The Performance of Cerebrospinal Fluid Treponemal-Specific Antibody Tests in Neurosyphilis: A Systematic Review

A 14-Year Retrospective Clinical Analysis of Ocular Manifestations of Syphilis in a Portuguese Tertiary Center

Purpose

Syphilis is a re-emerging infectious disease with various systemic manifestations, including ocular involvement, which can lead to significant morbidity if untreated. This study aims to analyze the ocular manifestations of syphilis in patients treated at a Portuguese tertiary center over a 14-year period.

Patients and Methods

A retrospective review of patients diagnosed with syphilis who presented with ocular symptoms from 2010 to 2023 was conducted. Data collected included demographic information, clinical presentation, ophthalmologic findings, serologic test results, treatment regimens and outcomes.

Results

A total of 47 patients with ocular syphilis were identified. The mean age of the cohort was 45, with a male predominance of 78.7%. The most common ocular manifestations included uveitis (mostly posterior and panuveitis), optic neuritis, acute syphilitic posterior placoid chorioretinitis and vitritis. Best corrected visual acuity (BCVA) at presentation was highly variable, ranging from hand movements to no impairment of visual acuity. At the end of the follow-up period, the majority of the study eyes achieved a BCVA between 0 and 0.1 (p<0,000). Acute syphilitic posterior placoid chorioretinitis was associated with poorer visual outcomes after treatment, indicating its presence is a poor prognosis factor. HIV status, the presence of vitritis, vasculitis and papillitis at presentation, a positive syphilis serology in cerebrospinal fluid and treatment regimen did not appear to have a significant impact on the final BCVA.

Conclusion

Ocular syphilis, though rare, remains a significant cause of visual morbidity. Early recognition and prompt treatment are crucial for preventing permanent vision loss. Regular screening and increased awareness among clinicians are essential to manage this potentially sight-threatening condition effectively. Further research is needed to optimize treatment protocols and improve patient outcomes.

BASHH UK guidelines for the management of syphilis 2024

The 2024 UK guidelines for the management of syphilis are in line with current evidence and practice within the UK. Key updates are detailed at the start of the article. These guidelines are accompanied by the first UK guidelines for the management of syphilis in pregnant people and children, 2024.

A Review of Syphilis Infection in Pediatric Patients

Nearly half of all sexually transmitted infections occur in adolescents and young adults. Among them, syphilis infections are on the rise in the United States. Sexually active adolescents, especially those who do not use condoms consistently or are men who have sex with men, are at particular risk for syphilis infection. With the rise in acquired syphilis infections, the incidence of congenital syphilis has also increased. Syphilis can have a variety of presentations based on infectious stage and central nervous system involvement. Careful physical examination and history can elicit the diagnosis. Screening with a nontreponemal test followed by treponemal testing can confirm the diagnosis, and staging is determined clinically. Testing for all sexually transmitted infections should be pursued because coinfections are common. Penicillin is the first-line treatment for syphilis, and duration of therapy depends on the presence of neurologic symptoms; all infants with possible congenital syphilis should receive treatment. Posttreatment monitoring is essential to confirm successful eradication of syphilis. All sexually active, at-risk patients, including pregnant persons, should be screened for syphilis, and those diagnosed as having syphilis should be counseled on disclosure to partners. Although not often found in a pediatric population, with the increasing incidence of syphilis infections in the United States, pediatric providers should have a low threshold for syphilis screening in adolescents and a high index of suspicion for congenital syphilis in infants.

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.

Cerebrospinal fluid CXCL13 concentration for diagnosis and monitoring of neurosyphilis in people with HIV

OBJECTIVES

The study aimed to assess and compare cerebrospinal fluid (CSF)-CXCL13 levels in People with HIV (PWH) with suspected neurosyphilis (NS), those with syphilis but without NS, and patients without treponema infection. Additionally, it aimed to evaluate changes in CSF-CXCL13 concentrations before and after antibiotic treatment.

DESIGN

This was a prospective cohort study involving 93 PWH suspected of NS. All participants underwent lumbar puncture, with CSF-CXCL13 levels measured at baseline and during follow-up in patients diagnosed with NS.

METHODS

CSF-CXCL13 levels were quantified using ELISA. The Mann-Whitney U test was used to analyze differences between groups, while the Wilcoxon test assessed within subject changes. ROC curve analysis determined the diagnostic efficacy of CSF-CXCL13 for NS.

RESULTS

Significantly higher CSF-CXCL13 levels were observed in patients with NS compared to those with syphilis without NS and non-syphilis patients. Posttreatment, a decline in CSF-CXCL13 levels was noted in all NS cases. A CSF-CXCL13 threshold exceeding 60.0 pg/ml, in conjunction with reactive CSF-FTA-ABS, yielded a sensitivity of 88.9% and a specificity of 97.6% for NS diagnosis.

CONCLUSIONS

CSF-CXCL13 emerges as a valuable adjunctive biomarker for detecting NS in PWH, especially in cases with nonreactive CSF-VDRL. Monitoring CSF-CXCL13 levels also appears effective in evaluating therapeutic response in PWH undergoing NS treatment.

