Normalization of serum rapid plasma reagin titer predicts normalization of cerebrospinal fluid and clinical abnormalities after treatment of neurosyphilis

State-of-the-Art Review: Neurosyphilis

We review key concepts in the diagnosis, treatment, and follow-up of individuals with neurosyphilis. We describe the epidemiology of syphilis in the United States, highlight populations that are markedly affected by this infection, and attempt to estimate the burden of neurosyphilis. We describe the cardinal clinical features of early and late (tertiary) neurosyphilis and characterize the clinical significance of asymptomatic neurosyphilis in the antibiotic era. We review the indications for cerebrospinal fluid (CSF) examination and the performance characteristics of different CSF assays including treponemal and lipoidal antibodies, white cell count, and protein concentration. Future biomarkers and the role of imaging are briefly considered. We review preferred and alternative treatments for neurosyphilis and evidence for their use, including evidence for the use of enhanced intramuscular benzathine penicillin G to supplement intravenous penicillin.

AEDV Expert Consensus for the Management of Syphilis

Syphilis -the "great simulator" for classical venereologists-is re-emerging in Western countries despite adequate treatment; several contributing factors have been identified, including changes in sexual behaviour, which won't be the topic of this article though. In 2021, a total of 6613 new cases of syphilis were reported in Spain, representing an incidence of 13.9×100 000 inhabitants (90.5%, men). Rates have increased progressively since 2000. The clinical presentation of syphilis is heterogeneous. Although chancroid, syphilitic roseola and syphilitic nails are typical lesions, other forms of the disease can be present such as non-ulcerative primary lesions like Follmann balanitis, chancres in the oral cavity, patchy secondary lingual lesions, or enanthema on the palate and uvula, among many others. Regarding diagnosis, molecular assays such as PCR have been replacing dark-field microscopy in ulcerative lesions while automated treponemal tests (EIA, CLIA) are being used in serological tests, along with classical tests (such as RPR and HAART) for confirmation and follow-up purposes. The interpretation of these tests should be assessed in the epidemiological and clinical context of the patient. HIV serology and STI screening should be requested for anyone with syphilis. Follow-up of patients under treatment is important to ensure healing and detect reinfection. Serological response to treatment should be assessed with the same non-treponemal test (RPR/VDRL); 3-, 6-, 12-, and 24-month follow-up is a common practice in people living with HIV (PLHIV). Sexual contacts should be assessed and treated as appropriate. Screening is advised for pregnant women within the first trimester of pregnancy. Pregnant women with an abortion after week 20 should all be tested for syphilis. The treatment of choice for all forms of syphilis, including pregnant women and PLHIV, is penicillin. Macrolides are ill-advised because of potential resistance.

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.

All Eyes and Ears: A Case of Neurosyphilis Presenting With Simultaneous Ocular and Otic Involvement

This report details a case of neurosyphilis manifesting as concurrent ocular and otosyphilis, an uncommon presentation of the disease. Here, we describe the diagnosis and treatment of a 27-year-old immunocompetent Caucasian male who presented with uveitis and tinnitus. Physical exam was consistent with uveitis and audiometric testing revealed bilateral sensorineural hearing loss. Serum rapid plasma reagin (RPR) was reactive at 1:512 with a follow-up cerebrospinal fluid (CSF) venereal disease research laboratory (VDRL) test likewise reactive at 1:2, confirming neurosyphilis. The patient was treated with intravenous penicillin G with improvement of symptoms and with subsequent improvement of serum and CSF RPR. However, he ultimately represented with recurrent symptoms and fluctuating serum RPR levels, necessitating repeat treatment and ongoing clinical monitoring. Neurosyphilis can occur at any point during the course of a syphilis infection and may present with a variety of nonspecific findings. This case documents a particularly uncommon instance of simultaneous ocular and otosyphilis, a presentation of neurosyphilis that has only been described a handful of times.

Neurosyphilis: insights into its pathogenesis, susceptibility, diagnosis, treatment, and prevention

Background and aim

Invasion of the central nervous system by Treponema pallidum can occur at any stage of syphilis. In the event that T. pallidum is not cleared promptly, certain individuals may experience progression to neurosyphilis, which manifests as cognitive and behavioral abnormalities, limb paralysis, and potentially fatal outcomes. Early identification or prevention of neurosyphilis is therefore crucial. The aim of this paper is to conduct a critical and narrative review of the latest information focusing exclusively to the pathogenesis and clinical management of neurosyphilis.

Methodology

To compile this review, we have conducted electronic literature searches from the PubMed database relating to neurosyphilis. Priority was given to studies published from the past 10 years (from 2013 to 2023) and other studies if they were of significant importance (from 1985 to 2012), including whole genome sequencing results, cell structure of T. pallidum, history of genotyping, and other related topics. These studies are classic or reflect a developmental process.

