neurosyphilis

What is neurosyphilis

Neurosyphilis is a Treponema pallidum bacteria infection of the coverings of the brain, the brain itself or the spinal cord, that usually occurs in people have had untreated syphilis for many years. Neurosyphilis is a life-threatening complication of syphilis and can occur at any stage of syphilis. Neurosyphilis usually occurs about 10 to 20 years after a person is first infected with syphilis. Not everyone who has syphilis develops neurosyphilis. Neurosyphilis is different from syphilis because it affects the nervous system, while syphilis is a sexually transmitted disease with different signs and symptoms.

There are five types of neurosyphilis:

  1. Asymptomatic neurosyphilis,
  2. Meningeal neurosyphilis,
  3. Meningovascular neurosyphilis,
  4. General paresis,
  5. Tabes dorsalis.

Asymptomatic neurosyphilis means that neurosyphilis is present, but the individual reports no symptoms and does not feel sick. Meningeal syphilis can occur between the first few weeks to the first few years of getting syphilis. Individuals with meningeal syphilis can have headache, stiff neck, nausea, and vomiting. Sometimes there can also be loss of vision or hearing. Meningovascular syphilis causes the same symptoms as meningeal syphilis but affected individuals also have strokes. This form of neurosyphilis can occur within the first few months to several years after infection. General paresiscan occur between 3 – 30 years after getting syphilis. People with general paresis can have personality or mood changes. Tabes dorsalis is characterized by pains in the limbs or abdomen, failure of muscle coordination, and bladder disturbances. Other signs include vision loss, loss of reflexes and loss of sense of vibration, poor gait, and impaired balance. Tabes dorsalis can occur anywhere from 5 – 50 years after initial syphilis infection. General paresis and tabes dorsalis are now less common than the other forms of neurosyphilis because of advances made in prevention, screening, and treatment. People with HIV/AIDS are at higher risk of having neurosyphilis.

The antibiotic penicillin is used to treat neurosyphilis. Penicillin can be given in different ways:

  • Injected into a vein several times a day for 10 to 14 days.
  • By mouth 4 times a day, combined with daily muscle injections, both taken for 10 to 14 days.

You must have follow-up blood tests at 3, 6, 12, 24, and 36 months to make sure the infection is gone. You will need follow-up lumbar punctures for CSF (cerebrospinal) fluid analysis every 6 months. If you have HIV/AIDS or another medical condition, your follow-up schedule may be different.

Is neurosyphilis curable?

Yes. However, treatment might not undo any damage that the neurosyphilis infection has already done. How well you do depends on how severe the neurosyphilis is before treatment. Individuals with neurosyphilis can be treated with penicillin antibiotic given by vein (penicillin G aqueous 18-24 million units daily, administered as 3–4 million units IV every 4 hours or continuous infusion), or by daily intramuscular injections (Procaine penicillin G 2.4 million units IM once daily) for 10 – 14 days. If they are treated with daily penicillin injections, individuals must also take 500 mg orally four times daily 1). You must have serial follow-up blood tests with venereal disease research laboratory tests (VDRL) and rapid plasma reagin test (RPR) at 3, 6, 12, 24, and 36 months to make sure the infection is gone. A 4-fold decline in these tests indicates successful treatment 2). You will need follow-up lumbar punctures for CSF fluid analysis every 6 months. If you have HIV/AIDS or another medical condition, your follow-up schedule may be different.

Is neurosyphilis contagious?

Yes. Neurosyphilis can occur at any stage of syphilis. Syphilis is a sexually transmitted infection. Syphilis is divided into stages (primary, secondary, latent, and tertiary). There are different signs and symptoms associated with each stage. A person with primary syphilis generally has a sore or sores at the original site of infection. These sores usually occur on or around the genitals, around the anus or in the rectum, or in or around the mouth. These sores are usually (but not always) firm, round, and painless. Symptoms of secondary syphilis include skin rash, swollen lymph nodes, and fever. The signs and symptoms of primary and secondary syphilis can be mild, and they might not be noticed. During the latent stage, there are no signs or symptoms. Tertiary syphilis is associated with severe medical problems.A doctor can usually diagnose tertiary syphilis with the help of multiple tests. It can affect the heart, brain, and other organs of the body.

Syphilis is contagious during its primary and secondary stages, and sometimes in the early latent period. The most common route of syphilis transmission is through contact with an infected person’s sore during sexual activity. The Treponema pallidum bacteria enter your body through minor cuts or abrasions in your skin or mucous membranes. Less commonly, syphilis may spread through direct unprotected close contact with an active lesion (such as during kissing) or through an infected mother to her baby during pregnancy or childbirth (congenital syphilis).