2023 Korean sexually transmitted infections guidelines for non-gonococcal bacterial infection (chlamydia, syphilis, etc.) by the Korean Association of Urogenital Tract Infection and Inflammation

Non-gonococcal sexually transmitted infections (STIs) include chlamydia, syphilis, and chancroids. Chlamydia is the most common STI caused by Chlamydia trachomatis and is mainly transmitted through sexual intercourse or vertical transmission at birth. Although symptoms are mostly absent or mild, untreated chlamydial infections in females can lead to pelvic inflammatory disease, chronic pelvic pain, and infertility due to the narrowing of fallopian tubes. Syphilis is caused by Treponema pallidum and is divided into phase I, phase II, latent syphilis, and phase III. The incidence of syphilis, including congenital syphilis, has significantly increased in the United States in recent years. The chronic status of this disease can significantly increase morbidity and potentially affect almost all body organs, which, in rare cases, can lead to death. Additionally, untreated maternal syphilis can lead to fetal death and fatal congenital infections in newborns. Chancroid is an STI caused by Haemophilus ducreyi, and its prevalence is gradually decreasing in Korea and worldwide. The symptoms include shallow genital ulcers with suppurative granulomatous inflammation and tender inguinal lymphadenopathy. Chancroids can be differentiated from syphilitic chancres based on their appearance. In contrast to painless chancres, chancroids are painful. Ureaplasma urealyticum, Ureaplasma parvum, and Mycoplasma hominis are considered symbiotic bacteria. Infections caused by these bacteria are usually not considered STIs and do not require treatment unless they are suspected of being associated with infertility. This article presents the 2023 Korean STI guidelines for non-gonococcal bacterial infections.

CDC Laboratory Recommendations for Syphilis Testing, United States, 2024

This report provides new CDC recommendations for tests that can support a diagnosis of syphilis, including serologic testing and methods for the identification of the causative agent Treponema pallidum. These comprehensive recommendations are the first published by CDC on laboratory testing for syphilis, which has traditionally been based on serologic algorithms to detect a humoral immune response to T. pallidum. These tests can be divided into nontreponemal and treponemal tests depending on whether they detect antibodies that are broadly reactive to lipoidal antigens shared by both host and T. pallidum or antibodies specific to T. pallidum, respectively. Both types of tests must be used in conjunction to help distinguish between an untreated infection or a past infection that has been successfully treated. Newer serologic tests allow for laboratory automation but must be used in an algorithm, which also can involve older manual serologic tests. Direct detection of T. pallidum continues to evolve from microscopic examination of material from lesions for visualization of T. pallidum to molecular detection of the organism. Limited point-of-care tests for syphilis are available in the United States; increased availability of point-of-care tests that are sensitive and specific could facilitate expansion of screening programs and reduce the time from test result to treatment. These recommendations are intended for use by clinical laboratory directors, laboratory staff, clinicians, and disease control personnel who must choose among the multiple available testing methods, establish standard operating procedures for collecting and processing specimens, interpret test results for laboratory reporting, and counsel and treat patients. Future revisions to these recommendations will be based on new research or technologic advancements for syphilis clinical laboratory science.

Infectious and Postinfectious Vasculopathies

Stroke is a complication of many central nervous system (CNS) infections, but only a few present with stroke without other symptoms or signs of CNS infection. Chief among these are varicella zoster virus (VZV) and syphilis. Delayed cerebral vasculopathy after successful treatment of bacterial meningitis, most commonly pneumococcal, is an emerging entity with uncertain pathogenesis.

Neurological manifestations of syphilis-HIV coinfection in South Africa

OBJECTIVE

Syphilis and HIV coinfection is highly prevalent in South Africa, and both can cause neurological complications. We describe the clinical presentation and outcome of neurosyphilis in patients with and without HIV coinfection diagnosed at a tertiary facility, Groote Schuur Hospital (GSH), in South Africa.

METHODS

We retrospectively analyzed folders of adults with positive cerebrospinal fluid (CSF) fluorescent treponemal antibody absorption test in 2018 and 2019, with follow-up data collected until 2022.

RESULTS

HIV-coinfection was identified in 35% of the 69 included patients. Patients with HIV-coinfection were more likely to be female (58% vs 25% female, p < 0.01), and present earlier (median age = 31 years vs. 40 years, p < 0.001). Neuropsychiatric manifestations (confusion, dementia, psychosis), and strokes were the commonest clinical presentations in both groups. Those with HIV-coinfection were significantly less likely to be diagnosed with neurosyphilis by the treating clinician (71% vs. 91%, p < 0.05), as were those with a negative CSF Venereal Disease Research Laboratory (74% vs. 94%, p < 0.05). Accurate diagnosis of neurosyphilis was associated with an increased 12-month survival (alive: N = 36 [63%]) relative to those who did not receive an accurate diagnosis (alive: N = 2 [17%], p < 0.05). Those who were optimally treated with antibiotics had significantly higher 12-month survival (alive: N = 33, 63%) compared to those with suboptimal treatment (alive: N = 5, 29%), p < 0.01.

CONCLUSION

Neurosyphilis presented similarly in those with and without HIV-coinfection. Accurate identification and optimal antibiotic treatment of neurosyphilis, particularly in CSF VDRL negative patients and those with HIV-coinfection, is necessary to improve patient survival.

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.

Comparison of molecular and serological assays on cerebrospinal fluid for the diagnosis of neurosyphilis

BACKGROUND

Many assays are available on cerebrospinal fluid (CSF) for the diagnosis of neurosyphilis (NS) but there is no 'gold standard'.

OBJECTIVES

The aim of this study was to evaluate different molecular and serological assays used in NS.

METHODS

We evaluated two PCR assays and three serological techniques in parallel on CSF samples collected between 2019 and 2020 from patients suspected of NS.

RESULTS

The study included 143 patients comprising 30 early NS, 7 late NS and 106 patients without a diagnosis of NS. All patients with NS were symptomatic and had either neurological (67.6%) or ophthalmological signs (54.1%). The qPCR and nPCR assays had overall sensitivities (Se) of 41% and 27%, respectively; with each an overall specificity (Sp) of 100%. VDRL had a Se of 51% and a Sp of 92%. Immunoblot had a Se of 62% and a Sp of 85%. Finally, treponemal tests (TT) had a Se of 96% and a Sp of 69%.