Results

Neurosyphilis has garnered global attention, yet susceptibility to and the pathogenesis of this condition remain under investigation. Cerebrospinal fluid examination plays an important role in the diagnosis of neurosyphilis, but lacks the gold standard. Intravenous aqueous crystalline penicillin G continues to be the recommended therapeutic approach for neurosyphilis. Considering its sustained prominence, it is imperative to develop novel public health tactics in order to manage the resurgence of neurosyphilis.

Conclusion

This review gives an updated narrative description of neurosyphilis with special emphasis on its pathogenesis, susceptibility, diagnosis, treatment, and prevention.

Syphilis

Syphilis is a curable systemic infectious disease with a clear increase in incidence in recent years. The disease presents with a broad clinical spectrum and challenges clinicians due to the long incubation period and the sometimes complex interpretation of serological test results. Penicillin G remains the treatment of choice in all stages of syphilis.

Syphilis

Syphilis is an important public health problem in the U.S. and many high-income nations. The rates of syphilis continue to increase and there is an urgent need for medical providers of a variety of backgrounds to recognize this disease. In this review, we cover the key clinical findings of syphilis and provide an overview of the diagnosis and management of this disease in adults.

Ceftriaxone compared with penicillin G for the treatment of neurosyphilis: study protocol for a multicenter randomized controlled trial

BACKGROUND

Neurosyphilis may cause irreversible neurological sequelae. First-line treatment consists of penicillin G, with ceftriaxone being an alternative treatment in patients allergic to penicillin. The lack of clinical data comparing the efficacy of these two drugs indicated the need for comparative clinical trials to improve national treatment guidelines in China.

METHODS/DESIGN

In this multicenter randomized controlled clinical trial, 290 patients newly diagnosed with neurosyphilis will be randomized 1:1 to treatment with aqueous crystalline penicillin G (ACPG) or ceftriaxone. Patients will be treated with standard regimens of ACPG or ceftriaxone according to Chinese National Guidelines and will be followed up for 12 months. All clinical parameters will be assessed at baseline and at follow-up 3, 6, 9, and 12 months later. The primary outcomes will include cerebrospinal fluid (CSF) white blood cell (WBC) count, serological efficacy, and clinical efficacy. The secondary outcomes will include CSF protein concentrations, Mini-Mental State Examination (MMSE) scores, imaging results, recurrence, and time to recovery from neurosyphilis. Adverse events will be monitored and recorded during the trial.

DISCUSSION

This trial will provide clinical data to determine whether ceftriaxone is non inferior to ACPG in treating neurosyphilis and will provide evidence for the improvement of treatment guidelines.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100047164. Registered on 9 June 2021 and updated on 23 November 2021.

Clinical Reasoning: A 68-Year-Old Man With Palmar Rash, Leg Pain, and Inability to Walk

We are reporting a 68-year-old man with palmar rash, leg pain and inability to walk, whose neurologic examination localized to multiple roots, leading to the diagnosis of polyradiculopathy. Polyradiculopathy has both structural and non-structural etiologies. Structural etiologies include spinal stenosis, tethered cord syndrome, tumors, and leptomeningeal metastasis. Non-structural etiologies include inflammatory, infectious, metabolic, and other neoplastic processes. His palmar rash in conjunction with neurological signs/symptoms raised the suspicion for an infectious etiology, and eventually serology and lumbar puncture confirmed the final diagnosis. In this report, we will further discuss how we determined the localization of polyradiculopathy, its specific etiologies, management decisions, and a transient complication, before he achieved a significant improvement at 6 months.

Case Report: A Case Report of Neurosyphilis Mimicking Limbic Encephalitis

Neurosyphilis (NS) is an infection of the central nervous system caused by Treponema pallidum. It mimics various neurological and psychiatric diseases. In recent years, there have been several NS cases that manifest as limbic encephalitis (LE). Therefore, the diagnosis of neurosyphilis in the early stages is difficult. Here, we present a case of an NS patient who presented with LE manifestation. The 62-year-old woman presented with acute clinical manifestations of gibberish speech, poor memory, and seizures. Brain MRI showed abnormal signals on the right medial temporal lobe. In addition, the patient had a positive serum leucine-rich glioma inactivated 1 (LGI1) antibody with a titer of 1:16. Therefore, an initial diagnosis of anti-LGI1 encephalitis was made. However, further tests carried out showed positive rapid plasma reagin (RPR), and treponema pallidum particle agglutination (TPPA) tests both in the serum and the cerebrospinal fluid (CSF). Therefore, uncertainty arose as to whether the patient had both anti-LGI1 encephalitis and NS or whether the LGI1 antibody and LE manifestations were due to the NS. The patient was initiated on the recommended dose of penicillin G sodium. Following treatment, the patient reported a significant improvement in clinical symptoms, normal signals in the right temporal lobe, and a negative serum LGI1 antibody. These findings suggested that NS induced the LE manifestations and the production of the LGI1 antibody. This case demonstrates that testing syphilis in patients with LE is important and positive autoimmune encephalitis (AE) antibodies in NS patients need to be viewed and interpreted with greater caution.

