiatric history yet a large proportion developed symptoms after the infection.

CONCLUSION

Although neurosyphilis is traditionally considered a reversible form of dementia, we found limited support for this claim in our two patients with close follow-up. Quality data on the cognitive and psychiatric changes in the rest of our cohort was dramatically lacking, and this could not be explained by absence of symptoms at presentation. Given the recrudescence of syphilis, we propose a systematic approach to the evaluation and follow-up of this disorder.

The effect of penicillin therapy on cognitive outcomes in neurosyphilis: a systematic review of the literature

OBJECTIVE

Neurosyphilis commonly presents with cognitive impairment, and penicillin remains the treatment of choice. However, despite a rapid increase in syphilis incidence, the effect of penicillin on long-term cognitive outcomes has not previously been evaluated. We therefore aimed to assess the effect of penicillin on cognitive function in neurosyphilis.

METHODS

We performed a systematic review of all studies of neurosyphilis, where cognitive function was assessed objectively both before and after penicillin therapy for at least one patient. Where Mini-Mental State Examination (MMSE) scores were taken, we performed a paired-samples t test to assess the change in cognitive function and aimed to correlate this with change in serological titers.

RESULTS

Nine studies met inclusion criteria. The one cohort study reported a nonsignificant overall improvement in MMSE, while amalgamation of case reports produced a significant improvement (P=.02) in MMSE after treatment. However, follow-up duration was inadequate, and data were insufficient to correlate changes in cognitive function with serological markers.

CONCLUSIONS

Despite evidence of short-term improvement, there are insufficient data to support the long-term benefit of penicillin therapy on cognitive function in neurosyphilis.

Central Nervous System Infections

Central nervous system (CNS) infections—i.e., infections involving the brain (cerebrum and cerebellum), spinal cord, optic nerves, and their covering membranes—are medical emergencies that are associated with substantial morbidity, mortality, or long-term sequelae that may have catastrophic implications for the quality of life of affected individuals. Acute CNS infections that warrant neurointensive care (ICU) admission fall broadly into three categories—meningitis, encephalitis, and abscesses—and generally result from blood-borne spread of the respective microorganisms. Other causes of CNS infections include head trauma resulting in fractures at the base of the skull or the cribriform plate that can lead to an opening between the CNS and the sinuses, mastoid, the middle ear, or the nasopharynx. Extrinsic contamination of the CNS can occur intraoperatively during neurosurgical procedures. Also, implanted medical devices or adjunct hardware (e.g., shunts, ventriculostomies, or external drainage tubes) and congenital malformations (e.g., spina bifida or sinus tracts) can become colonized and serve as sources or foci of infection. Viruses, such as rabies, herpes simplex virus, or polioviruses, can spread to the CNS via intraneural pathways resulting in encephalitis. If infection occurs at sites (e.g., middle ear or mastoid) contiguous with the CNS, infection may spread directly into the CNS causing brain abscesses; alternatively, the organism may reach the CNS indirectly via venous drainage or the sheaths of cranial and spinal nerves. Abscesses also may become localized in the subdural or epidural spaces. Meningitis results if bacteria spread directly from an abscess to the subarachnoid space. CNS abscesses may be a result of pyogenic meningitis or from septic emboli associated with endocarditis, lung abscess, or other serious purulent infections. Breaches of the blood–brain barrier (BBB) can result in CNS infections. Causes of such breaches include damage (e.g., microhemorrhage or necrosis of surrounding tissue) to the BBB; mechanical obstruction of microvessels by parasitized red blood cells, leukocytes, or platelets; overproduction of cytokines that degrade tight junction proteins; or microbe-specific interactions with the BBB that facilitate transcellular passage of the microorganism. The microorganisms that cause CNS infections include a wide range of bacteria, mycobacteria, yeasts, fungi, viruses, spirochaetes (e.g., neurosyphilis), and parasites (e.g., cerebral malaria and strongyloidiasis). The clinical picture of the various infections can be nonspecific or characterized by distinct, recognizable clinical syndromes. At some juncture, individuals with severe acute CNS infections require critical care management that warrants neuro-ICU admission. The implications for CNS infections are serious and complex and include the increased human and material resources necessary to manage very sick patients, the difficulties in triaging patients with vague or mild symptoms, and ascertaining the precise cause and degree of CNS involvement at the time of admission to the neuro-ICU. This chapter addresses a wide range of severe CNS infections that are better managed in the neuro-ICU. Topics covered include the medical epidemiology of the respective CNS infection; discussions of the relevant neuroanatomy and blood supply (essential for understanding the pathogenesis of CNS infections) and pathophysiology; symptoms and signs; diagnostic procedures, including essential neuroimaging studies; therapeutic options, including empirical therapy where indicated; and the perennial issue of the utility and effectiveness of steroid therapy for certain CNS infections. Finally, therapeutic options and alternatives are discussed, including the choices of antimicrobial agents best able to cross the BBB, supportive therapy, and prognosis.