CONCLUSIONS

Our study confirms the excellent specificity of molecular techniques allowing to avoid overdiagnosis of NS, and thus, unjustified intensive antibiotic therapy protocols. CSF TT, although not very specific, has an excellent Se confirming that there is almost never NS with negative CSF TT. VDRL and immunoblot tests have better overall diagnostic performance. However, none of these techniques has sufficient diagnostic performance to represent a 'gold standard'. Thus, the diagnosis of NS relies on a combination of clinical and biological parameters with the association of PCR with serology, associating VDRL and immunoblot, in CSF.

Advances in laboratory diagnostic methods for cerebrospinal fluid testing for neurosyphilis

Neurosyphilis is a chronic infectious disease caused by the invasion of Treponema pallidum into the central nervous system. In recent years, with the increase in the latent syphilis infection rate, the incidence of neurosyphilis has gradually increased, the typical symptoms of neurosyphilis have decreased, atypical manifestations have increased, and the clinical manifestations have become increasingly diverse. Cerebrospinal fluid testing plays an important role in the diagnosis of neurosyphilis. In recent years, there have been many advances in cerebrospinal fluid testing. This review focuses on the current and potential laboratory indicators of neurosyphilis in cerebrospinal fluid, aiming to provide a reference for clinical application and ideas for future experimental research of neurosyphilis.

When modern diagnostics is challenged by a historical disease: A case report

RATIONALE

Syphilis is a bacterial, systemic infectious disease caused by Treponema pallidum spirochetes, which spread rapidly through the body affecting various organs. The term neurosyphilis (NS) refers to a CNS infection that can occur at any stage of the disease. The lack of a gold standard for the diagnosis of NS greatly hinders diagnosis, which must be based mainly on clinical assessment.

PATIENT CONCERNS

A 58-year-old man reported dizziness and headache for a week and right-sided hearing impairment, with suspected transient cerebral ischemic attack. A month later he experience transient speech disturbance and suspected cerebral ischemic stroke.

DIAGNOSIS

MRI showed fresh ischemic lesions with a diameter up to 10 mm in the deep brain structures on the left side and foci of subacute ischemia also in the deep structures and the brain stem. Cerebrospinal fluid examination showed positive Pandy's reaction, doubtful Noone-Apelt reaction, increased protein level and decreased glucose level. The reactive result of the USR test performed (VDRL) finally allowed the diagnosis of symptomatic CNS syphilis.

INTERVENTIONS

Empiric treatment for bacterial meningitis was administered. The patient was transferred to the Department of Infectious Diseases for further treatment.

OUTCOMES

The diagnosis has been confirmed at the Department of Infectious Diseases after repeating CSF analysis including VDRL and FTA-ABS.

LESSON

Symptoms of NS are nonspecific, hence the diagnostic process is not straightforward. Despite the availability of modern diagnostic techniques, establishing a final diagnosis was challenging, but the patient ultimately received appropriate treatment. It is important to remember that syphilis is not only a disease known from history lessons but is still present in modern times and its incidence is increasing.

Clinical and laboratory features in patients with positive syphilis serology presenting with acute ischemic stroke or transient ischemic attack: a prospective cohort study

Background

Neurosyphilis (NS) can lead to acute ischemic stroke (AIS) or transient ischemic attack (TIA). We compared the clinical characteristics and laboratory features among AIS and TIA patients who were syphilis-seronegative (control group) or had latent syphilis (LS) or NS to evaluate their stroke outcome.

Methods

This prospective cohort study was conducted on patients who had recently suffered AIS or TIA. After serological syphilis screening, clinical and laboratory data were collected, and brain imaging and spinal tap (serologically syphilis-positive patients only) were performed. Stroke outcome was re-evaluated approximately three months later.

Results

The 344 enrolled patients were divided into three groups: control group (83.7%), LS (13.1%), and NS (3.2%). A multivariate analysis revealed: 1) age of ≥ 70 years, generalized brain atrophy via imaging, and alopecia (adjusted odds ratio [AOR] = 2.635, 2.415, and 13.264, respectively) were significantly associated with LS vs controls; 2) age of ≥ 70 years (AOR = 14.633) was significantly associated with NS vs controls; and 3) the proportion of patients with dysarthria was significantly lower (AOR = 0.154) in the NS group than in the LS group. Regarding the NS patient cerebrospinal fluid (CSF) profile, only 2/11 cases had positive CSF-Venereal Disease Research Laboratory (VDRL) test results; the other nine cases were diagnosed from elevated white blood cell counts or protein levels combined with positive CSF fluorescent treponemal antibody absorption (FTA-ABS) test results. Regarding disability, the initial modified Rankin scale (mRS) score was lower in the control group than in the NS group (p = 0.022). At 3 months post-stroke, the mRS score had significantly decreased in the control (p < 0.001) and LS (p = 0.001) groups. Regarding activities of daily living, the 3-month Barthel Index (BI) score was significantly higher in control patients than in LS (p = 0.030) or NS (p = 0.002) patients. Additionally, the 3-month BI score was significantly increased in the control (p < 0.001) and LS (p = 0.001) groups.

Conclusions

Because syphilis was detected in many AIS and TIA patients, especially those aged ≥ 70 years, routine serological syphilis screening may be warranted in this population. Patients with syphilitic infection had worse stroke outcomes compared with NS patients.

