Otosyphilis: a diagnostic and therapeutic dilemma

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.

Syphilis for dermatologists: Current concepts

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

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.

Otosyphilis: A rare case of reversible hearing loss in a young man with secondary syphilis

Background

Over the last decade, it has been noticed a significant increase in the number of cases of syphilis with a concurrent increased number of patients presenting with syphilis-related complications. Otosyphilis is a well-known complication of syphilis that most of the time, can lead to irreversible hearing loss, especially with delayed diagnosis and treatment. A high index of suspicion is needed for an accurate diagnosis of otosyphilis. Complete audiologic recovery is rare but still possible with the appropriate treatment.

Case report

Herein, we describe a case of reversible hearing loss secondary to otosyphilis in a young healthy man who was initially diagnosed and treated as a case of secondary syphilis, and presented later to the clinic with unilateral tinnitus and hearing loss. Audiology findings were consistent with asymmetric sensorineural hearing loss. Fortunately, complete recovery of hearing was achieved after treatment with a 14-day course of intravenous penicillin.

Conclusion

Otosyphilis is one of the rare presentations of syphilis; thus, the diagnosis is often missed or delayed. Prompt diagnosis and treatment can help prevent the occurrence of permanent hearing loss.

[Syphilis infection in the ENT area]

The number of reported cases of syphilis has been increasing for years. The sexually transmitted disease is caused by the spirochete Treponema pallidum subspecies pallidum and progresses in different stages. Symptoms in the ENT area can occur in all stages. This means that a syphilis infection should always be considered by the ENT doctor as a differential diagnosis if the symptoms are suitable. Thus, with increasing oral sexual intercourse, the primary effect/hard chancre is more often observed in the oral cavity. In addition, symptoms can occur not only in the oral cavity, but also in the ear, nose, larynx, cervical and facial regions. The diagnosis is confirmed by direct pathogen detection or by serological detection. The spirochete cannot be cultivated. The therapeutic gold standard is the administration of benzathine penicillin G or procaine penicillin G. Doxycycline, macrolides or ceftriaxone are available as alternatives. In case of inner ear or cranial nerve involvement, the additional administration of a glucocorticoid is recommended. Before antibiotic therapy is administered, the patient must be informed about the possibility of a Jarisch-Herxheimer reaction. In cases of a syphilis infection, a collegial cooperation with the venereologists is always recommended so that an effective and comprehensive diagnosis and therapy can be carried out.

Otosyphilis: A Rare Cause of Reversible Hearing Loss in a Teenage Male

A high index of suspicion and a thorough neurotologic examination at the onset of presentation are imperative to generate the diagnosis of otosyphilis. Complete audiologic recovery is rare but possible in approximately 20%-25% of patients after appropriate treatment. We present a case of reversible hearing loss secondary to otosyphilis in a teenage male patient with a new diagnosis of human immunodeficiency virus (HIV). Audiology findings were consistent with mixed hearing loss. Lumbar puncture results were consistent with neurosyphilis. Prompt treatment with a 14-day course of intravenous penicillin led to the complete recovery of hearing. In this case report, the pathophysiology, symptomology, and management of otosyphilis are discussed.

Otosyphilis with Clinical and Serologic Responses with Weekly Intramuscular Penicillin: A Case Report and Literature Review

With the increasing prevalence of syphilis in different parts of the world, it is important to be cognizant of serious forms of syphilis. Otosyphilis is a rare form of syphilis with an extremely high rate of complications. Early diagnosis is essential to prevent a complete loss of hearing and decrease mortality. We present a unique case of otosyphilis who presented with left hearing loss, tinnitus, and vertigo, with audiometric findings confirming the hearing loss. An MRI brain showed asymmetric enhancement of the left cochlea and vestibular apparatus. She initially received oral steroids and trans-tympanic steroid injections with transient improvement of symptoms. She was diagnosed with syphilis through contact tracing after her ex-boyfriend tested positive. She received three weekly doses of intramuscular penicillin. Interestingly, her symptoms, rapid plasma regain (RPR) titer, and audiometry findings markedly improved. Once a diagnosis of otosyphilis was established, she received 14 days of intravenous penicillin.

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.

Syphilis Laboratory Guidelines: Performance Characteristics of Nontreponemal Antibody Tests

We reviewed the relevant syphilis diagnostic literature to address the following question: what are the performance characteristics, stratified by the stage of syphilis, for nontreponemal serologic tests? The database search included key terms related to syphilis and nontreponemal tests from 1960–2017, and for data related to the venereal disease research laboratory test from 1940–1960. Based on this review, we report the sensitivity and specificity for each stage of syphilis (primary, secondary, early latent, late latent, or unknown duration; tertiary as well as neurosyphilis, ocular syphilis, and otic syphilis). We also report on reactive nontreponemal tests in conditions other than syphilis, false negatives, and automated nontreponemal tests. Overall, many studies were limited by their sample size, lack of clearly documented clinical staging, and lack of well-defined gold standards. There is a need to better define the performance characteristics of nontreponemal tests, particularly in the late stages of syphilis, with clinically well-characterized samples. Published data are needed on automated nontreponemal tests. Evidence-based guidelines are needed for optimal prozone titrations. Finally, improved criteria and diagnostics for neurosyphilis (as well as ocular and otic syphilis) are needed.

