HIV and Syphilis: When to Perform a Lumbar Puncture

Neurosyphilis

No portion of the central nervous system is immune to the ravages of syphilis. Infection by Treponema pallidum can affect the meninges, brain, brainstem, spinal cord, nerve roots, and cerebral and spinal blood vessels. As a consequence, the disease may present in diverse and, at times, diagnostically challenging fashions. Neurologic manifestations of syphilis may develop within months of the initial infection or, alternatively, take decades to appear. Although approximately one-third of individuals infected by T. pallidum display cerebrospinal fluid abnormalities suggestive of invasion of the central nervous system by the organism, only a fraction of these develop clinically significant neurologic manifestations. The features of neurosyphilis may be modified by the concomitant presence of immunosuppressive agents or conditions such as HIV/AIDS. The epidemiology of neurosyphilis has largely paralleled that of syphilis in general. A dramatic decline occurred by the early 1950s as a consequence of public health measures and the widespread use of antibiotics. The incidence had increased by the onset of the AIDS pandemic and has since corresponded with the adoption of safe sex practices. The CSF Venereal Disease Research Laboratory (VDRL) test remains the "gold standard" for diagnosis, but is not invariably positive. Penicillin remains the most effective and recommended therapy.

Use of cerebrospinal fluid enzyme immunoassay for diagnosis of neurosyphilis

Summary

Neurosyphilis is a difficult clinical stage of syphilis as there is no ideal method for diagnosis and workup requires lumbar puncture which may sometimes provide ambiguous results especially in HIV co-infected patients. Enzyme immunoassay is a widely used screening test for syphilis in serum, but its test performance was not well studied in cerebrospinal fluid. To examine the diagnostic performance of cerebrospinal fluid-enzyme immunoassay (CSF-EIA) in neurosyphilis, we conducted a prospective study for two years. All consecutive patients admitted for workup of neurosyphilis under the Social Hygiene Service, in Hong Kong, were included. Laboratory tests on CSF included several serological tests, CSF cell count, and protein. Forty-five patients were prospectively recruited, of which 29 people were living with HIV / AIDS. Using diagnostic case definition standard stipulated in the IUSTI 2008 guidelines, 17 patients satisfied the diagnosis of neurosyphilis. The CSF-EIA test provided 100% in both sensitivity and negative predictive value; its specificity was 46.4% (13/28, 95% CI 31.8–61%). Specificity improved to 80.8% (95% CI: 68.4–93.2%) with optical density cut-off value at 1.4 for cases with CSF red cell counts <600/mm3. This is the first study on use of CSF-EIA in neurosyphilis. CSF-EIA showed high sensitivity and high negative predictive value in the study population and the presence of CSF red cells < 600/mm3 might not affect its accuracy.

Clinical prediction and diagnosis of neurosyphilis in HIV-infected patients with early Syphilis

The diagnosis of neurosyphilis (NS) is a challenge, especially in HIV-infected patients, and the criteria for deciding when to perform a lumbar puncture (LP) in HIV-infected patients with syphilis are controversial. We retrospectively reviewed demographic, clinical, and laboratory data from 122 cases of HIV-infected patients with documented early syphilis who underwent an LP to rule out NS, and we evaluated 3 laboratory-developed validated real-time PCR assays, the Treponema pallidum particle agglutination (TPPA) assay, the fluorescent treponemal antibody absorption (FTA-ABS) assay, and the line immunoassay INNO-LIA Syphilis, for the diagnosis of NS from cerebrospinal fluid (CSF) samples of these patients. NS was defined by a reactive CSF-VDRL test result and/or a CSF white blood cell (WBC) count of >20 cells/μl. Thirty of the 122 patients (24.6%) had early NS. Headache, visual symptoms, a CD4 cell count of <500 cells/μl, and viremia, as defined by an HIV-1 RNA count of ≥50 copies/ml, were associated with NS in multivariate analysis (P = <0.001 for each factor). Blood serum rapid plasma reagin (RPR) titers were not associated with early NS (P = 0.575). For the diagnosis of NS, the PCR, FTA-ABS, TPPA, and INNO-LIA assays had sensitivities of 58%, 100%, 68%, and 100%, specificities of 67%, 12%, 49%, and 13%, and negative predictive values of 85%, 100%, 84%, and 100%, respectively. Visual disturbances, headache, uncontrolled HIV-1 viremia, and a CD4 cell count of <500 cells/μl were predictors of NS in HIV-infected patients with early syphilis, while blood serum RPR titers were not; therefore, RPR titers should not be used as the sole criterion for deciding whether to perform an LP in early syphilis. When applied to CSF samples, the INNO-LIA Syphilis assay easily helped rule out NS.