You face an increased risk of acquiring syphilis if you:

  • Engage in unprotected sex
  • Have sex with multiple partners
  • Are a man who has sex with men
  • Are infected with HIV, the virus that causes AIDS

Syphilis can’t be spread by using the same toilet, bathtub, clothing or eating utensils, or from doorknobs, swimming pools or hot tubs.

Once cured, syphilis doesn’t recur on its own. However, you can become reinfected if you have contact with someone’s syphilis sore.

Persons exposed sexually to a person who has primary, secondary, or early latent syphilis should be evaluated clinically and serologically and treated according to the following recommendations 3):

  • Persons who have had sexual contact with a person who receives a diagnosis of primary, secondary, or early latent syphilis within 90 days preceding the diagnosis should be treated presumptively for early syphilis, even if serologic test results are negative.
  • Persons who have had sexual contact with a person who receives a diagnosis of primary, secondary, or early latent syphilis >90 days before the diagnosis should be treated presumptively for early syphilis if serologic test results are not immediately available and the opportunity for follow-up is uncertain. If serologic tests are negative, no treatment is needed. If serologic tests are positive, treatment should be based on clinical and serologic evaluation and stage of syphilis.
  • In some areas or populations with high rates of syphilis, health departments recommend notification and presumptive treatment of sex partners of persons with late latent syphilis who have high nontreponemal serologic test titers (i.e., >1:32), because high titers might be indicative of early syphilis. These partners should be managed as if the index case had early syphilis.
  • Long-term sex partners of persons who have late latent syphilis should be evaluated clinically and serologically for syphilis and treated on the basis of the evaluation’s findings.
  • The following sex partners of persons with syphilis are considered at risk for infection and should be confidentially notified of the exposure and need for evaluation: partners who have had sexual contact within 1) 3 months plus the duration of symptoms for persons who receive a diagnosis of primary syphilis, 2) 6 months plus duration of symptoms for those with secondary syphilis, and 3) 1 year for persons with early latent syphilis.

I’ve been treated. Can I get syphilis again?

Yes. Having syphilis once does not protect you from getting it again. Even after you’ve been successfully treated, you can still be re-infected. Only laboratory tests can confirm whether you have syphilis. Follow-up testing by your health care provider is recommended to make sure that your treatment was successful.It may not be obvious that a sex partner has syphilis because syphilis sores can be hidden in the vagina, anus, under the foreskin of the penis, or in the mouth. Unless you know that your sex partner(s) has been tested and treated, you may be at risk of getting syphilis again from an infected sex partner.

How can I reduce my risk of getting syphilis?

To help prevent the spread of syphilis, follow these suggestions:

  • The only way to avoid sexually transmitted infections is to not have vaginal, anal, or oral sex.
  • If you are sexually active, you can do the following things to lower your chances of getting syphilis:
    • Being in a long-term mutually monogamous relationship with a partner who has been tested for syphilis and does not have syphilis
    • Use a latex condom. Condoms can reduce your risk of contracting syphilis, but only if the condom covers the syphilis sores.
  • Avoid recreational drugs. Excessive use of alcohol or other drugs can cloud your judgment and lead to unsafe sexual practices.
  • All pregnant women should be tested for syphilis at their first prenatal visit.
  • You should get tested regularly for syphilis if you are sexually active and
    • are a man who has sex with men;
    • are living with HIV; or
    • have partner(s) who have tested positive for syphilis.

There is no vaccine for syphilis.

Neurosyphilis causes

Neurosyphilis is caused by Treponema pallidum, the bacteria that causes syphilis.

Neurosyphilis prevention

Prompt diagnosis and treatment of the original syphilis infection can prevent neurosyphilis.

Neurosyphilis symptoms

Neurosyphilis symptoms usually affect the nervous system. Depending on the form of neurosyphilis, symptoms may include any of the following:

  • Abnormal walk (gait), or unable to walk
  • Numbness in the toes, feet, or legs
  • Problems with thinking, such as confusion or poor concentration
  • Mental problems, such as depression or irritability
  • Headache, seizures, or stiff neck
  • Loss of bladder control (incontinence)
  • Tremors, or weakness
  • Visual problems, even blindness
  • Difficulty coordinating muscle movements
  • Paralysis (not able to move certain parts of your body)
  • Nnumbness
  • Dementia (mental disorder).

