Neurosyphilis cerebrospinal fluid findings in patients with ocular syphilis

Enhancing clinical awareness: retrospective analysis of neurosyphilis cases and diagnostic predictors for early recognition and treatment

OBJECTIVE

This is a retrospective analysis of clinical data from individuals diagnosed with neurosyphilis, aiming to enhance healthcare professionals' understanding of the disease and expedite early diagnosis and intervention.

METHODS

A retrospective analysis was conducted on the clinical records of 50 patients who received a diagnosis of symptomatic neurosyphilis and were admitted to the Neurology Department during the period spanning January 2012 to December 2022.

RESULTS

Clinical manifestations encompassed diverse phenotypes, with syphilitic meningitis accounting for 16% of cases, characterized by symptoms such as headache, blepharoptosis, paralysis, blurred vision, and tinnitus. Meningovascular syphilis presented in 36% of cases, exhibiting episodic loss of consciousness, limb numbness, and limb convulsion. Paralytic dementia manifested in 36% of cases, featuring symptoms such as memory loss, sluggish response, and slow movement. Tabes dorsalis was observed in 12% of cases, presenting with weakness, numbness, and staggering. Routine cerebrospinal fluid (CSF) analysis indicated abnormal white blood cell counts in 60% of patients, while biochemical testing revealed abnormal protein content in 52% of patients. Notably, statistically significant differences were observed between patients with interstitial and parenchymatous neurosyphilis (Z = 2.023, P = 0.044) in terms of CSF protein content. Electroencephalogram (EEG) results were abnormal in six patients, and imaging studies unveiled diverse findings in 46 patients.

CONCLUSION

The study highlights the importance of neurological and/or ocular symptoms in diagnosing symptomatic neurosyphilis. Individuals with hypomnesia should be closely monitored for potential neurosyphilis. Integrating clinical manifestations, laboratory tests, EEG, and imaging can reduce misdiagnosis. This comprehensive approach shows promise in improving early identification and management of neurosyphilis.

Syphilis for dermatologists: Current concepts

Dermatologists are familiar with the classic aspects of syphilis. Our objective in this update is to display novel features of sexually acquired syphilis, its pathophysiology, natural history, atypical clinical variants, skin of color, clinical pearls, and prospects. Textbook knowledge, congenital syphilis, epidemiology, and historical data are excluded.

An Updated Review of Recent Advances in Neurosyphilis

Neurosyphilis is caused by Treponema pallidum invading the central nervous system, of which the incidence is increasing worldwide. Due to its variable clinical manifestations, diagnosis of neurosyphilis remains challenging, especially the asymptomatic form. This review focuses on recent advances in neurosyphilis, including epidemiology, clinical manifestations, laboratory findings, comorbidities, diagnosis, treatment, prognosis, and basic research. The expansion of men who have sex with men and the infection of human immunodeficiency virus mainly accounted for the increasing incidence of neurosyphilis. The rate of some historically described forms of neurosyphilis in the pre-antibiotic era declined significantly; atypical features are more prevalent. Neurosyphilis, regarded as a great mimicker for neuro-ophthalmic, audio-vestibular, and psychiatric disorders, often presents concomitantly with other diseases, including metabolic disorders. Studies on long non-coding RNAs, miRNAs, chemokines, and metabolites in peripheral blood and cerebrospinal fluid may facilitate exploring the pathogenesis and identifying novel biomarkers of neurosyphilis. The drug resistance of Treponema pallidum to penicillin has not been reported; ceftriaxone was proposed to be more effective than penicillin, whereas few randomized controlled trials supported this view. This study may pave the way for further research, especially the diagnosis and treatment of neurosyphilis.

Ophthalmologic Assesment of Patients with Syphilitic Optic Neuropathy

PURPOSE

To assess the different clinical findings and symptoms of patients with optic neuritis (ON) and uveitis, who were diagnosed with syphilis.

METHODS

The medical records of patients, who had ocular involvement of syphilis, were retrospectively reviewed. Thirteen patients with syphilitic optic neuropathy (SON) were enrolled and underwent complete ophthalmological examinations and auxiliary laboratory testing.

RESULTS

Nine patients (69.2%) had comorbidities in addition to syphilis. One patient (with two eyes) presented with retrobulbar neuritis, and 12 patients (with 17 eyes) presented with anterior optic neuritis. Three patients (23.1%) had no uveitis, and 10 patients (76.9%) had uveitis in cases with SON. Four eyes (16.6%) had subretinal fluid, and three eyes (12.5%) had cystoid macular edema.

CONCLUSIONS

Visual function can be preserved with early diagnosis and proper treatment. Accordingly, newly diagnosed patients with ON and uveitis should undergo syphilitic investigation in routine practice.

Diagnostic value of lumbar puncture for the etiological assessment of uveitis: a retrospective cohort of 188 patients

AIM

To assess the relevance of lumbar puncture (LP) for the etiological diagnosis of uveitis and to establish predictive factors associated with its contributory use.

METHODS

We performed a retrospective study of patients with de novo uveitis who were referred to our tertiary hospital for etiological diagnosis of uveitis, between January 2003 and July 2018. We included patients who underwent a LP as part of the etiological assessment of uveitis. LP was considered as contributory if it led to the etiological diagnosis or to correct the initially suspected diagnosis.

RESULTS

One hundred eighty eight of the 1211 patients referred for evaluation (16%) had an LP, among these patients, 93 (49.4%) had abnormal results including 69 (36.7%) patients with hypercellularity, 69 (36.7%) with hyperproteinorachia, and 28 (14.9%) with oligoclonal bands and/or increased IgG index. LP was considered as contributing to the diagnosis in only 31 (16.4%) cases, among which there were 10 (5.3%) contributions to the etiological diagnosis and 21 (11.2%) modifications in the diagnosis classification. Multivariate analysis established that African ethnicity (p < 0.001), bilateral uveitis (p = 0.01), presence of macular edema or retinal serous detachment (p = 0.048), presence of retinal vasculitis (p < 0.001), presence of neurological signs or symptoms (p = 0.01), and contributing cerebral MRI (p < 0.001) were all significantly associated with a contributory LP. LP did not lead to any therapeutic modification.

CONCLUSION

LP direct contribution to the diagnosis was rare and most often detected non-specific abnormalities. LP should be performed only in cases of neurological clinical signs or symptoms, suspicion of multiple sclerosis, Vogt-Koyanagi-Harada, or syphilis.

Ocular Syphilis Presenting As Non-arteritic Anterior Ischemic Optic Neuropathy

Syphilis is a sexually transmitted disease caused by the spirochetal bacteria Treponema pallidum. It can cross the blood-brain barrier within days of the infection, causing neurosyphilis and ocular syphilis at any stage of the disease. Ocular syphilis can manifest in any part of the eye but usually as posterior uveitis and pan-uveitis or various types of inflammatory or immune-mediated optic neuritis. Misdiagnosing ocular syphilis as a non-infectious disease has been reported even when seen by ophthalmologists due to the wide variety of possible presentations. In this case report, we describe a case of ocular syphilis that presented with a non-arteritic anterior ischemic optic neuropathy (NA-AION), which to our knowledge, has not been described before in the literature.