Neurosyphilis: epidemiology, pathogenesis, clinical course and laboratory diagnostics

The article describes the key achievements and problems related to studying neurosyphilis. It also shows the dynamics of neurosyphilis incidence in Russia and abroad from the early twentieth century and up to present. The article also describes issues related to the pathogenesis, clinical course and pathomorphism of the disease. The authors present current approaches to the laboratory diagnostics of neurosyphilis.

Elevated cerebrospinal fluid nitrite level in human immunodeficiency virus-infected patients with neurosyphilis

BACKGROUND/PURPOSE

Human immunodeficiency virus (HIV) and syphilis coinfection is a common phenomenon. A percentage of neurosyphilis cases is asymptomatic in HIV-infected patients. The diagnosis of neurosyphilis is more difficult because of the alteration of cerebrospinal fluid (CSF) presentation by the HIV itself. The CSF levels of the degradation products of nitric oxide (NO; e.g., nitrate and nitrite) are reportedly elevated in animals and patients with bacterial meningitis. We hypothesized that an elevated CSF nitrite concentration may be present in patients coinfected with HIV and neurosyphilis.

METHODS

This cohort study was conducted from January 2007 to June 2008. Forty patients were enrolled and included seven patients in the control group and 33 HIV-infected patients with or without syphilis. Nitrite levels in the serum and the CSF were measured by using the Griess assay.

RESULTS

The CSF nitrite levels were significantly higher in HIV-infected patients with neurosyphilis, compared to the control group or patients with HIV infection only or patients with HIV and syphilis coinfection (p = 0.026). The CSF nitrite levels were correlated with the CSF white blood cell counts (Spearman correlation test, r(2) = 0.324; p < 0.001). There was no significant difference between different groups in serum nitrite levels.

CONCLUSION

Marked elevation of CSF nitrite level was observed in HIV-infected patients with neurosyphilis.

Clinical spectrum of neurosyphilis among HIV-negative patients in the modern era

BACKGROUND

The clinical spectrum of neurosyphilis (NS) has changed over time.

OBJECTIVE

To describe the clinical spectrum and characteristics of NS in HIV-negative patients.

METHODS

A retrospective chart review was performed for 149 in patients with NS.

RESULT

All patients were >25 years old, including 16.8% asymptomatic for NS, 15.4% with syphilitic meningitis, 24.2% with meningovascular NS, 38.9% with general paresis, 4.0% with tabes dorsalis and 0.7% with gummatous NS. The original misdiagnosis rate was 84.6%. All 149 patients had positive serum Treponema pallidum particle agglutination (TPPA) and rapid plasma reagin (RPR). The overall positive rates of cerebrospinal fluid RPR (CSF-RPR) and CSF-TPPA were 57.0 and 89.9%, respectively. CSF pleocytosis and elevated CSF protein were found in 40.3% of patients. Nonspecific abnormal brain magnetic resonance imaging and electroencephalography findings were present in 60.4 and 54.8% of NS patients, respectively.

CONCLUSIONS

NS has various clinical manifestations, laboratory findings and magnetic resonance imaging and electroencephalography findings, but all studies lack specificity. Every patient with neurological or psychiatric symptoms that are without unambiguous causes should have blood tests for syphilis. When serology proves positive, patients should undergo CSF examination.

Neurosyphilis presenting with unusual hippocampal abnormalities on magnetic resonance imaging and positron emission tomography scans: a case report

Introduction

The incidence of neurosyphilis has declined markedly since the introduction of penicillin therapy. While there are a number of case reports in the literature of neurosyphilis causing focal decreased 18F-fluorodeoxyglucose uptake on positron emission tomography/computed tomography scans, to the best of our knowledge this is the first published report of neurosyphilis presenting with intensely increased 18F-fluorodeoxyglucose uptake in the hippocampus.

Case presentation

A 55-year-old Caucasian man presented to our facility with acute collapse against a background of memory difficulties over the previous six months. The results of his initial physical examination were normal. He scored 24 out of 30 on the Montreal Cognitive Assessment test. A magnetic resonance imaging scan of his brain revealed high T2 signal intensity and atrophy within the right frontal area in addition to high T2 signal intensity in the bilateral mesial temporal areas. Blood and cerebrospinal fluid analysis revealed an active syphilis infection. An 18F-fluorodeoxyglucose positron emission tomography brain scan showed intensely increased 18F-fluorodeoxyglucose uptake limited to the head of the right hippocampus. He responded to penicillin treatment with an improvement in his cognition, which was further reflected in a complete resolution of the findings previously seen on magnetic resonance imaging and 18F-fluorodeoxyglucose positron emission tomography scans.

Conclusions

Diagnosis of neurosyphilis can be difficult, as many patients are either asymptomatic or present with non-specific symptoms such as memory disturbance or seizures. This report highlights the importance of considering neurosyphilis in the differential diagnosis when mesiotemporal changes are seen on magnetic resonance imaging or 18F-fluorodeoxyglucose positron emission tomography scans.