Clinical and magnetic resonance imaging findings of HIV-negative patients with neurosyphilis

There have been no serial studies about neuroradiological findings of neurosyphilis in the literature. There have been only case reports concerning HIV negative patients with neurosyphilis. We present 8 HIV negative neurosyphilis patients two of whom are women. The mean age of the patients was 48 years+/-12.37. Five of the 8 patients had general paresis, two optic atrophy and one multiple cranial neuropathies. The CSF findings were quite similar in 6 of 8 patients. In half of the patients cranial MRI showed mild cerebral atrophy. Nonspecific hyperintense small foci in 3 patients are thought to be related to syphilis. Hyperintensity involving bilateral medial and anterior temporal regions more prominent on the left side was seen in one of the patients with general paresis. This finding may be due to cytotoxic edema associated with status epilepticus and may mimic herpes simplex and other limbic encephalitides. Though not typical, certain MRI findings guides for the diagnosis of neurosyphilis.

MRI in patients with general paresis

Few cases of MRI in neurosyphilis have been reported. We examined the value of MRI in patients with general paresis; MRI was performed on four HIV-negative patients with parenchymatous neurosyphilis. It demonstrated frontal and temporal atrophy, subcortical gliosis and, in one patient, increased ferritin in the basal ganglia. The progression of the lesions on MRI correlated well with the neuropsychiatric disturbances. The MRI findings correlated with the well-known neuropathological findings. This combination of pathological findings in neurosyphilis has not been described before and we suggest that MRI is of prognostic value in patients with general paresis.

Cognitive change after treatment for neurosyphilis. Correlation with CSF laboratory measures

The decision to re-treat a patient with neurosyphilis is usually based on the clinical response, cerebrospinal fluid (CSF), cell count, and CSF protein concentration. The value of the CSF Venereal Disease Research Laboratory (VDRL) test on its own as a marker for treatment response in neurosyphilis has not been established. To assess the usefulness of CSF markers for continuing infection, 12 patients with neurosyphilis were reevaluated 1 year after treatment. Change in cognitive functioning, as assessed by the Mini-mental State Examination (MMSE), was correlated with the CSF cell count, protein content, IgG index, and VDRL test titer at follow-up. A significant negative correlation was obtained between 1 year improvement in MMSE score and CSF VDRL titers at both the 6- and the 12-month follow-up examinations, and with the 6-month CSF protein concentration. These findings suggest that the CSF VDRL titer may be an indicator of continued Treponema pallidum activity in patients without obvious clinical deterioration.