Changes of serofast status in HIV negative asymptomatic neurosyphilis patients after treatment

Serofast status after therapy in syphilis patients is a common phenomenon. A proportion of patients who have serofast status exhibit abnormal cerebrospinal fluid test results, which can be defined as asymptomatic neurosyphilis (ANS); however, it remains unclear whether ANS patients can achieve serological cure after anti-neurosyphilis treatment as quickly as other serofast patients. In this study, non-treponemal pallidum antibody serological responses were studied in ANS and serofast control patients, and the cumulative rates of serological cure in the ANS group were 9.6, 22.1, 25.9, and 30.2% in 3, 6, 9, and 12 month after treatment, which were statistically higher than those of the serofast control group. The change gap in serological cure rates was even more pronounced within 6 months after treatment, but the majority of ANS patients had no change in serofast status at 12 months after treatment. Our study indicates that anti-neurosyphilis therapy can partially change the serofast status. As serofast status cannot easily be changed even under neurosyphilis treatment in the majority of patients, the pathogenesis of this condition needs further research.

Intrathecal Synthesis Index of Specific Anti-Treponema IgG: a New Tool for the Diagnosis of Neurosyphilis

Neurosyphilis (NS) diagnosis is challenging because clinical signs are diverse and unspecific, and a sensitive and specific laboratory test is lacking. We tested the performance of an antibody index (AI) for intrathecal synthesis of specific anti-Treponema IgG by enzyme-linked immunosorbent assay (ELISA) for NS diagnosis. We conducted a retroprospective monocentric study including adults with neurological symptoms who had serum and cerebral spinal fluid (CSF) samples collected between 2006 and 2021. Two NS definitions were used. NS1 included patients with neurological symptoms, positive Treponema pallidum particle agglutination (TPPA) serology, and CSF-TPPA of ≥320, as well as CSF-leukocytes of >5 cells/mm³ and/or CSF-protein of >0.45 g/L and/or a reactive CSF-VDRL/RPR test. NS2 included patients with acute ocular and/or otologic symptoms, positive TPPA serology, and a response to NS treatment. Controls were patients with central nervous system disorders other than neurosyphilis. Anti-Treponema pallidum IgG were measured simultaneously in serum and CSF, and AI was calculated according to Reiber diagram. We assessed the AI test area under the curve (AUC), sensitivity/specificity, and estimated positive and negative predictive values. In total, 16 NS1 patients, 11 NS2 patients, and 71 controls were included. With an AI of ≥1.7 as a positive test for NS diagnostic, specificity was 98.6% (95% confidence interval [CI 95%] of 92.4 to 100.0) and sensitivity was 81.3% (CI 95% of 54.4 to 96.0) for NS1 and 98.6% (CI 95% 92.4 to 100.0) and 27.3% (CI 95% 6.0 to 61.0), respectively, for NS2. Positive and negative predictive values were >95% for NS1 and >85% for NS2, for prevalence above and below 20%. Measuring an AI for intrathecal synthesis of specific anti-Treponema pallidum IgG is a new promising tool highly specific for NS diagnosis.

IMPORTANCE In the context of a lack of a gold standard for the diagnosis of neurosyphilis due to either nonspecific or nonsensitive tests, we present in this article a new promising tool highly specific for NS diagnosis. This new test involves measuring an intrathecal synthesis index of specific anti-Treponema IgG by ELISA.

Diagnosis and Treatment of Sexually Transmitted Infections: A Review

IMPORTANCE

Approximately 1 in 5 adults in the US had a sexually transmitted infection (STI) in 2018. This review provides an update on the epidemiology, diagnosis, and treatment of gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, trichomoniasis, and genital herpes.

OBSERVATIONS

From 2015 to 2019, the rates of gonorrhea, chlamydia, and syphilis increased in the US; from 1999 to 2016, while the rates of herpes simplex virus type 1 (HSV-1) and HSV-2 declined. Populations with higher rates of STIs include people younger than 25 years, sexual and gender minorities such as men and transgender women who have sex with men, and racial and ethnic minorities such as Black and Latinx people. Approximately 70% of infections with HSV and trichomoniasis and 53% to 100% of extragenital gonorrhea and chlamydia infections are asymptomatic or associated with few symptoms. STIs are associated with HIV acquisition and transmission and are the leading cause of tubal factor infertility in women. Nucleic acid amplification tests have high sensitivities (86.1%-100%) and specificities (97.1%-100%) for the diagnosis of gonorrhea, chlamydia, M genitalium, trichomoniasis, and symptomatic HSV-1 and HSV-2. Serology remains the recommended method to diagnose syphilis, typically using sequential testing to detect treponemal and nontreponemal (antiphospholipid) antibodies. Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles, such as metronidazole, are effective treatments for gonorrhea, chlamydia, syphilis, M genitalium, and trichomoniasis, respectively, but antimicrobial resistance limits oral treatment options for gonorrhea and M genitalium. No cure is available for genital herpes. Effective STI prevention interventions include screening, contact tracing of sexual partners, and promoting effective barrier contraception.

CONCLUSIONS AND RELEVANCE

Approximately 1 in 5 adults in the US had an STI in 2018. Rates of gonorrhea, chlamydia, and syphilis in the US have increased, while rates of HSV-1 and HSV-2 have declined. Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles are effective treatments for gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, and trichomoniasis, respectively, but antimicrobial resistance limits oral therapies for gonorrhea and Mycoplasma genitalium, and no cure is available for genital herpes.

Clinical features associated with neurosyphilis in people living with HIV and late latent syphilis

Background

The diagnosis of neurosyphilis is a challenge, and the criteria for deciding when to perform a lumbar puncture are still controversial, especially in people living with HIV with a late latent syphilis diagnosis.