Optimal treatment for asymptomatic neurosyphilis

In the pre-penicillin era, patients with asymptomatic neurosyphilis (ANS) were more likely to develop long-term neurological sequelae than those patients with normal cerebrospinal fluid (CSF). Although benzathine penicillin G cannot achieve treponemicidal levels in the CSF, decreased rates of neurological complications of syphilis and non-treponemal titre serological responses are usually observed after treatment with this antibiotic. We here a homosexual man with ANS successfully treated with benzathine penicillin G. This case suggests that reconsideration on the necessity of a lumbar puncture in HIV-infected patients with ANS is warranted.

The rapid plasma reagin test cannot replace the venereal disease research laboratory test for neurosyphilis diagnosis

BACKGROUND

The cerebrospinal fluid (CSF) Venereal Disease Research Laboratory (VDRL) test is a mainstay for neurosyphilis diagnosis, but it lacks diagnostic sensitivity and is logistically complicated. The rapid plasma reagin (RPR) test is easier to perform, but its appropriateness for use on CSF is controversial.

METHODS

RPR reactivity was determined for CSF from 149 individuals with syphilis using 2 methods. The CSF-RPR was performed according to the method for serum. The CSF-RPR-V was performed using the method recommended for the CSF-VDRL. Laboratory-defined neurosyphilis included reactive CSF-fluorescent treponemal antibody absorption test and CSF white blood cells >20/uL. Symptomatic neurosyphilis was defined as vision loss or hearing loss.

RESULTS

CSF-VDRL was reactive in 45 (30.2%) patients. Of these, 29 (64.4%) were CSF-RPR reactive and 37 (82.2%) were CSF-RPR-V reactive. There were no instances where the CSF-VDRL was nonreactive but the CSF-RPR or CSF-RPR-V was reactive. Among the 28 samples that were reactive in all 3 tests, CSF-VDRL titers (median [IQR], 1:4 [1:4-1:16]) were significantly higher than CSF-RPR (1:2 [1:1-1:4], P = 0.0002) and CSF-RPR-V titers (1:4 [1:2-1:8], P = 0.01). The CSF RPR and the CSF-RPR-V tests had lower sensitivities than the CSF-VDRL: 56.4% and 59.0% versus 71.8% for laboratory-diagnosed neurosyphilis and 51.5% and 57.6% versus 66.7% for symptomatic neurosyphilis.

CONCLUSIONS

Compared with the CSF-VDRL, the CSF-RPR has a high false-negative rate, thus not improving upon this known limitation of the CSF-VDRL for neurosyphilis diagnosis. Adapting the RPR procedure to mimic the CSF-VDRL decreased, but did not eliminate, the number of false negatives and did not avoid all the logistical complications of the CSF-VDRL.

A case of lues maligna in an AIDS patient

Lues maligna is a severe and rare manifestation of syphilis, also known as malignant syphilis or ulceronodular syphilis and mostly occurring in patients with HIV infection. In this report, we present a case of lues maligna in an AIDS patient. Our report shows the typical clinical features of lues maligna and the important association between lues maligna and HIV/AIDS. Although the clinical manifestations of lues maligna are complicated and severe, the response to the therapy of penicillin is excellent.

Syphilis and neurosyphilis in human immunodeficiency virus-infected patients: a retrospective study at a teaching hospital in Taiwan

BACKGROUND AND PURPOSE

Some studies have reported that the risk factors for neurosyphilis in patients with human immunodeficiency virus (HIV) and syphilis co-infection, include CD4 cell counts ≤350cells/μL and rapid plasma reagin (RPR) titer ≥1:32. However, neurosyphils can develop even in patients with CD4 cell counts >350cells/μL or RPR titer <1:32. In this study, we evaluated the outcome of syphilis to treatment in HIV-infected patients, and analysed the predictors of neurosyphilis in this population.

METHODS

We retrospectively reviewed medical records of HIV-infected patients with syphilis who visited the China Medical University Hospital between January 2000 and December 2009. Neurosyphilis was defined by white blood cell (WBC) counts >20cells/μL in the cerebrospinal fluid (CSF) sample or elevated Venereal Disease Research Laboratory (VDRL) titers of the CSF samples. Treatment failure was defined as less than 4-fold decrease in the serum RPR titer at or beyond 12 months post-treatment in case of early syphilis, and, at or beyond 24 months in case of late syphilis.

RESULTS

One hundred and twenty-one HIV-infected patients (average age, 32 years) with syphilis were included in this study. Of 63 patients who had follow-up of serologic responses, 30 (47.6%) failed to respond to treatment. CD4 cell counts ≤200cells/μL was the indicator for treatment failure (P=.029). Lumbar puncture was performed in 65 patients, and 14 patients were diagnosed with neurosyphilis. At the time of lumbar puncture, 31 and 19 of the 65 patients showed CD4 cell counts of >350cells/μL and RPR of <1:32, respectively. An HIV viral load (VL) ≥10000copies/mL was found to be associated with the development of neurosyphilis (P=.016).