A review and update on adult syphilis, with particular reference to its treatment

Syphilis has become less common in Europe in the last decade, but has once again become a major problem in the USA, and remains so in many developing countries. Several treponemal genes have now been cloned and expressed in Escherichia coli, allowing study of treponemal proteins. The importance of cell mediated immunity in syphilis has been demonstrated in animal models. A diagnosis of syphilis is usually confirmed by dark-field microscopy or serological tests. Seroconversion may be delayed in HIV infected individuals. A positive reaginic test in cerebrospinal fluid (CSF) has a high specificity but low sensitivity in the diagnosis of neurosyphilis. Indeed, virulent treponemes can be identified in CSF samples which have negative reaginic tests, normal cell counts and protein levels. In the CSF, the FTA-Abs test has a high sensitivity but low specificity for neurosyphilis. Penicillin remains the treatment of choice for all stages of syphilis, although it penetrates the blood brain barrier poorly. Treatment with intramuscular benzathine penicillin 2.4 million units stat, or 600,000 units procaine penicillin daily does not produce treponemicidal levels within the CSF. However, the incidence of neurosyphilis is low in immunocompetent patients treated with such regimens during early syphilis. Acceptable alternatives in penicillin-allergic patients include ceftriaxone and doxycycline. Erythromycin is not recommended as it has produced unacceptably high rates of treatment failure. Recently, a strain of macrolide-resistant Treponema pallidum was isolated from a patient with secondary syphilis. For the treatment of neurosyphilis, treponemicidal levels of penicillin can be achieved in the CSF using 2.4 million units procaine penicillin daily with concurrent probenecid 500 mg 4 times a day, or an intravenous infusion of benzyl penicillin 12-24 million units daily. Early syphilis can be treated adequately over 10 days, but 21 to 28 days is appropriate for late syphilis. In HIV-infected patients syphilis may present atypically with initially negative serological tests. Treatment of early syphilis in HIV-positive patients has been associated with the early development of neurosyphilis. It is advisable to treat all patients co-infected with HIV with an antibiotic regimen that achieves adequate levels within the CSF.

Nonmedical complications of diagnostic workup for dementia [clinic conference]

Testing for patients presenting with dementias can lead to diagnosis of disorders that can contribute to cognitive dysfunction, and to improvement, stabilization, or slowed deterioration in some demented patients. However, possible benefits must be balanced against possible costs. The present recommendations for workup of patients with dementia includes some tests with only marginal benefits, and a more limited workup may be as effective. This case demonstrates how important it is to be sensitive as well to possible effects on family relationships of demented patients. When we evaluate and treat demented patients, the dependence of the demented patient on the caregiver and the emotional and physical stresses experienced by many caregivers make it important to consider the patient and caregiver as a system vulnerable to many potential risks.

Clinical significance of cerebrospinal fluid tests for neurosyphilis

From 1978 to 1987, 1,665 cerebrospinal fluid (CSF) fluorescent treponemal antibody absorption (CSF-FTA-ABS) tests were performed as the screening procedure for neurosyphilis. The CSF samples from 48 patients were reactive, and the medical history and results of the CSF-Venereal Disease Research Laboratory test (CSF-VDRL) for syphilis for 38 of these patients were reviewed. Likely active neurosyphilis was diagnosed if the patient had a reactive CSF-FTA-ABS test, recent onset of neurological signs consistent with neurosyphilis, abnormal CSF, and no other recognized cause for the neurological illness. Fifteen patients were so classified. Four had a reactive CSF-VDRL test. The specificity of the CSF-VDRL in diagnosing likely active neurosyphilis was 100%, but the sensitivity was only 27%. The insensitivity of the CSF-VDRL test limits its usefulness as a screening test for neurosyphilis. The CSF-FTA-ABS test appears more sensitive for screening but is less specific than the CSF-VDRL test in distinguishing currently active neurosyphilis from past syphilis. These findings imply that clinical judgment is still essential in establishing the diagnosis of active neurosyphilis.