Management of Adult Syphilis: Key Questions to Inform the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines

A panel of experts generated 5 "key questions" in the management of adult syphilis. A systematic literature review was conducted and tables of evidence were constructed to answer these questions. Available data suggest no clinical benefit to >1 dose of benzathine penicillin G for early syphilis in human immunodeficiency virus (HIV)-infected patients. While penicillin remains the drug of choice to treat syphilis, doxycycline to treat early and late latent syphilis is an acceptable alternate option if penicillin cannot be used. There are very limited data regarding the impact of additional antibiotic doses on serologic responses in serofast patients and no data on the impact of additional antibiotic courses on long-term clinical outcomes. In patients with isolated ocular or otic signs and symptoms, reactive syphilis serologic results, and confirmed ocular/otic abnormalities at examination, a diagnostic cerebrospinal fluid (CSF) examination is not necessary, because up to 40% and 90% of patients, respectively, would have no CSF abnormalities. Based on the results of 2 studies, repeated CSF examinations are not necessary for HIV-uninfected patients or HIV-infected patients on antiretroviral therapy who exhibit appropriate serologic and clinical responses after treatment for neurosyphilis. Finally, several important gaps were identified and should be a priority for future research.

'Neurosyphilis in the Northern Territory of Australia: a clinical guideline'

BACKGROUND

The Northern Territory (NT) of Australia is currently experiencing a syphilis epidemic. Neurosyphilis is commonly considered in the differential diagnosis for patients presenting with neurologic conditions such as dementia and stroke in the NT.

AIMS

To explore the local epidemiologic, diagnostic and treatment complexities of neurosyphilis in the NT and produce a guideline for clinical practice.

METHODS

A database search was undertaken and local and global neurosyphilis guidelines were analysed. A guideline was created based on findings of the critical review and consultation with local multi-disciplinary experts.

RESULTS

Neurosyphilis is frequently encountered in the NT but studies suggest it is often under-treated. Dementia is the most common clinical presentation locally. Establishing a diagnosis of neurosyphilis is complex and requires stepwise evaluation of clinical, laboratory and radiological findings.

CONCLUSIONS

A clinical guideline and algorithm have been developed for the diagnosis and management of patients with neurosyphilis. This article is protected by copyright. All rights reserved.

Neurosyphilis in a suspected case of giant cell arteritis

A 67-year-old man had a few month history of deteriorating visual acuity. He had originally presented to ophthalmology with right-sided visual blurring. This subsequently progressed to involve the left eye. At this point, he was empirically treated with high-dose glucocorticoids, both orally and intravenously, with the suspicion that giant cell arteritis was causing acute visual deterioration of his left eye. Unfortunately, his symptoms did not improve. During an admission to hospital for a pneumonia, he underwent further investigations for this bilateral visual loss. He was diagnosed with left neuroretinitis and right vitritis. A thorough workup revealed positive syphilis serology and cerebrospinal fluid was positive on venereal disease research laboratory testing. He was diagnosed and treated for neurosyphilis with intravenous benzylpenicillin 4 million units 4 hourly for 14 days. His left-sided vision improved but he still suffers from severe visual impairment in his right eye.

Neurosyphilis

PURPOSE OF REVIEW

This article focuses on the epidemiology, clinical presentation, diagnosis, and management of neurosyphilis, with an emphasis on clinically relevant issues faced by the practicing neurologist.

RECENT FINDINGS

The incidence of primary and secondary syphilis, the sexually transmissible stages of infection, has been on the rise for the past 2 decades. A concerning recent trend is the surge in cases of syphilis in women and of congenital syphilis. Neurosyphilis remains a relatively common complication that can occur at any stage of syphilis. Along with meningitis, meningovascular syphilis, which has been historically described as a late presentation of neurosyphilis, now frequently occurs as a manifestation of early infection. Late forms of neurosyphilis, including tabes dorsalis and general paresis, are less prevalent in the era of widespread penicillin use. As more laboratories adopt the reverse-sequence algorithm for syphilis testing, patients with serodiscordant results (ie, a reactive serum treponemal test with a nonreactive nontreponemal test) may present an increasingly encountered diagnostic challenge for neurologists. Although the CSF Venereal Disease Research Laboratory (VDRL) remains a mainstay of diagnostic testing for neurosyphilis, using a higher titer cutoff (greater than 1:320) for the Treponema pallidum particle agglutination assay (TPPA) from the CSF may improve the utility of the TPPA as a supporting criterion for the diagnosis of neurosyphilis. Penicillin G is the treatment of choice for neurosyphilis, although ceftriaxone may be a reasonable alternative therapy.