CONCLUSION

In HIV-infected patients with syphilis, RPR titer should be evaluated more frequently when CD4 count ≤200cell/μL is associated with treatment failure. Lumbar puncture for the diagnosis of neurosyphilis should be considered in patients with HIV and syphilis co-infection, even in patients with CD4 cell counts >350cells/μL, and particularly when the HIV VL ≥10000copies/mL.

Syphilis: using modern approaches to understand an old disease

Syphilis is a fascinating and perplexing infection, with protean clinical manifestations and both diagnostic and management ambiguities. Treponema pallidum subsp. pallidum, the agent of syphilis, is challenging to study in part because it cannot be cultured or genetically manipulated. Here, we review recent progress in the application of modern molecular techniques to understanding the biological basis of this multistage disease and to the development of new tools for diagnosis, for predicting efficacy of treatment with alternative antibiotics, and for studying the transmission of infection through population networks.

Screening for syphilis with the treponemal immunoassay: analysis of discordant serology results and implications for clinical management

BACKGROUND

Screening for syphilis with treponemal chemiluminescence immunoassays (CIA) identifies patients with discordant serology who are not identified with traditional screening methods (eg, CIA-positive, rapid plasma regain (RPR)-negative). We sought to describe the clinical characteristics and management of patients with discordant syphilis serology.

METHODS

From August 2007-October 2007, patients with CIA-positive, RPR-negative serology were tested with the Treponema pallidum particle agglutination assay (TP-PA) at Kaiser Permanente Northern California. Clinical and demographic characteristics, prior syphilis history and CIA index values were compared for CIA-positive, RPR-negative patients according to TP-PA status.

RESULTS

Of 21,623 assays, 439 (2%) were CIA-positive and 255/439 (58%) were RPR-negative; subsequently, 184 (72%) were TP-PA-positive and 71 (28%) were TP-PA--negative. TP-PA--positive patients were more likely to be male, HIV-positive, homosexual, previously treated for syphilis (57% versus 9%), with higher median CIA index values (9.8 versus 1.6) (all P < .0001). After repeat testing, 7/31 (23%) CIA-positive, RPR-negative, TP-PA--negative patients seroreverted to CIA-negative.

CONCLUSIONS

TP-PA results in conjunction with clinical/behavioral assessment helped guide the management of patients with CIA-positive, RPR-negative serology. TP-PA-positive patients were both highly likely to have prior syphilis and major epidemiologic risk factors for syphilis. CIA-positive, RPR-negative, TP-PA-negative serology may represent a false-positive CIA in low-prevalence populations.

Evaluation and Management of Syphilis in the HIV-Infected Patient

Rates of syphilis continue to increase in the United States and HIV-infected patients make up a large proportion of cases. The interaction between syphilis and HIV is complex and still incompletely understood. Although diagnosis and management of HIV-infected patients with syphilis is, in general, similar to HIV-uninfected patients, the former may be at increased risk for complications. Recent data suggest that HIV-induced immunosuppression may alter the course of syphilis and that highly active antiretroviral therapy may have a beneficial effect on syphilis outcomes. Prevention strategies consisting of sexual risk assessments, condom use, treatment of infected partners, yearly screening for syphilis of all HIV-infected patients, and enhanced clinical and serologic follow-up of treated HIV-infected patients are critical components of a comprehensive approach to care.

The changing face of neurosyphilis

The incidence of syphilis has increased over the past decade, particularly among HIV-positive patients, and the presenting clinical features have changed since the beginning of the HIV epidemic. The clinical manifestations of neurosyphilis are protean, and include acute stroke. In patients with HIV, the diagnosis and treatment of neurosyphilis is challenging. We review the clinical presentation, pathophysiology, and treatment of neurosyphilis, with emphasis on neurosyphilis in the HIV population, and neurosyphilis as a cause of acute stroke.

Symptomatic and asymptomatic early neurosyphilis in HIV-infected men who have sex with men: a retrospective case series from 2000 to 2007