[High-dose intravenous penicillin therapy in neurosyphilis: study of 62 cases. II. Evaluation of cerebrospinal fluid]

Sixty-two patients with symptomatic neurosyphilis were treated with 20 or 24 megaunits of intravenous penicillin G daily for 15 to 30 days. The mean follow-up time after the treatment was 30 months. Forty-one patients had pleocytosis in the CSF before treatment. Six months and twelve or more months later, abnormal cell count was observed in 4 (9.8%) and in 3 patients (7.3%), respectively. The CSF protein level and the titers of Wassermann reaction in the CSF decreased slowly after treatment. The gammaglobulin concentration of the CSF and the immunoglobulin production inside the blood-brain barrier were still increased beyond the first year after treatment. The results of the treatment of these patients with high doses of intravenous penicillin G were not different from the results verified with lesser doses of intramuscular penicillin that were reported in the literature.

[Intravenous penicillin therapy in high doses in neurosyphilis: study of 62 cases. I. Clinical evaluation]

Sixty-two patients with symptomatic neurosyphilis were treated with 20 or 24 megaunits of intravenous penicillin G daily for 15 to 30 days. The mean follow-up time after the treatment was 30 months. Thirteen patients developed new neurological signs after the treatment. Their diagnosis were: general paresis (9), taboparesis (2), tabes dorsalis (1) and meningovascular neurosyphilis (1). After the treatment, thirty-six patients (58.1%) improved, 22 patients (35.5%) were unchanged and 4 patients (6.4%) deteriorated on clinical grounds. In two patients there was a progression to other forms of neurosyphilis. The results of the treatment of these patients with high doses of intravenous penicillin G were not different from the results verified with classical intramuscular penicillin that were reported in the literature, from the clinical standpoint.

Survival of treponemes after treatment: comments, clinical conclusions, and recommendations

Treponemes may persist after treatment that has been accepted as effective; the reasons for this are discussed. Nevertheless, the epidemic of syphilis after the second world war was not followed by an epidemic of late syphilis, and the results of treatment with penicillin are excellent. Neurological signs may progress in some treated patients, and the standard doses of soluble penicillin and any dose of benzathine penicillin (even with added probenecid by mouth) cannot be relied on to achieve treponemicidal concentrations in the cerebrospinal fluid (CSF). There are no large scale studies of CSF findings after treatment of early syphilis with benzathine penicillin. Standard dosage, such as procaine penicillin G 600 000 international units (IU) by intramuscular injection for 10 days, is the treatment of choice for the patient suffering from uncomplicated early syphilis; this should be preferred to benzathine penicillin, which should only be used when standard treatment as above cannot be given. Treponemicidal concentrations of penicillin should be achieved in the CSF of patients suffering from neurosyphilis by schedules of probenecid by mouth and procaine penicillin by single daily intramuscular injections; treatment should last for 17 to 21 days. Benzathine penicillin should not be used for the treatment of patients suffering from neurosyphilis or from the iritis of late syphilis including that accompanying interstitial keratitis. Treatment for interstitial keratitis should initially be as for neurosyphilis, but in recurrent cases it may have to be prolonged to eradicate Treponema pallidum that is dividing slowly. Doxycycline 200 mg by mouth daily for 21 days provides a supervisable outpatient schedule for patients allergic to penicillin. Cephaloridine (and probably cefuroxime and the new cephalosporins) may be useful for patients who are allergic to penicillin but have not developed anaphylactic allergy. If erythromycin is used for treating syphilis in pregnant women who are allergic to penicillin, then the newborn babies should be treated with penicillin.

[Neurosyphilis resistant to high doses of penicillin: report of a case]

A case of neurosyphilis that got worse despite several therapeutical trials with high doses of penicillin is described. The clinical condition was stabilized and cerebrospinal fluid data normalized following treatment with chloramphenicol.

Asymptomatic neurosyphilis

Lumbar puncture was performed in 18 patients with latent syphilis to rule out asymptomatic neurosyphilis. In seven patients the CSF findings were abnormal. The parameters used in CSF were cell count, total protein, immunoglobulins (IgG, IgA, IgM), IgG index, and serologic tests for syphilis (VDRL, Kolmer, RPCF and FTA-ABS, including monospecific IgG and IgM conjugates). In three patients, the CSF findings 7-10 months after treatment are also given. Penicillin levels in serum and CSF were determined in two patients after aqueous procaine penicillin G im with and without oral probenecid. The effect of blood contamination on the differentiation between normal and abnormal CSF may not be significant.