SUMMARY

A high index of suspicion and awareness of the variable clinical presentations of neurosyphilis are essential to the approach to this treatable infection. Neurologists should be mindful of the limitations of serologic testing in the diagnosis of neurosyphilis and exercise clinical judgment to determine the likelihood of the diagnosis.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

The Intersection of HIV and Syphilis: Update on the Key Considerations in Testing and Management

Purpose of Review

To highlight recent trends in the epidemiology of HIV and syphilis, the impact of the COVID epidemic, our approach to care of co-infected patients, and our views on important next steps in advancing the field.

Recent Findings

HIV and syphilis co-infection has been on the rise in recent years although since the COVID pandemic there is a decrease in new diagnoses—it remains unclear if this represents a true decline or inadequate testing or under-reporting. Standard HIV care should include regular syphilis serology .Treatment and serological follow-up of syphilis in HIV positive and negative patients can be conducted similarly. Challenges remain in the diagnosis and management of neurosyphilis. New models for testing and prevention will be crucial next steps in controlling co-infection.

Summary

The intersection of HIV and syphilis infections continues to pose new and unique challenges in diagnosis, treatment, and prevention.

Brazilian Protocol for Sexually Transmitted Infections 2020: acquired syphilis

The Clinical Protocol and Therapeutic Guidelines for Comprehensive Care of People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health in 2020, includes updates concerning acquired syphilis. The document comprises rapid test use, safety and efficacy of benzathine benzylpenicillin, case follow-up, neurosyphilis clinical and laboratory management, approaching sex partners, assistance and monitoring of diagnosed pregnant women, and syphilis and HIV co-infection specificities, as well as a case notification summary. Health managers and professionals must be continuously trained so as to integrate care and surveillance, to strengthen actions for efficient control of syphilis, to broaden the search for sex partners, and to expand access of most vulnerable populations to health services. Most people with syphilis are asymptomatic; this contributes to the maintenance of the transmission chain. Without adequate treatment of pregnant women with syphilis, severe consequences can occur, such as miscarriage, prematurity, low birth weight, natimortality, and congenital syphilis.

Prevalence of Self-reported Neurologic and Ocular Symptoms in Early Syphilis Cases

BACKGROUND

Neurosyphilis, a complication of syphilis, can occur at any stage of infection. Measuring the prevalence of neurosyphilis is challenging, and there are limited data on the prevalence of neurologic or ocular symptoms among patients with syphilis. We sought to describe the prevalence of neurologic and/or ocular symptoms among early syphilis (ES) cases and the clinical management of symptomatic cases enrolled in the STD Surveillance Network (SSuN) Neuro/Ocular Syphilis Surveillance project.

METHODS

Persons diagnosed with ES were selected for interviews based on current health department protocols in 5 participating SSuN jurisdictions from November 2016 through October 2017. All interviewed ES cases were screened for self-reported neurologic and/or ocular symptoms. Additional clinical information on diagnostic testing and treatment for cases concerning for neurosyphilis/ocular syphilis was obtained from providers.

RESULTS

Among 9123 patients with ES who were interviewed, 151 (1.7%; 95% confidence interval [CI], 1.4%-1.9%) reported ≥ 1 neurologic or ocular symptom. Of the 53 (35%) who underwent lumbar puncture, 22 (42%) had documented abnormal cerebrospinal fluid, of which 21 (95%) were treated for neurosyphilis/ocular syphilis. Among the remaining 98 symptomatic patients with no documented lumbar puncture (65%), 12 (12%) were treated for and/or clinically diagnosed with neurosyphilis/ocular syphilis.

CONCLUSIONS

We observed a low prevalence of self-reported neurologic and/or ocular symptoms in interviewed ES cases. Approximately one-third of ES cases who self-reported symptoms underwent further recommended diagnostic evaluation. Understanding barriers to appropriate clinical evaluation is important to ensuring appropriate management of patients with possible neurologic and/or ocular manifestations of syphilis.

Ocular syphilis

Syphilis is a sexually transmitted, systemic, inflammatory disease caused by the spirochaete, Treponema pallidum. The natural history of untreated syphilis progresses through four distinct stages: primary, secondary, latent, and tertiary syphilis. Ocular involvement can occur at any stage of syphilis and any part of the eye can be affected. With the exception of syphilitic posterior placoid chorioretinitis, the diverse manifestations of ocular syphilis have few distinct features that can be used to assist in clinical diagnosis. Therefore, ocular syphilis should always be a part of the differential diagnosis of most, if not all, ocular infectious and inflammatory presentations. Specifically, uveitis presentations, high-risk sexual history, illicit drug use history, treatment failure, prior history of syphilis should prompt further diagnostic workup for ocular syphilis. A presumptive diagnosis of ocular syphilis relies on serological testing, both treponemal and nontreponemal tests. All patients with ocular syphilis should have their cerebrospinal fluids tested for the co-existence of neurosyphilis and their blood tested for human immunodeficiency virus co-infection. In the United States, Centers for Disease Control and Prevention recommend that ocular syphilis be managed according to its treatment guidelines for neurosyphilis, with parenteral aqueous crystalline penicillin G the drug of choice. With the timely diagnosis and appropriate treatment, ocular syphilis is curable. However, delayed diagnosis of ocular syphilis may result in long-term visual impairment. Delayed diagnosis occurs because of its diverse presentations mimicking other ocular diseases, and failure of the clinician to order serological testing. With the recent worldwide resurgence of ocular syphilis, clinicians should be familiar with the manifestation, diagnosis, and treatment of ocular syphilis.