Background The rise in serious complications of early syphilis, including neurosyphilis, particularly in those with HIV infection and in men who have sex with men (MSM), is of concern. Objectives: To review the manifestations and management of neurosyphilis in a population of HIV-infected MSM. Methods: Retrospective review of patients with HIV and early neurosyphilis in three centres in Melbourne, Australia, in 2000–07. Results: Eighteen male HIV patients met the criteria for diagnosis of early neurosyphilis. Thirteen patients (72.2%) had neurological symptoms: six with headache (33.3%), four with tinnitus (22.2%) and five with impaired vision (27.8%), and one patient each with ataxia, leg weakness and anal discharge with faecal incontinence. Five patients (27.8%) reported no neurological symptoms. All had serum rapid plasma reagin (RPR) titres ≥1 : 32 and all except one had cerebrospinal fluid positive for syphilis fluorescent treponemal antibodies-absorbed. After treatment with 14–15 days of 1.8 g intravenous benzylpenicillin 4-hourly, 12 of 17 patients (71%) demonstrated a four-fold drop in serum RPR titre over 6–12 months and were considered successfully treated. A rise in RPR was noted in three patients during the 12-month follow-up period, suggesting re-infection or recurrence. Conclusion: HIV-infected patients found to have syphilis either because of symptoms or by routine screening should be carefully assessed for neurological, ophthalmic and otological symptoms and signs. A low threshold for a diagnostic lumbar puncture to exclude the diagnosis of neurosyphilis enables appropriate administration and dose of penicillin for treatment, which appears successful in ~75% of cases.

Expression of matrix metalloproteinases and their tissue inhibitors in the serum and cerebrospinal fluid of patients with meningitis

Meningitis is associated with an imbalance between matrix metalloproteinases (MMPs) and endogenous tissue inhibitors of MMP (TIMPs). Serum and CSF were collected prospectively from all patients with meningitis between January 2008 and December 2008 to measure the concentrations of MMP/TIMP in those patients who underwent a lumbar puncture for a presumptive diagnosis of meningitis. A total of 199 patients were enrolled into the study. The concentrations of CSF MMP-9 and TIMP-1 were significantly higher in the meningitis group compared with the control group (p 0.032 and p <0.001, respectively). However, the CSF TIMP-4 levels were significantly lower in the meningitis groups compared with the control groups (p <0.001). Patients with bacterial meningitis had higher CSF MMP-9 and TIMP-1 levels than those who had aseptic meningitis and controls. Patients with various infectious meningitis etiologies tended to have higher CSF MMP-9 expression by gelatin zymography when compared with the controls. In conclusion, MMP/TIMP system dysregulation was found in patients with meningitis, and CSF MMP and TIMP might act as novel indicators in patients with meningitis.

The intersection between HIV and syphilis in men who have sex with men: some fresh perspectives

Syphilis is increasing in men who have sex with men and disproportionately affects HIV-infected men. Here we review the epidemiology, diagnostic techniques, treatment guidelines, follow-up procedures and control of syphilis. The difference in these factors in HIV-infected men and uninfected men and evidence for this is reviewed. We explain that HIV-infected men are at higher risk of syphilis acquisition as a result of different behavioral factors. Thus, some control strategies may be different for HIV-infected men owing to these factors and also because HIV-infected men are more closely linked with medical care. There is no strong evidence to suggest there should be any differences in diagnostic techniques, treatment guidelines or follow-up procedures between HIV-infected and uninfected men.

Enhanced molecular typing of treponema pallidum: geographical distribution of strain types and association with neurosyphilis

BACKGROUND

Strain typing is a tool for determining the diversity and epidemiology of infections.

METHODS

Treponema pallidum DNA was isolated from 158 patients with syphilis from the United States, China, Ireland, and Madagascar and from 15 T. pallidum isolates. Six typing targets were assessed: (1) the number of 60‐bp repeats in the acidic repeat protein gene, (2) restriction fragment length polymorphism (RFLP) analysis of T. pallidum repeat (tpr) subfamily II genes, (3) RFLP analysis of the tprC gene, (4) determination of tprD allele in the tprD gene locus, (5) the presence of a 51‐bp insertion between tp0126 and tp0127, and (6) sequence analysis of an 84‐bp region of tp0548. The combination of targets 1 and 2 comprises the Centers for Disease Control and Prevention (CDC) T. pallidum subtyping method.

RESULTS

Adding sequence analysis of tp0548 to the CDC method yielded the most discriminating typing system. Twenty‐five strain types were identified and designated as "CDC subtype/tp0548 sequence type." Type 14d/f was found in samples from 5 of 6 locations. In Seattle, Washington, strain types changed from 1999 through 2008 (P < .001). Twenty‐one (50%) of 42 patients infected with type 14d/f had neurosyphilis compared with 10 (24%) of 41 patients infected with any of the other types combined (P = .02).

CONCLUSION

We describe an enhanced T. pallidum strain typing system that shows biological and clinical relevance.

Secondary syphilis: the classical triad of skin rash, mucosal ulceration and lymphadenopathy

After years of declining incidence in many developed countries, syphilis infection has re-emerged as a major public health problem in the past decade. The secondary stage of syphilis epitomizes the capacity of the infection to present in myriad ways. The skin, lymph glands and mucosal membranes are the most commonly affected tissues.