Methods

Retrospective analysis of demographic, clinical, and laboratory data of people with HIV and documented late latent syphilis or syphilis of unknown duration with a cerebrospinal fluid VDRL test.

Results

122 patients were evaluated, of whom 52 had the diagnosis of neurosyphilis. Patients with and without neurosyphilis presented a similar viral load and lymphocyte CD4⁺ T-cell count. Neurological symptoms (OR 6.4, 95% CI 2.1–22.4; p < 0.01), serum VDRL titers of 1:32 (p<0.01), 1:64 (p = 0.055), and ≥1:128 (p < 0.001) were associated with neurosyphilis. Furthermore, serum VDRL ≥1:32 were associated with (OR 24.9, 95% CI 5.45–154.9; p < 0.001) or without (OR 6.5, 95% CI 2.0–29.2; p = 0.004) neurological symptoms with neurosyphilis; however, VDRL ≤1:16 with neurological symptoms can be associated with neurosyphilis (OR 7.6, 95% CI 1.03–64.3; p = 0.046).

Conclusion

Neurological symptoms, particularly headache, were predictors of neurosyphilis in people with HIV irrespective of their viral load and lymphocyte CD4⁺ T-cell count in late latent syphilis. A serum VDRL ≥1:32 increased the risk of neurosyphilis in patients with or without any symptoms.

The Use of Intracranial Vessel Wall Magnetic Resonance Imaging to Detect a Presumptive Syphilitic Brain Aneurysm

ABSTRACT

Syphilitic intracranial aneurysm is a rare presentation of meningovascular syphilis in developed countries. In this case report, we discuss the utilization of the intracranial vessel wall magnetic resonance imaging in the management of a patient with a rare fusiform brain aneurysm, positive syphilis serologies, and inconclusive cerebrospinal fluid findings.

A 2021 Update on Syphilis: Taking Stock from Pathogenesis to Vaccines

In 2021 the scientific community's efforts have been focused on solving the back-breaking challenge of the COVID-19 pandemic, but sexually transmitted infections (STI) are still one of the most common global health problems. Syphilis is a systemic disease caused by the spirochaete Treponema pallidum (TP) and is one of the oldest known diseases. Its incidence has increased in the last few years and syphilis still remains a contemporary plague that continues to afflict millions of people worldwide. Despite research improvements, syphilis pathogenesis is not completely clear; clinical presentation is very heterogeneous and the diagnosis can sometimes be difficult. Furthermore, few therapeutic options are available, and a vaccine has not been found yet. In this review, we describe the most recent evidence concerning the clinical manifestation, diagnosis, treatment and vaccine prospectives for this disease.

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.

Clinical and serological outcomes in patients treated with oral doxycycline for early neurosyphilis

OBJECTIVES

Penicillin-based antibiotic treatment for syphilis infection with CNS involvement (early neurosyphilis) is not always a suitable treatment option. We compared outcomes of patients diagnosed with early neurosyphilis and treated with doxycycline or procaine G penicillin.

METHODS

Serological and clinical outcomes were analysed in patients diagnosed with early neurosyphilis between January 2015 and October 2019 at 56 Dean Street, a combined sexual health and HIV service based in London, UK. Acute onset of CNS, ocular and/or otic symptomatology and a documented seroconverting syphilis serology or a >4-fold increase in rapid plasma reagin ('RPR)' test titre within the previous 12 months were criteria used to define a case. Mann-Whitney U-test and χ2 tests were used to test distributions between baseline characteristics and outcomes according to treatment administered.

RESULTS

Eighty-seven patients were included: median age = 35 years (IQR = 31-45), 98% MSM, 79% white ethnicity, 53% HIV-1 positive and 40% previously diagnosed with syphilis at any stage. They were treated exclusively with either intramuscular (IM) procaine G penicillin (71%) or oral doxycycline (18%). Patients received doxycycline treatment over a penicillin-based regimen due to IM treatment declined (31%), inability to attend for IM injections (31%) or penicillin allergy (19%). Serological response was achieved by all patients; 91% reported full symptom resolution at 30 days from end of treatment. Similar rates of clinical and serological response and seroreversion were observed in the groups treated with procaine G penicillin versus doxycycline.

CONCLUSIONS

The clinical and serological outcomes seen with penicillin-based versus doxycycline treatments were similar. A randomized controlled trial is needed to establish the effectiveness of doxycycline in the treatment of early neurosyphilis.

Diagnostic tools for neurosyphilis: a systematic review

Purpose

Increasing incidences of syphilis highlight the preoccupation with the occurrence of neurosyphilis. This study aimed to understand the current diagnostic tools and their performance to detect neurosyphilis, including new technologies and the variety of existing methods.

Methods

We searched databases to select articles that reported neurosyphilis diagnostic methods and assessed their accuracy, presenting sensitivity and specificity values. Information was synthesized in tables. The risk of bias was examined using the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy recommendations.

Results

Fourteen studies were included. The main finding was a remarkable diversity of tests, which had varied purposes, techniques, and evaluation methodologies. There was no uniform criterion or gold standard to define neurosyphilis. The current basis for its diagnosis is clinical suspicion and cerebrospinal fluid analysis. There are new promising tests such as PCR tests and chemokine measurement assays.

Conclusions

The diagnosis of neurosyphilis is still a challenge, despite the variety of existing and developing tests. We believe that the multiplicity of reference standards adopted as criteria for diagnosis reveals the imprecision of the current definitions of neurosyphilis. An important next step for the scientific community is to create a universally accepted diagnostic definition for this disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06264-8.