Ocular and neurosyphilis: epidemiology and approach to management

PURPOSE OF REVIEW

In the context of a resurgence of syphilis worldwide, it can be anticipated that a rise in cases of ocular, otic, and neurosyphilis will also be seen. This article reviews the current epidemiology, manifestations, and approach to management and treatment.

RECENT FINDINGS

Although studies continue investigating alternate approaches and new diagnostic tests for ocular and neurosyphilis, few data exist to change current diagnostic algorithms and approaches to diagnosis, management, or follow up.

SUMMARY

The diagnosis of neurologic and eye/ear involvement with syphilis may be delayed because of a lack of specificity of findings, low suspicion for syphilis, fluctuation in symptoms, and/or similarities in presentation to other diseases. A high index of suspicion for syphilis and re-education about the protean manifestations of syphilis by all clinicians is required provide timely diagnosis and management of ocular, otic, and neurosyphilis.

[Brazilian Protocol for Sexually Transmitted Infections 2020: acquired syphilis]

The Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Ministry of Health of Brazil in 2020, includes the update on acquired syphilis. The document comprises rapid tests use, safety and efficacy of the administration of benzathine benzylpenicillin, follow-up of cases, clinical and laboratory management of neurosyphilis, approach to sexual partnerships, assistance and monitoring of diagnosed pregnant women, and specificities of syphilis and HIV co-infection, as well as a summary of the notification of cases. It is necessary to train health managers and professionals on a continuous basis, with a view to integrating care and surveillance, strengthening effective syphilis control actions, increasing the search for sexual partnerships, and expanding the access of the most vulnerable populations to health services.

Neurosyphilis Treatment Outcomes After Intravenous Penicillin G Versus Intramuscular Procaine Penicillin Plus Oral Probenecid

BACKGROUND

Data comparing neurosyphilis treatment regimens are limited.

METHODS

Participants were enrolled in a study of cerebrospinal fluid (CSF) abnormalities in syphilis that was conducted at the University of Washington between April 2003 to May 2014. They were diagnosed with syphilis and referred by their providers due to concerns for neurosyphilis. We evaluated 150 people with CSF abnormalities who were treated with either intravenous aqueous penicillin G (PenG) or intramuscular aqueous procaine penicillin G plus oral probenecid (APPG-P). An abnormal CSF diagnosis was defined as a white blood cell (WBC) count >20/µL, a CSF protein reading >50 mg/dL, or a reactive CSF-Venereal Disease Research Laboratory test (VDRL). Hazard ratios for normalization of CSF or serum measures were determined using Cox regression.

RESULTS

In individuals treated with either PenG or APPG-P, CSF WBCs and CSF-VDRL reactivity normalized within 12 months after treatment, while protein normalized more slowly and less completely. There was no relationship between treatment regimen or human immunodeficiency virus (HIV) status and likelihood of normalization of any measure. Among those living with HIV, CSF WBC counts and CSF-VDRL reactivity were more likely to normalize in those treated with antiretrovirals. Unexpectedly, CSF WBCs were more likely to normalize in those with low CD4+ T cell counts. When neurosyphilis was more stringently defined as a reactive CSF-VDRL, the relationship with the CD4+ T cell count remained unchanged.

CONCLUSIONS

In the current antiretroviral treatment era, neurosyphilis treatment outcomes are not different for PenG and APPG-P, regardless of HIV status. The relationship between the normalization of CSF WBC counts and CD4+ T cell counts may indicate continued imprecision in neurosyphilis diagnostic criteria, due to HIV-related CSF pleocytosis.

Neurosyphilis and Lyme neuroborreliosis

PURPOSE OF REVIEW

Neurosyphilis (NS) and Lyme neuroborreliosis (LNB) are spirochetal diseases with distinct clinical manifestations. The diagnosis of NS remains challenging due to imperfect diagnostic criteria and testing modalities. With LNB, misconceptions about diagnosis and treatment lead to considerable morbidity and drug related adverse effects.

RECENT FINDINGS

Although studies continue investigating alternate approaches and new diagnostic tests for NS, few data exist to change current approaches to diagnosis, management or follow up. In the diagnosis of LNB, the chemokine CXCL13 shows promising diagnostic accuracy. A systematic review discourages the use of cell-based assays when investigating Lyme disease. Clinical studies show no benefit from extended antibiotic treatment for patients with unspecific symptoms labelled as having Lyme disease.