Occurrence, risk factors, diagnosis and treatment of syphilis in the prospective observational Swiss HIV Cohort Study

BACKGROUND

Annual syphilis testing was reintroduced in the Swiss HIV Cohort Study (SHCS) in 2004. We prospectively studied occurrence, risk factors, clinical manifestations, diagnostic approaches and treatment of syphilis.

METHODS

Over a period of 33 months, participants with positive test results for Treponema pallidum hemagglutination assay were studied using the SHCS database and an additional structured case report form.

RESULTS

Of 7244 cohort participants, 909 (12.5%) had positive syphilis serology. Among these, 633 had previously been treated and had no current signs or symptoms of syphilis at time of testing. Of 218 patients with newly detected untreated syphilis, 20% reported genitooral contacts as only risk behavior and 60% were asymptomatic. Newly detected syphilis was more frequent among men who have sex with men (MSM) [adjusted odds ratio (OR) 2.8, P < 0.001], in persons reporting casual sexual partners (adjusted OR 2.8, P < 0.001) and in MSM of younger age (P = 0.05). Only 35% of recommended cerebrospinal fluid (CFS) examinations were performed. Neurosyphilis was diagnosed in four neurologically asymptomatic patients; all of them had a Venereal Disease Research Laboratory (VDRL) titer of 1:>or=32. Ninety-one percent of the patients responded to treatment with at least a four-fold decline in VDRL titer.

CONCLUSION

Syphilis remains an important coinfection in the SHCS justifying reintroduction of routine screening. Genitooral contact is a significant way of transmission and young MSM are at high risk for syphilis. Current guidelines to rule out neurosyphilis by CSF analysis are inconsistently followed in clinical practice. Serologic treatment response is above 90% in the era of combination antiretroviral therapy.

CXCL13 as a cerebrospinal fluid marker for neurosyphilis in HIV-infected patients with syphilis

BACKGROUND

Asymptomatic neurosyphilis is more difficult to diagnose in human immunodeficiency virus (HIV)-infected patients because HIV itself can cause cerebrospinal fluid (CSF) pleocytosis. The proportion of CSF lymphocytes that are B cells is elevated in neurosyphilis, suggesting that the CSF concentration of the B cell chemoattractant, chemokine (C-X-C motif) ligand 13 (CXCL13) concentration may also be elevated.

METHODS

CSF and blood were collected from 199 HIV-infected patients with syphilis and neurosyphilis. Serum and CSF CXCL13 concentrations were determined.

RESULTS

Patients with neurosyphilis had higher CSF and serum CXCL13 concentrations compared to patients with syphilis but not neurosyphilis. The odds of having symptomatic neurosyphilis were increased by 2.23-fold for every log increase in CSF CXCL13 concentration and were independent of CSF white blood cell and plasma HIV RNA concentrations, peripheral blood CD4+ T cell count and use of antiretroviral medications. A cut-off of 10 pg/mL CSF CXCL13 had high sensitivity and a cut-off of 250 pg/mL or evidence of intrathecal synthesis of CXCL13 had high specificity for diagnosis of both symptomatic and asymptomatic neurosyphilis. CSF concentrations of CXCL13 declined after treatment for neurosyphilis.

CONCLUSIONS

CSF CXCL13 concentration may be particularly useful for diagnosis of neurosyphilis in HIV-infected patients because it is independent of CSF pleocytosis and markers of HIV disease.

Update on neurosyphilis

Neurosyphilis literally means syphilitic infection of the central nervous system, but it is often referred to incorrectly as "tertiary syphilis." Neurosyphilis can occur at any time in the course of syphilis, even in the earliest, primary, stage. Early forms of neurosyphilis primarily affect the meninges, cerebrospinal fluid, and cerebral or spinal cord vasculature. Late forms of neurosyphilis primarily affect the brain and spinal cord parenchyma. Uveitis and hearing loss related to syphilis are most common in early syphilis and may be accompanied by early neurosyphilis. The treatment for syphilis-related eye disease and hearing loss is the same as the treatment for neurosyphilis. Neurosyphilis is more commonly seen in patients infected with HIV, and much of the recent literature pertains to this risk group. This article provides a critical review of recent literature on the diagnosis, clinical findings, risk factors, and management of neurosyphilis.

Reversible dementias

The causes of potentially reversible dementia syndromes are legion, as many perturbations of body chemistry can lead to dysfunction of higher cortical function, including the chemical interventions we call medication. It is vital for the cautious clinician to take a painstaking history to develop a differential diagnosis of potential causally related reversible phenomena. This, coupled with an extensive examination and a widecast net of serological, and when appropriate, cerebrospinal, electrophysiologic, and neuroimaging studies can increase the potential for discovering these mimics of the primary neurodegenerative dementias. While some cases of reversible dementia will be obvious from history and physical and only require a few confirmatory tests or even just a trial of treatment (or often, discontinuation of a suspect treatment), it is worthwhile to perform more extensive work-up in cases of dementia, as the costs to allowing our patients to remain in an incapacitated, possibly progressive, state of disability far outweigh the costs of ruling out reversible causes. This chapter provides a lengthy, though by no means exhaustive, review of etiologies and work-up for the currently recognized reversible dementias.