Neurosyphilis diagnosis

Your health care provider will do a physical examination and may find the following:

  • Abnormal reflexes
  • Muscle atrophy
  • Muscle contractions
  • Mental changes

Blood tests can be done to detect substances produced by the bacteria that cause syphilis, this includes:

  • Venereal disease research laboratory (VDRL) test
  • Fluorescent treponemal antibody absorption (FTA-ABS)
  • Rapid plasma reagin (RPR)
  • Treponema pallidum particle agglutination assay (TPPA)

With neurosyphilis, it is important to test the spinal fluid for signs of syphilis.

Tests to look for problems with the nervous system may include:

  • Cerebral angiogram
  • Head CT scan
  • Lumbar puncture (spinal tap) and cerebrospinal fluid analysis (CSF fluid analysis)
  • MRI scan of the brain, brainstem, or spinal cord

Laboratory testing is helpful in supporting the diagnosis of neurosyphilis; however, no single test can be used to diagnose neurosyphilis in all instances 4). The diagnosis of neurosyphilis depends on a combination of cerebrospinal fluid (CSF) tests (CSF cell count or protein and a reactive CSF-VDRL) in the presence of reactive serologic test results and neurologic signs and symptoms (e.g., cranial nerve dysfunction, auditory or ophthalmic abnormalities, meningitis, stroke, acute or chronic altered mental status, and loss of vibration sense). CSF laboratory abnormalities are common in persons with early syphilis and are of unknown significance in the absence of neurologic signs or symptoms 5). CSF-VDRL is highly specific but insensitive. In a person with neurologic signs or symptoms, a reactive CSF-VDRL (in the absence of blood contamination) is considered diagnostic of neurosyphilis 6). When CSF-VDRL is negative despite the presence of clinical signs of neurosyphilis, reactive serologic test results, and abnormal CSF cell count and/or protein, neurosyphilis should be considered 7). In this instance, additional evaluation using fluorescent treponemal antibody absorption (FTA-ABS) testing on CSF may be warranted. The CSF fluorescent treponemal antibody absorption (FTA-ABS) test is less specific for neurosyphilis than the CSF-VDRL but is highly sensitive 8). Neurosyphilis is highly unlikely with a negative CSF fluorescent treponemal antibody absorption (FTA-ABS) test, especially among persons with nonspecific neurologic signs and symptoms 9).

Among persons with HIV infection, CSF leukocyte count usually is elevated (>5 white blood cell count [WBC]/mm³). Using a higher cutoff (>20 white blood cell count/ mm³) might improve the specificity of neurosyphilis diagnosis 10).

Neurosyphilis treatment

Individuals with neurosyphilis can be treated with penicillin antibiotic given by vein (penicillin G aqueous 18-24 million units daily, administered as 3–4 million units IV every 4 hours or continuous infusion), or by daily intramuscular injections (Procaine penicillin G 2.4 million units IM once daily) for 10 – 14 days. If they are treated with daily penicillin injections, individuals must also take 500 mg orally four times daily 11). Some medical professionals recommend another antibiotic called ceftriaxone for neurosyphilis treatment. This drug is usually given daily by vein, but it can also be given by intramuscular injection. Individuals who receive ceftriaxone are also treated for 10 – 14 days. People with HIV/AIDS who get treated for neurosyphilis may have different outcomes than individuals without HIV/AIDS.

Follow-Up

You must have serial follow-up blood tests with venereal disease research laboratory tests (VDRL) and rapid plasma reagin test (RPR) at 3, 6, 12, 24, and 36 months to make sure the infection is gone. A 4-fold decline in these tests indicates successful treatment 12). You will need follow-up lumbar punctures for CSF fluid analysis every 6 months. If you have HIV/AIDS or another medical condition, your follow-up schedule may be different.

If CSF pleocytosis was present initially, a CSF examination should be repeated every 6 months until the cell count is normal. Follow-up CSF examinations also can be used to evaluate changes in the CSF-VDRL or CSF protein after therapy; however, changes in these two parameters occur more slowly than cell counts, and persistent abnormalities might be less important 13). Leukocyte count is a sensitive measure of the effectiveness of therapy. If the cell count has not decreased after 6 months, or if the CSF cell count or protein is not normal after 2 years, retreatment should be considered. Limited data suggest that in immunocompetent persons and persons with HIV infection on highly active antiretroviral therapy, normalization of the serum RPR titer predicts normalization of CSF parameters following neurosyphilis treatment 14).

Neurosyphilis prognosis

Prognosis can change based on the type of neurosyphilis and how early in the course of the disease people with neurosyphilis get diagnosed and treated. Individuals with asymptomatic neurosyphilis or meningeal neurosyphilis usually return to normal health. People with meningovascular syphilis, general paresis, or tabes dorsalis usually do not return to normal health, although they may get much better. Individuals who receive treatment many years after they have been infected have a worse prognosis. Treatment outcome is different for every person.

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