SUMMARY

The diagnosis of NS may be delayed due to a lack of specificity of findings, low suspicion for syphilis, and/or similarities in presentation to other diseases. A high index of suspicion for syphilis is required provide timely diagnosis and management of NS. Fortunately, penicillin remains the treatment of choice. Overdiagnosis and overtreatment in patients labelled as having Lyme disease can be avoided by an evidence-based approach towards diagnosis and treatment.

Decomplexifying Serum and Cerebrospinal Fluid (CSF) Serologic Testing of Neurosyphilis: A Case Report of Ocular Syphilis and Highlights of the Principles of Serologic Testing

Serologic tests for syphilis can be quite complex. The screening and confirmatory tests, which number at least eight, are mathematically interpreted as a total of 16 possible combinations, if we choose one test from each of two sets of four. However, this bewildering complexity is simplified if we apply certain principles. We reiterate and propose four axioms. First, we distinguish between treponemal versus non-treponemal tests. The former, the treponemal test, is specific for the spirochete, treponema pallidum, and is used as a confirmatory test. It rarely declines over time. The latter, the non-treponemal test, is a screening test and reflects treponemal or tissue damage, is reported as a titer, and is used to monitor disease activity. We usually need both for screening and confirmatory diagnostic testing. Secondly, for rapid plasma reagin (RPR) tests, a non-treponemal serology test titer of at least 1:8 is suggestive of syphilis, but not necessarily neurosyphilis. A false-negative test usually registers below this dilution level and may be due to the "prozone phenomenon". Serum RPR titers are usually greater than 1:32. Thirdly, a negative treponemal test in the cerebrospinal fluid excludes neurosyphilis and a positive test is highly sensitive but lacks specificity, usually due to blood contamination. Most patients with neurosyphilis will have a positive non-treponemal test in the cerebrospinal fluid (CSF) with elevated protein and pleocytosis. Fourthly, a serological cure is defined as at least a four-fold decline in a non-treponemal test titer at three and six months, or a persistently low titer after treatment. Patients who do not fulfill these criteria are known as "serofast". We describe the case of a 38-year-old man with human immunodeficiency virus-type 1 who developed bilateral optic disc edema with photopsias and transient visual obscurations.

2020 European guideline on the management of syphilis

The 2020 edition of the European guideline on the management of syphilis is an update of the 2014 edition. Main modifications and updates include: -The ongoing epidemics of early syphilis in Europe, particularly in men who have sex with men (MSM) -The development of dual treponemal and non-treponemal point-of-care (POC) tests -The progress in non-treponemal test (NTT) automatization -The regular episodic shortage of benzathine penicillin G (BPG) in some European countries -The exclusion of azithromycin as an alternative treatment at any stage of syphilis -The pre-exposure or immediate post-exposure prophylaxis with doxycycline in populations at high risk of acquiring syphilis.

Incidental finding of neurosyphilis with intracranial hemorrhage and cerebral infarction: A case report

Syphilis has recently increased in prevalence in Japan. Neurosyphilis is a special pathological condition of syphilis well known to cause cerebral vasculitis and ischemic stroke. Neurosyphilis in the meningovascular stage rarely causes caliber irregularity of the cerebral blood vessels or cerebral hemorrhage. We describe the case of a 49-year-old Japanese man with neurosyphilis. Cerebral hemorrhage, multiple cerebral infarctions, and caliber irregularity of the cerebral blood vessels were observed, the patient underwent surgery for cerebral hemorrhage on the day of admission, all of which were suspected to be caused by syphilis. He was started on an antibacterial treatment of penicillin on the day of admission and was diagnosed with neurosyphilis the following week based on his serum and spinal fluid test results. His condition improved, and he was transferred to another hospital after 4 weeks of treatment consisting of 3 weeks of infusion treatment with benzylpenicillin followed by oral treatment with amoxicillin. To the best of our knowledge, this is a rare case of neurosyphilis in conjunction with cerebral hemorrhage and cerebral infarction. Clinicians should consider syphilis in the differential diagnosis of cerebral hemorrhage and cerebral infarction and test patients for sexually transmitted diseases, in addition to cerebrospinal fluid testing, when cerebral hemorrhage occurs with an unknown cause. This is especially pertinent when patients present with cerebral infarction or caliber irregularity of the cerebral blood vessels.

Management of Intraocular Infections in HIV

Purpose: Overview of treatment options for the most common intraocular opportunistic infections in patients with acquired immunodeficiency syndrome (AIDS), including ocular syphilis, ocular tuberculosis, toxoplasmic chorioretinitis, and viral retinitis. Method: Narrative Review. Results: Despite the huge advances in the development of combined antiretroviral therapy (cART) for the management of patients with human immunodeficiency virus (HIV) infection, opportunistic infections still represent a significant diagnostic dilemma and cause of ocular morbidity in patients with HIV. Conclusion: Although the treatment of intraocular infections in patients with AIDS may be challenging, prompt assessment of the clinical features and appropriate aggressive management of the underlying etiology are critical to avoid life and vision threatening.