Lumbar puncture in HIV-infected patients with syphilis and no neurologic symptoms

BACKGROUND

The decision to perform lumbar puncture in patients with asymptomatic human immunodeficiency virus (HIV) infection and syphilis is controversial. The Centers for Disease Control and Prevention recommend certain criteria that warrant lumbar puncture. Here, we assess the performance of these criteria for detecting asymptomatic neurosyphilis (ANS).

METHODS

Eligible subjects consisted of all patients with concurrent HIV infection and syphilis in a prospective clinical cohort who had no neurologic symptoms at the time of lumbar puncture. We retrospectively applied different stratification criteria to calculate the performance of lumbar puncture in detecting ANS: (1) lumbar puncture in patients with late latent syphilis or syphilis of an unknown duration, regardless of the CD4 cell count or rapid plasma reagin titer; (2) lumbar puncture if the CD4 cell count was 350 cells/mL and/or the rapid plasma reagin titer was 1:32, regardless of the syphilis stage; and (3) lumbar puncture in the context of serologic nonresponse to syphilis therapy.

RESULTS

Two hundred two of 231 patients with syphilis did not have neurologic symptoms. Immediate lumbar puncture was performed for 46 patients, and 10 cases (22%) of ANS were detected. With use of the first criterion, 2 (14%) of 10 cases of ANS in patients with early-stage syphilis would have been missed (sensitivity, 80% [95% confidence interval [CI], 44%-97%]; specificity, 23% (95% confidence interval [CI], 11.4%-40.2%) [corrected] Criterion 2 would not have missed any cases of ANS (sensitivity, 100% [95% CI, 70%-100%]; specificity, 13.2% (95% CI, 4.4%-29.1%) [corrected] but would have required that a lumbar puncture be performed for 88% of patients. Performance of lumbar puncture performed in 13 cases based on serologic nonresponse to syphilis therapy yielded 4 cases (31%) of ANS.

CONCLUSIONS

In patients with concurrent HIV infection and syphilis, the use of criteria based on rapid plasma reagin titer and CD4 cell count, instead of stage-based criteria, improved the ability to identify ANS.

Syphilis: continuing public health and diagnostic challenges

As the "great imitator" of disease, syphilis, caused by the bacterium Treponema pallidum, continues to be a conceptually elusive condition that is surrounded by diagnostic ambiguity and clinical misunderstanding. Concurrent HIV infection adds further difficulty by introducing the oldest and most confusing medical conundrum into the socially and biologically complex situation of treating patients with a virus we are still only learning to manage. Syphilis continues to be a challenge to the health of men who have sex with men and people of color as infection rates continue to increase within these substantial subgroups living with HIV. As the resurgence of syphilis continues, a clear understanding of diagnostic testing, disease-staging paradigms, and treatment strategies are necessary for optimal management of the HIV co-infected patient.

Epidemiology of infectious syphilis in Ottawa. Recurring themes revisited

OBJECTIVES

To describe the epidemiology of an outbreak of infectious syphilis in Ottawa.

METHODS

A retrospective chart review of infectious syphilis cases in Ottawa from 2001-2006.

RESULTS

Rates of syphilis have risen more than tenfold. The epidemic was centered in men, with the majority of cases (83.5%) occurring among men who have sex with men (MSM). These individuals differed from the general MSM population residing in Ottawa in their being older, more likely to be HIV positive, and more sexually promiscuous. Inconsistent condom use by MSM engaged in either oral or anal sex was pervasive. Thirty-seven percent of MSM reported sexual encounters with men from Montreal and Toronto. Visceral manifestations of syphilis, including neurosyphilis, were more common in persons co-infected with HIV. As a result, this subgroup was more likely to have received an extended antibiotic treatment regimen. There was a substantial delay between serological diagnosis and treatment. Less than half of treated cases returned for a six-month evaluation.

CONCLUSIONS

Multiple sexual partners, unprotected oral sex, and increased age among MSM were the predominant risk factors contributing to this syphilis epidemic. Co-infection with HIV modified the clinical presentation of syphilis, necessitating a more intensive diagnostic and therapeutic approach. The interconnection of urban sexual networks has likely contributed to the dynamics of local syphilis transmission and suggests that effective interventions will require a coordinated national approach.

Syphilis and HIV co-infection

Syphilis is a complex disease, which is sexually transmitted. The incidence of syphilis is rising all over the world, partly due to the increased transmission in HIV patients and other high risk groups such as men who have sex with men. Interestingly syphilis itself facilitates HIV infection in several ways. Great importance exists in recognition of both diseases and their complex interactions. This article will review the manifestations of syphilis in the context of HIV infected patients, and the challenging diagnosis and management of these patients.