Outcomes From Re-Treatment and Cerebrospinal Fluid Analyses in Patients With Syphilis Who Had Serological Nonresponse or Lack of Seroreversion After Initial Therapy

BACKGROUND

We conducted an observational study to determine whether patients with syphilis who do not demonstrate serological cure or lack of seroreversion in nontreponemal (NT) antibody titers after initial therapy benefit from re-treatment and cerebrospinal fluid (CSF) analysis.

METHODS

We enrolled patients with syphilis from sexually transmitted disease clinics in Guangzhou, China, who had persistent NT titers after therapy. Serological nonresponse was defined as a <4-fold decline in baseline NT titers after therapy. Lack of seroreversion was defined as demonstrating a ≥4-fold NT titer decline but without seroreversion to negative, or having persistent low-level titers (i.e., 1:1-1:2) after therapy. After consent, we abstracted medical record data regarding syphilis diagnoses, initial and re-treatment regimens, and serological outcomes. Nontreponemal titers were obtained from participants at enrollment and follow-up. We evaluated CSF findings among a subgroup of participants relative to re-treatment.

RESULTS

From March 2012 to February 2016, we enrolled 135 HIV-negative patients with syphilis with persistent NT titers after initial therapy. Among 116 participants with ≥12 months of follow-up, 60 (52%) received re-treatment of syphilis. Overall, there were no significant differences in serological response between those who were re-treated and those who were not among serological nonresponders (29% vs. 27%; P = 1.0) or among participants without seroconversion (41% vs. 37%; P = 0.8). Of 60 participants who underwent CSF analyses, 8 (13%) had CSF abnormalities, but only 2 (3%) met the neurosyphilis criteria after re-treatment.

CONCLUSIONS

Most HIV-negative patients with syphilis who have serological nonresponse or lack of seroreversion after therapy do not benefit from re-treatment in the short term, and neurosyphilis is uncommon.

Sensitivity and Specificity of Treponemal-specific Tests for the Diagnosis of Syphilis

We conducted a systematic review of relevant syphilis diagnostic literature to address the question, “What is the sensitivity and specificity of the treponemal tests currently approved by the Food and Drug Administration (FDA) for the diagnosis of syphilis (by stage)?” There were 16 treponemal assays evaluated: 13 immunoassays and 3 manual assays (fluorescent treponemal antibody absorbed test [FTA-ABS], microhemagglutination assay for Treponema pallidum antibodies [MHA-TP], Treponema pallidum particle agglutination assay [TP-PA]). MHA-TP and FTA-ABS were less sensitive in primary and secondary syphilis than TP-PA; TP-PA is the most specific manual treponemal assay. There is insufficient evidence to recommend one particular treponemal immunoassay (eg, enzyme immunoassays, chemiluminescence immunoassays, microbead immunoassays) over another based on published performance data. For diagnosis of neurosyphilis, cerebrospinal fluid (CSF) TP-PA has similar performance to CSF FTA-ABS in studies with patients with definitive or presumptive neurosyphilis. However, CSF treponemal testing has limitations in its sensitivity and specificity and should be interpreted within the context of the clinical scenario, additional CSF test results and syphilis prevalence.

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.

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.

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.

Neurosyphilis: Still prevalent and overlooked in an at risk population

BACKGROUND

Neurosyphilis (NS) presents with a variety of clinical syndromes that can be attributed to other aetiologies due to difficulties in its diagnosis. We reviewed all cases of NS from the "Top End" of the Australian Northern Territory over a ten-year period to assess incidence, clinical and laboratory manifestations.

METHODS

Patient data (2007-2016) were extracted from hospital records, centralised laboratory data and Northern Territory Centre for Disease Control records. Clinical records of patients with clinically suspected NS were reviewed. A diagnosis of NS was made based on the 2014 US CDC criteria. Results were also recategorized based on the 2018 US CDC criteria.

RESULTS

The population of the "Top End" is 185,570, of whom 26.2% are Indigenous. A positive TPPA was recorded in 3126 individuals. A total of 75 (2.4%) of TPPA positive patients had a lumbar puncture (LP), of whom 25 (35%) were diagnosed with NS (9 definite, 16 probable). Dementia was the most common manifestation (58.3%), followed by epilepsy (16.7%), psychosis (12.5%), tabes dorsalis (12.5%) and meningovascular syphilis (8.3%). 63% of probable NS cases were not treated appropriately due to a negative CSF VDRL. Despite increased specificity of the 2018 US CDC criteria, 70% of patient in the probable NS group were not treated appropriately. The overall annual incidence [95%CI] of NS was 2.47[1.28-4.31] per 100 000py in the Indigenous population and 0.95[0.50-1.62] in the non-Indigenous population (rate ratio = 2.60 [1.19-5.70];p = 0.017).

CONCLUSION

Neurosyphilis is frequently reported in the NT, particularly in Indigenous populations. Disturbingly, 60% of probable neurosyphilis patients based on the 2014 criteria, and 70% based on the 2018 criteria with were not treated appropriately. It is critical that clinicians should be aware of the diagnosis of NS and treat patients appropriately.

Neurosyphilis in AIDS patient presenting as isolated cranial nerve 6 palsy

Early neurosyphilis can occur in an immunocompromised host. It has a widely varied presentation. Isolated CN6 as presenting symptom has not been described.

Neurosyphilis: mighty imitator forays with benign presentation and unique neuroimaging findings

Background Common causes of temporal lobe hyper intensities are central nervous system infections like herpes simplex encephalitis, Lyme disease, limbic encephalitis and vascular pathology like Cerebral Autosomal Dominant Arteriopathy with Subcortical infarcts and Leukoencephalopathy.

METHODS

Personal assessment, laboratory data analysis and neuroimaging for the patient who was admitted to a central Pennsylvania tertiary care referral centre were conducted.