Ocular syphilis in an immunocompetent host

Syphilis is an old disease that experienced a resurgence with the emergence of HIV/AIDS. Syphilis is a reportable infection that is monitored by the Centers for disease Control (CDC) in the U.S. and rates have been rising since 2000. Although ocular syphilis is a well known consequence of syphilis infection it continues to be less frequently diagnosed, partially because ocular manifestations are not reportable to CDC. While the majority of recent cases in the U.S. have been reported in men who have sex with men (MSM) population, 50 % of these cases are HIV negative. We present a case of acute iridocyclitis and ocular hypertension due to syphilis infection. This case reiterates the need to increase healthcare workers' awareness of the importance of timely recognition of potential ocular syphilis to prevent visual sequelae from the infection. Ocular syphilis should be kept in the differential diagnosis in immunocompetent/HIV negative patients, and the importance of obtaining a detailed sexual history should not be forgotten.

Analysis of EEG Lemple-Ziv complexity and correlative aspects before and after treatment of anti-syphilis therapy for neurosyphilis

Objective To investigate the diagnostic value of electroencephalogram (EEG) complexity in patients with neurosyphilis by comparing the changes of electroencephalogram Lempel-Ziv complexity (EEG-LZC) before and after anti-syphilis treatment. Methods The EEG complexity of neurosyphilis patients diagnosed in our hospital from July in 2015 to June in 2017 was analyzed and compared with other diagnostic results such as serology examination and cerebrospinal fluid examination. Results A total of 27 patients were diagnosed, including 19 males and 8 females, of which 6 were mesenchymal(cerebrospinal membrane and meningeal vascular), 16 were parenchymal(paralytic dementia, spinal cord tuberculosis and optic neuropathy), and 5 were asymptomatic. After intensive anti-syphilis therapy, the LZC increased significantly in all patients while the trend and degree of change were consistent with other diagnostic results. Conclusion The LZC can be used as one of the diagnostic indexes meanwhile the trend and degree of its change can be used as the reference index of curative effect to neurosyphilis.

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.

Neurosyphilis: The shape of a rising threat

This report describes a case of neurosyphilis presenting with memory disturbances, attention deficit, and acute psychotic decompensation in an immunocompetent man. Despite the known connection of neurosyphilis with psychiatric symptoms, this cause often remains unrecognized. This report emphasizes the importance of maintaining a suspicion for the disease in patients with vague symptoms and describes the diagnostic difficulties.

The performance of rapid plasma reagin (RPR) titer in HIV-negative general paresis after neurosyphilis therapy

BACKGROUND

Repeated nontreponemal serologic test for syphilis titers is recommended to evaluate treatment response. However, it is unknown whether serum rapid plasma reagin (RPR) titer can serve as a surrogate for determining the efficacy of treatment in general paresis (GP) remains unknown.

METHODS

We retrospectively reviewed data from 105 GP patients, who were divided into two groups (62 CSF RPR+ patients and 43 CSF RPR- patients) according to reactive RPR test status in CSF. Clinical assessment included the Mini-Mental State Examination (MMSE) scores, CSF examinations (WBC count, protein concentration and RPR titer), and serum tests (RPR titer and TPPA). Among the 105 GP patients, 13 CSF RPR+ patients and 6 CSF RPR- patients had a 12 months follow-up of CSF, serum measures and MMSE.

RESULTS

The median serum RPR titer was significantly higher in CSF RPR+ patients than that in CSF RPR- GP patients, 1:8 [IQR 1:4-1:32] vs. 1:4 [IQR 1:4-1:8] (P < 0.001). The number of CSF RPR+ patients with serum RPR titer≥1:32 was significantly higher when compared with CSF RPR- patients (P = 0.001). For CSF RPR+ patients, the MMSE scores improved or remained constantly after penicillin treatment. For CSF RPR+ patients, the CSF RPR titer declined four-fold in 85% (11/13) of the patients, whereas the serum RPR titer declined four-fold in only 46% (6/13) of the patients, the odds ratio is 6.4 (95% confidence interval 1.0-41.2).

CONCLUSIONS

A four-fold decline in CSF RPR titer is a good predictor for treatment efficacy in CSF RPR+ GP patients within 12 months after the completion of therapy.

Ischemic Stroke in an HIV Positive Patient: An Initial Presentation of Neurosyphilis

Ischemic stroke occurring in patients with human immunodeficiency virus (HIV) needs to be approached with a vast differential diagnosis in mind. We report a case of middle-aged male patient with immune reconstituted HIV on therapy without known cardiovascular risk factors who had a right middle cerebral artery territory infarct. After a thorough evaluation, he received a final diagnosis of neurosyphilis-associated vasculitis leading to stroke. He recovered without any neurological deficits following treatment with intravenous benzylpenicillin. Neurosyphilis is an easily diagnosed and treatable cause of a stroke that can be an initial presentation of neurosyphilis but requires a high index of suspicion.