Gynecologic issues in the HIV-infected woman

In this article, gynecologic conditions of increased importance in the HIV-infected woman are discussed. Women living with HIV may have an increase in menstrual disorders, lower genital tract neoplasias, gynecologic surgery, and sexually transmitted infections. The literature relevant to choosing a method of contraception for HIV-positive women is also discussed. With the advent of HAART, seropositive women are now facing issues around longevity, such as menopause and disorders of bone mineral density, as well as those associated with fertility.

Neurosyphilis in HIV-infected patients: clinical manifestations, serum venereal disease research laboratory titers, and associated factors to symptomatic neurosyphilis

GOAL

To describe clinical and laboratory features of human immunodeficiency infection (HIV)-infected patients with neurosyphilis.

STUDY DESIGN

Retrospective study of 27 consecutive cases of HIV-infected patients with a positive Venereal Disease Research Laboratory (VDRL) in cerebrospinal fluid (CSF).

RESULTS

Median of age was 36 years and 89% were men. Ten (37%) patients had previous nonneurologic syphilis treatment. At the time of neurosyphilis diagnosis, 10 (37%) patients had early syphilis, and 6 of them were neurologically asymptomatic. Nine (33%) patients had symptomatic neurosyphilis. Twenty-six (96%) patients were classified with early neurosyphilis. The medians of serum VDRL and CD4 T cell counts were 1:128 and 182 cell/muL, respectively. Twenty five (93%) patients presented serum VDRL titers > or =1:16. Five of 6 patients with early syphilis and asymptomatic neurosyphilis, presented serum VDRL > or =1:16. Symptomatic patients showed lower CD4 T cell counts (59 cell/muL vs. 208 cell/muL, P = 0.03) and higher protein concentration on CSF (118 mg/dL vs. 39 mg/dL, P <0.001) than asymptomatic patients.

CONCLUSIONS

Most patients had early and asymptomatic neurosyphilis, and more than one third had early syphilis. Patients with symptomatic neurosyphilis showed lower CD4 T cell counts and higher protein concentration on CSF than those asymptomatic. Most patients had serum VDRL titers > or =1:16, regardless of syphilis stage.

A consequence of the syphilis epidemic among men who have sex with men (MSM): neurosyphilis in Los Angeles, 2001-2004

OBJECTIVES

To describe the epidemiology and clinical findings of neurosyphilis (NS) cases diagnosed during the current syphilis epidemic occurring predominantly among men who have sex with men.

METHODS

Syphilis cases reported to the health department were reviewed for diagnosis of NS, cerebrospinal fluid venereal disease research laboratory results, and/or treatment for NS.

RESULTS

During 2001-2004, 7083 cases of syphilis were diagnosed in Los Angeles. One hundred nine cases of confirmed or probable NS occurring among persons aged 19 to 65 years were identified during this period (1.5%). Symptomatic NS was present in 1.2% of reported syphilis cases (86 of 7083). NS cases were inclusive of 71 (65%) men who have sex with men. Forty-two (49%) of the symptomatic NS cases occurred during secondary (N = 28) or early latent (N = 14) syphilis. Sixty-eight percent (N = 74) of the NS cases were human immunodeficiency virus (HIV)-positive. The estimated incidence of symptomatic NS among HIV-infected persons with early syphilis was 2.1% as compared with 0.6% among HIV-negative persons.

CONCLUSION

Providers should maintain a high index of suspicion for NS among patients with syphilis, particularly those with HIV infection.

Syphilis in the United States: an update for clinicians with an emphasis on HIV coinfection

Diagnosis and treatment of syphilis are challenging because of its variable clinical presentation and course and the lack of definitive tests of cure after treatment. This review of the most recent literature on the epidemiology, clinical manifestations, current diagnosis, and treatment of syphilis is focused toward clinicians who treat patients with this disease. Syphilis coinfection with human immunodeficiency virus is emphasized because it is increasingly common in the United States and affects the initial presentation, disease course, diagnosis, and treatment of syphilis. Of particular consequence is the effect of human immunodeficiency virus on the clinical diagnosis, prevalence, and course of neurosyphilis, one of the most serious consequences of syphilis infection.

Syphilis and HIV infection: an update

The striking increase in the prevalence of concordant human immunodeficiency virus (HIV) infection and syphilis observed by clinicians and public health officers over the past decade has renewed interest in the subject. Although the effect of HIV infection on the natural history of syphilis has been known for a long time, it was not until recently that several studies documented that syphilis may also impact the course of HIV infection. Despite an improved understanding of the interaction of these 2 conditions, many controversies still exist. In this article, we focus on the most recent literature describing the epidemiology, clinical manifestations, and treatment of syphilis in the context of HIV infection.