RESULTS

A 52-year-old male presented with a 1-year history of diffuse dysesthesia in upper and lower extremities with associated intermittent headaches and neck stiffness. Evaluation with lumbar puncture revealed increased nucleated cells (50ul) with lymphocytic predominance (96%) and an elevated protein level of 109mg/dl. Magnetic resonance imaging (MRI) of the brain showed T2/FLAIR hyper intensity in bilateral subcortical temporal white matter, left-greater-than-right and associated volume loss in cerebral parenchyma. Additional abnormal work up included reactive serum reactive plasma regain and Treponema pallidum antibody particle agglutination. Diagnosis of neurosyphilis was made and the patient was treated with intramuscular (IM) penicillin for 3 weeks. At the time of discharge, his headache and neck stiffness resolved and dysesthesias were decreased in intensity.

CONCLUSIONS

The diagnosis of neurosyphilis is intricate, and no reference standard exists. Neuroimaging findings of neurosyphilis commonly are cerebral infarctions, leptomeningeal enhancement or non-specific white matter lesions. Less common features on fluid-attenuated inversion recovery (FLAIR) sequences are cortical atrophy and mesial temporal parenchymal signal changes. It is prudent to keep neurosyphilis in differential of mesial temporal lobe white matter changes, as early diagnosis and treatment results in better prognosis.

Diagnostic Testing in Central Nervous System Infection

Patients with central nervous system (CNS) infection experience very high levels of morbidity and mortality, in part because of the many challenges inherent to the diagnosis of CNS infection and identification of a causative pathogen. The clinical presentation of CNS infection is nonspecific, so clinicians must often order and interpret many diagnostic tests in parallel. This can be a daunting task given the large number of potential pathogens and the availability of different testing modalities. Here, we review traditional diagnostic techniques including Gram stain and culture, serology, and polymerase chain reaction (PCR). We highlight which of these are recommended for the pathogens most commonly tested among U.S. patients with suspected CNS infection. Finally, we describe the newer broad-range diagnostic approaches, multiplex PCR and metagenomic sequencing, which are increasingly used in clinical practice.

Neurosyphilis: Concordance between cerebrospinal fluid analysis and subsequent antibiotic strategy for patients undergoing evaluation of a diagnosis of neurosyphilis

INTRODUCTION

The confirmation or analysis and exclusion of a diagnosis of neurosyphilis has long presented a challenge for infectious diseases clinicians. The authors reviewed the concordance between cerebrospinal fluid (CSF) analysis and the subsequent antibiotic strategy for patients undergoing evaluation of a diagnosis of neurosyphilis.

METHODS

All patients with positive serum syphilis serology referred for CSF analysis between January 2009 and May 2016 were included. Indications for CSF analysis were determined by review of the hospital electronic medical records. CSF parameters were determined from the hospital pathology database. Cases were defined as either 'confirmed', 'supportive' of, or 'not supportive' of a diagnosis of neurosyphilis based on existing definitions. Subsequent therapy was defined as for neurosyphilis, late latent primary syphilis or no therapy based on existing guidelines.

RESULTS

Of 131 patients reviewed, 95.4% were male and HIV co-infected (74%). A confirmed diagnosis of neurosyphilis was met by fourteen patients (10.7%). All but two of these were treated with a neurosyphilis-directed regimen. Of the 58 patients treated with neurosyphilis antibiotics, 17.2% had no CSF findings suggestive of the diagnosis. Seventy-three patients were not treated for neurosyphilis; however 35 of these met the CSF criteria for a diagnosis supportive of neurosyphilis.

CONCLUSIONS

The results of routine CSF analysis in patients with a possible diagnosis of neurosyphilis are inconsistently applied in the clinical setting, calling into question the value of routine CSF. Empirical neurosyphilis treatment should be considered up front in patients with high pre-test probability of the diagnosis.

Syphilis

Syphilis is an infectious disease caused by the spirochaete Treponema pallidum subsp. pallidum which is transmitted by sexual contact or vertical transmission during pregnancy. The incidence of syphilis has increased in the last years, mainly among men who have sex with men. Without treatment, the disease develops into different clinical stages, being able to present cardiovascular or irreversible neurological complications after a number of years. The disease is classified as early syphilis - primary, secondary and early latent syphilis (less than 12 months) - which is contagious, and as late syphilis - late latent and tertiary syphilis- which is rarely contagious. Diagnosis and management are often a challenge because of its diversity of manifestations and the difficulty of interpretation of serological tests. The treatment of syphilis is based on penicillin or doxycycline in allergic patients. Treatment failure because of resistance has been described with azithromycin. The follow up with a serological test is recommended in all patients with syphilis in order to ascertain cure after the treatment and to diagnose possible reinfections.

Diagnostic Testing of Neurologic Infections

Neuroinfectious diseases continue to cause morbidity and mortality worldwide, with many emerging or reemerging infections resulting in neurologic sequelae. Careful clinical evaluation coupled with appropriate laboratory investigations still forms the bedrock for making the correct etiologic diagnosis and implementing appropriate management. The treating physician needs to understand the individual test characteristics of each of the many conventional candidate-based diagnostics: culture, pathogen-specific polymerase chain reaction, antigen, antibody tests, used to diagnose the whole array of neuroinvasive infections. In addition, there is a growing need for more comprehensive, agnostic testing modalities that can identify a diversity of infections with a single assay.

Consider Syphilis in Case of Lymphopenia in HIV-Infected Men Who Have Sex with Men (MSM): A Single-center, Retrospective Study

Introduction

The way syphilis affects the immunologic and virologic parameters of a human immunodeficiency virus (HIV) infection remains controversial. The aim of this study was to investigate the impact of syphilis infection on lymphocyte and lymphocyte subset counts as well as viral load in HIV-infected patients.