Other central nervous system infections: cytomegalovirus, Mycobacterium tuberculosis, and Treponema pallidum

Human immunodeficiency virus (HIV)-infected individuals are particularly susceptible to several central nervous system infections: human cytomegalovirus, which may cause encephalitis, ventriculitis, polyradiculitis, or polyradiculomyelitis; Mycobacterium tuberculosis, which can cause meningitis or space-occupying lesions; and Treponema pallidum subspecies pallidum (T. pallidum), which affects the meninges, cerebrospinal fluid, cranial nerves, and vasculature in early neurosyphilis, and additionally the brain and spinal cord parenchyma in late neurosyphilis. Central nervous system cytomegalovirus infection is seen in HIV-infected individuals with very advanced immunosuppression. Its prognosis is poor and optimal therapy has not been determined. Tuberculous meningitis has a high mortality in those also infected with HIV, especially in the developing world, and better therapies are urgently needed. As the rates of syphilis increase in the developed world, neurosyphilis and in particular ocular syphilis are increasingly reported. The likelihood of all three of these central nervous system infections is decreased in individuals who receive potent antiretroviral therapy.

Serological Response Predicts Normalization of Cerebrospinal Fluid Abnormalities at Six Months after Treatment in HIV-Negative Neurosyphilis Patients

This study aimed to determine whether a serological response could predict the normalization of cerebrospinal fluid (CSF) abnormalities at 6 months after treatment in human immunodeficiency virus (HIV)-negative neurosyphilis patients. A total of 123 neurosyphilis patients were recruited at baseline, 58 of these patients undergoing treatment, repeated CSF examinations and serological tests for syphilis at 6 months after treatment were included in the follow-up study. Before treatment, the CSF rapid plasma reagin (RPR) titer, CSF Treponema pallidum particle agglutination (TPPA) titer, CSF leukocyte count, and CSF protein concentration were correlated with both serum RPR and TPPA titers. At 6 months after treatment, 28 and nine patients achieved serological responses of RPR and TPPA tests, respectively. The sensitivities of the serological response of RPR and TPPA tests for identifying the normalization of CSF abnormalities were 60.0∼83.3% and 17.1~22.2%, respectively; and 75.0∼91.3% of patients showing serological response of RPR test also achieved CSF normalization, suggesting that the serological response could predict CSF normalization to some degree. Particularly, in patients with ≥8-fold decreases in the serum RPR titer, the CSF RPR, CSF leukocyte count, and CSF protein concentration had normalized, and follow-up lumbar puncture could be reduced considering the resolution of neurological symptoms.

Syphilis

Syphilis is a chronic bacterial infection caused by Treponema pallidum that is endemic in low-income countries and and occurs at lower rates in middle-income and high-income countries. The disease is of both individual and public health importance and, in addition to its direct morbidity, increases risk of HIV infection and can cause lifelong morbidity in children born to infected mothers. Without treatment the disease can progress over years through a series of clinical stages and lead to irreversible neurological or cardiovascular complications. Although syphilis is an ancient disease and the principles of recommended management have been established for decades, diagnosis and management are often challenging because of its varied manifestations and difficulty in interpretation of serological tests used to confirm diagnosis and evaluate response to therapy. In North America and western Europe, incidence of syphilis has increased dramatically in the past decade among men who have sex with men, particularly those with coexistent HIV infection. Only one drug, penicillin, is recommended for syphilis treatment and response to therapy is assessed based on changes over months in serological test titres. Treatment for patients who cannot receive penicillin and management of patients who do not serologically respond to treatment are common clinical problems.

The Great Impostor: Transaminitis Masking the Coinfection of Syphilis and Human Immunodeficiency Virus

Introduction. The incidence of syphilis continues to rise in the United States over the past 15 years. This disease process is classified into stages and may present with a coinfection of Human Immunodeficiency Virus (HIV). Case Report. We present a case of a 32-year-old African American male who presented with cutaneous manifestations of secondary syphilis and transaminitis. A workup revealed that the transaminitis was secondary to underlying syphilitic hepatitis in the presence of HIV coinfection. The patient had a reactive rapid plasma reagin (RPR) of 1 : 64 TU and reactive Treponema pallidum particle agglutination assay (TPPA). Lab findings showed alkaline phosphate (ALP) of 648 unit/L, aspartate aminotransferase (AST) of 251 unit/L, and alanine aminotransferase (ALT) of 409 unit/L. Conclusion. Syphilitic hepatitis is a recognized entity in the medical literature. It is a manifestation of secondary syphilis and it is more commonly seen in coinfected patients with both syphilis and HIV. Therefore, primary care physicians should keep infectious etiologies (e.g., syphilis and HIV) in the differential diagnosis of patients who present with unexplained liver dysfunction in a cholestatic pattern.