A Rare Cause of Acute Bilateral Hearing Loss: Otosyphilis

Syphilis is a bacterial infection caused by Treponema pallidum. It spreads usually via sexual contact. Syphilis generally presents as a multisystem disease, with symptoms resembling and often confused with those of other diseases, thus often called “the great mimicker”. Neurosyphilis is a rare but late course of the disease process when the meninges and central nervous system (CNS) are involved. Otosyphilis is an even rarer, yet important complication of neurosyphilis and a rare cause of sensorineural deafness often misdiagnosed. We present the case of a 46-year-old Caucasian male admitted for acute onset bilateral hearing loss caused by otosyphilis. We include a discussion about cerebrospinal fluid (CSF) protein analysis in individuals diagnosed with neurosyphilis.

Pediatric otosyphilis—An unusual cause of conductive hearing loss

We present the case of a 5 year old female with a unilateral conductive hearing loss which had a relapsing and remitting course over a 3 year period. An initial noncontrast CT temporal bone study was unremarkable and a diagnosis of otitis media was made in the first instance. However, a second CT temporal bone study performed 3 years later demonstrated bilateral demineralisation of the ossicles and abnormal lucency affecting both the otic capsules. A diagnosis of otosyphilis was proposed on the basis of the imaging features and a prior medical history of previously treated congenital syphilis. With the benefit of hindsight, early pericochlear lucency was identified on the initial CT temporal bone study. There has been a steady rise of syphilis cases since the millennium with resurgence in many high income countries. Otosyphilis has a highly variable clinical presentation and there is limited data to establish the pattern of hearing loss in pediatric patients with a background of congenital otosyphilis. Temporal bone and otic capsule demineralisation carries a broad differential diagnosis including osteogenesis imperfecta, otosclerosis, Paget's disease and radiation related changes. Otosyphilis is a rare but potentially treatable cause of deafness and a high index of suspicion is required to make the diagnosis. In conjunction with a positive syphilis serology, a noncontrast temporal bone CT can aid the diagnosis and expedite the treatment.

Penicillin G Sodium as a Treatment of Otosyphilis with Hearing Loss

Otosyphilis is one contributing cause of hearing loss in adult patients. There are limited studies on the treatment regimens of otosyphilis. Penicillin G sodium (PGS) plus additional medications, such as benzathine penicillin and probenecid, is an effective regimen. This study investigated the efficacy of PGS alone for the treatment of otosyphilis. We conducted a retrospective study and included all consecutive patients diagnosed with otosyphilis who received only PGS treatment. The study period was from 2009 to 2013. The PGS treatment regimen was PGS 4 mu intravenously every four hours (24 mu/day) for 14 days. Clinical and audiogram outcomes were evaluated one year after treatment. There were 34 otosyphilis patients that were treated with PGS. After one year of treatment, 18 patients (52.9%) had a clinical improvement and 11 patients (32.4%) had an audiogram improvement. In conclusion, PGS at 24 mu/day for two weeks provided an audiogram improvement one year after treatment in one-third of the patients.

Otosyphilis: Resurgence of an Old Disease

OBJECTIVES

To describe the clinical characteristics of patients presenting with a new diagnosis of otosyphilis over the past 10 years in a large, urban, safety-net hospital affiliated with a large county sexually transmitted disease clinic.

METHODS

Retrospective case series. A chart review was performed of all patients who presented to an adult otolaryngology clinic with a new diagnosis of syphilis and hearing loss from January 2008 to December 2017.

RESULTS

Twelve patients met the criteria for "suspected" or "likely" otosyphilis based on Centers for Disease Control and Prevention definitions. The average age was 48 years (range 19-59). All were male. Nine (75%) were men who have sex with men. Eight (67%) were positive for human immunodeficiency virus. One (8%) presented with primary, nine (75%) with secondary, and two (17%) with early latent syphilis. Seven (58%) presented with bilateral audiogram-confirmed hearing loss, two (17%) with unilateral hearing loss, and three (25%) with suspected hearing loss based on fluctuating symptoms. Nine (75%) presented with tinnitus and two (17%) with vertigo. The median duration of otologic symptoms prior to presentation was 2 weeks (range: 0-16 weeks). All presented within the last 2 years surveyed.

CONCLUSION

We have seen an increase in the number of otosyphilis cases in our clinic. We suspect otosyphilis may be underdiagnosed and emphasize the importance of screening for syphilis in patients with new audiologic symptoms of vertigo, tinnitus, or hearing loss.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1680-1684, 2019.

Prevention and treatment of mother-to-child transmission of syphilis

PURPOSE OF REVIEW

Athough more than 90% of syphilis cases are diagnosed in developing countries, syphilis rates in industrialized countries have been increasing since the 1980s. Untreated syphilis in pregnancy is associated with high rates of adverse pregnancy outcomes, including fetal loss, premature birth, congenital syphilis, and neonatal death. We reviewed the recent literature on adverse pregnancy outcomes associated with untreated syphilis and the benefits of early and effective treatment.