Methods

All HIV-infected patients attending the outpatient clinic for infectious diseases of Hannover Medical University Hospital diagnosed with syphilis between 2009 and 2016 were retrospectively evaluated for changes in total lymphocyte, B cell, CD3⁺ T cell, CD4⁺ and CD8⁺ T cell counts as well as in HIV viral load. These parameters were assessed at three different time points, i.e., 3–6 months before, at diagnosis and 3–6 months after treatment of syphilis.

Results

Eighty-four HIV-infected patients, all with early syphilis, were identified. The vast majority were men who have sex with men (MSM), and 80% were receiving antiretroviral therapy (ART). Syphilis was associated with a significant reduction in the total lymphocyte count and counts of all studied lymphocyte subsets, including CD4⁺ T cells, whose percentage among lymphocytes did not change. No significant changes in HIV viral load were observed at any of the studied time points. Further, antibiotic treatment of syphilis restored lymphocyte counts back to pretreatment levels.

Conclusion

Syphilis induces a relative non-CD4⁺ T cell-specific lymphopenia in HIV-infected patients. Our data suggest that serologic testing for syphilis should be considered in HIV-infected MSM in case of an otherwise unexplained drop in total lymphocyte count.

Electronic supplementary material

The online version of this article (10.1007/s40121-018-0219-9) contains supplementary material, which is available to authorized users.

Diagnostic performance of PCR assays for the diagnosis of neurosyphilis: a systematic review

INTRODUCTION

Syphilis continues to be a major public health problem and the recent resurgence in syphilis in high-income settings has seen an accompanying increase in cases of neurosyphilis. While the introduction of PCR has had a significant impact on the diagnosis of early syphilis, cerebrospinal fluid (CSF) serological assays remain the most commonly used tests to diagnosis neurosyphilis. We reviewed data on the performance of CSF-PCR for the diagnosis of neurosyphilis.

METHODS

We searched Pubmed, Medline, EMBASE and the grey literature for references on PCR in neurosyphilis. We calculated the sensitivity and specificity of PCR compared with reference testing for the diagnosis of neurosyphilis.

RESULTS

We identified 66 articles of which seven met the study inclusion criteria. The sensitivity of PCR for definite neurosyphilis varied between 40% and 70% and specificity between 60% and 100% across the studies. The most commonly used PCR assay targeted Tp47 which had an overall sensitivity of 68% and a specificity of 91.9%.

DISCUSSION

The sensitivity of PCR was low compared with CSF-serological assays but the challenges of evaluating a diagnostic test in the absence of a clear gold standard make definitive interpretation challenging. Most studies were small and not adequately powered highlighting the need for multicentre, multicountry trials to provide adequate statistical power in evaluations of new tests the diagnosis of neurosyphilis.

Neurosyphilis: A Simulation Case for Emergency Medicine Residents

Neurosyphilis is a dangerous and increasingly more prevalent sexually transmitted infection of the central nervous system caused by the bacterium Treponema pallidum that can present during the advanced stages of the disease (tertiary syphilis). Health care providers must remain vigilant in screening for syphilis in patients with high-risk behaviors as a delay in diagnosis and treatment may lead to symptom progression and debilitating sequelae years later. To date, there have been no published simulation case studies on neurosyphilis. This simulation case, based on a real patient encounter, is written for emergency medicine residents to diagnose and manage a patient presenting with the sequelae of neurosyphilis. This case was run for four separate iterations at a simulation center with two residents and an attending physician acting as confederates. Following the case, learners were provided with bedside debriefing, and a question and answer session. Based on post-simulation qualitative assessment, junior residents alone were less likely to perform a comprehensive integumentary exam without the presence of senior residents, although both groups failed to elicit pertinent sexual history until they discovered syphilitic lesions. After case completion and debriefing, all learners were able to demonstrate the understanding of the primary learning objectives.

Neurosyphilis as a Cause of Transverse Myelitis in a Teenage Girl

BACKGROUND

Syphilis is a sexually transmitted infection that was nearly eradicated in 2001 but is now making a resurgence. It has a wide range of clinical manifestations depending on disease stage. Neurosyphilis is an infrequently seen infectious disease with central nervous system involvement that can occur in either early- or late-stage syphilis. The diagnosis of neurosyphilis is challenging, primarily because Treponema pallidum, the infecting organism, cannot be cultured in vitro. This article describes a patient with neurosyphilis and reviews the epidemiology and clinical manifestations, diagnostics, and treatment of neurosyphilis.

CASE REPORT

In compliance with the request of the Privacy Board of our institution, the numerical age of this patient has been omitted. A sexually active teenage girl who was treated for primary syphilis 2 years earlier presented to a tertiary children's hospital with paresthesia and weakness of her right leg, left arm, and neck. Magnetic resonance imaging revealed cervical intramedullary cord edema consistent with transverse myelitis. Serum studies showed positive syphilis enzyme immunoassay, T. pallidum particle agglutination assay, and fluorescent treponemal antibody absorption. A serum rapid plasma reagin test was negative. A lumbar puncture was performed with normal cell count and protein. A cerebrospinal fluid Venereal Disease Research Laboratory test was negative. She was diagnosed with neurosyphilis and treated with intravenous steroids and penicillin G, with near complete resolution of symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The Centers for Disease Control and prevention has noted a steady rise of the incidence of syphilis since 2002. Emergency physicians should be familiar with the spectrum of the clinical manifestations of syphilis, challenges in diagnostics, and appropriate treatment course.

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.