Treatment of neurosyphilis with chloramphenicol. A case report

Although penicillin is the drug of choice in syphilis, treatment failures with benzathine and procaine penicillin have occurred in neurosyphilis. Patients allergic to penicillin have traditionally been treated with tetracycline but, since this drug diffuses poorly into the cerebrospinal fluid, its use in neurosyphilis is uncertain. In the case reported here, a penicillin allergic patient with general paresis of the insane was successfully treated with chloramphenicol. This drug has been used in the treatment of syphilis and achieves high concentrations in the cerebrospinal fluid. Thus chloramphenicol may be a more appropriate agent than tetracycline in treating patients with neurosyphilis who are allergic to penicillin.

Parkinson's disease of post-encephalitic type following general paresis--an autopsied case

A clinico-pathological report is given of a case of Parkinson's disease following a general paresis. A 66-year-old male, with no previous history of febrile disease or viral encephalitides, developed a dementing illness. The general paresis was diagnosed from serological studies at the age of 45. He underwent a series of penicillin plus fever therapies as treatment for neurosyphilis. He also developed generalized rigidity and slow mobility 12 years after the diagnosis of general paresis. An anti-Parkinson drug was given. Finally he fell in a state of muteness and became bedridden. He had been hospitalized for 21 years and died from bronchopneumonia. The pathological findings were strikingly similar to post-encephalitic parkinsonism in addition to a healed state of general paresis. They consisted of a widespread nerve cells loss, gliosis and the presence of Alzheimer's neurofibrillary tangles in the substantia nigra. In the cerebral cortex, a diffuse loss of nerve cells and the presence of a weak positive iron reaction were observed. The coexistence of general paresis and post-encephalitic parkinsonism is unusual and the authors discussed the etiological relationship between the two different conditions.

Neurosyphilis revisited. A contemporary wolf in sheep's clothing?

Neurosyphilis has become an uncommon clinical problem, for primary and secondary infections are usually recognised and treated early and successfully. However, patients occasionally receive no treatment for their acute infections--usually because they fail to seek advice--or may receive inadequate therapy when prescribed oral penicillin for other infections. The natural course of the disease is thus influenced, but the syphilis is not cured. Variegated clinical presentations of late disease arise and may make objective diagnosis difficult, especially when this occurs in a clinical setting where neurosyphilis may not be entertained in the initial diagnostic deliberations. Details of three such patients, seen during the last five years in the Aberdeen hospitals, are described--and highlight the range and diversity of clinical presentations which may occur, and typify the problem of making a firm diagnosis while the condition is still potentially curable.

Tabes dorsalis progressing to general paresis after 20 years despite routine penicillin therapy

A man with a history of treatment for early syphilis presented with tabes dorsalis. Despite receiving a course of penicillin accepted as adequate by the World Health Organisation the illness progressed to tabo-paresis after 20 years. Reinfection cannot be excluded.

Seronegative dementia paralytica: report of a case

Dementia paralytica may present diagnostic difficulties when routine serological test using a non-treponemal antigen is non-reactive. We present an illustrative demented patient who initially had negative VDRL test both in his serum and cerebrospinal fluid. However, the brain biopsy specimen showed active meningoencephalitis. By special staining technique, a spiral organism was found in the brain exhibiting morphology perfectly compatible with treponema pallidum. Later in the course, the VDRL became reactive in the blood but remained non-reactive in the cerebrospinal fluid. On the basis of the experience of other workers in the field and ours with this patient, we advise the use of FTA-ABS test as a screening procedure in patients with neurological problems of possible syphilitic origin. We urge further research in this field.