RECENT FINDINGS

Up to two-thirds of pregnant women with untreated syphilis may develop unwanted complications compared with a background rate of 14% in pregnant women without syphilis. A review of interventions to screen and manage infections during pregnancy found that those focusing on syphilis demonstrated an 80% reduction in stillbirths as compared with strategies to treat, detect, or prevent other infections in pregnancy, such as malaria (22% reduction), HIV (7% reduction) or bacterial vaginosis (12% reduction). Detection and treatment of syphilis before the third trimester (28 weeks) can revert the risk of adverse outcomes to background rates.

SUMMARY

Transplacental transmission of syphilis, especially in the third trimester, is associated with high rates of adverse outcomes, but the risk can be significantly reduced with early detection and treatment in the first and second trimesters, along with careful management of the infant after birth.

Otosyphilis: A review of 85 cases

OBJECTIVE: To review the clinical manifestations and the follow-up hearing results of the treatment modalities in the patients with otosyphilis.

STUDY DESIGN AND SETTINGS: A retrospective review between 1984 and 2000 at a university hospital. Patients who presented with cochleovestibular symptoms and were confirmed seropositive for specific treponemal tests were included. Excluded were patients older than 70, or who had other identified causes of cochleovestibular symptoms.

RESULTS: Subjects included 56 males and 29 females with an average age of 59.5 years (range, 40 to 70). Common presenting symptoms included hearing loss (90.6%), tinnitus (72.9%), and vertigo (52.9%). The cerebrospinal fluid analysis was positive in 5.4%. The overall respective hearing results in the short- and long-term follow-up were improved or stable in 93.4% and 83.3% of patients. Even though adding steroids and neurosyphilis regimens tended to improve and stabilize hearing, the results were not statistically significant among treatment modalities.

CONCLUSION: Further study about hearing outcomes among treatment modalities is suggested.

© 2007 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

Unilateral sudden hearing loss due to otosyphilis

The differential diagnosis of sudden hearing loss is very extensive. However, in most patients, no underlying pathology will be found and the patient is consequently diagnosed with idiopathic sudden hearing loss. Nevertheless, it is important that one stays alert in everyday routine practice to less common but potentially treatable pathology. We report a case of a 53-year old patient with sudden unilateral hearing loss and tinnitus caused by otosyphilis. Diagnosis, therapy and the incidence of (oto)syphilis are discussed. Also, as ENT-surgeons, it is important to realise that syphilis is still with us, and that its prevalence might well increase in the near future.

Sudden sensorineural hearing loss: a review of diagnosis, treatment, and prognosis

Sudden sensorineural hearing loss (SSNHL) is commonly encountered in audiologic and otolaryngologic practice. SSNHL is most commonly defined as sensorineural hearing loss of 30 dB or greater over at least three contiguous audiometric frequencies occurring within a 72-hr period. Although the differential for SSNHL is vast, for the majority of patients an etiologic factor is not identified. Treatment for SSNHL of known etiology is directed toward that agent, with poor hearing outcomes characteristic for discoverable etiologies that cause inner ear hair cell loss. Steroid therapy is the current mainstay of treatment of idiopathic SSNHL in the United States. The prognosis for hearing recovery for idiopathic SSNHL is dependent on a number of factors including the severity of hearing loss, age, presence of vertigo, and shape of the audiogram.

Bilateral otosyphilis in a patient with HIV infection

Otosyphilis is a rare but important cause of sensorineural hearing loss and dizziness, because this hearing loss can be reversed by early diagnosis and aggressive treatment. Moreover, HIV may alter the course of otosyphilis and hasten the development of otosyphilis by reducing host cellular immunity. We report the case of a 35-year-old HIV-infected patient with bilateral fluctuating sensorineural hearing loss and bilateral total vestibular loss caused by otosyphilis. We include a discussion of the relationship between otosyphilis and HIV infection.

Syphilis and otolaryngology

Syphilis is the oldest known sexually transmitted disease. Because of its multiple clinical manifestations it is known as "the great imitator." Although the antibiotic era has greatly diminished the prevalence of syphilis, sporadic outbreaks continue to occur. Because of its multiple head and neck manifestations, the otolaryngologist should be familiar with the basic pathogenesis and clinical presentations of this disease.

Otologic neurotologic manifestations of HIV-related disease

Human immunodeficiency virus (HIV), the causative agent of acquired immunodeficiency syndrome (AIDS), has reached worldwide epidemic proportions and is increasing. Otologists, neurotologists, and audiologists practicing in metropolitan centers in North America can expect to encounter patients with HIV-related illnesses, including patients with AIDS-related complex (ARC) and AIDS. Five representative cases are presented: chronic otitis media, facial palsy, Gradenigo's syndrome with facial paralysis, otosyphilis, and Kaposi sarcoma of the mastoid. The common link in all cases was HIV infection. This presentation discusses the management of several HIV-infected patients with otologic and neurotologic findings. HIV infection has extended to all parts of North America. The worldwide incidence is increasing. As the epidemic continues to unfold, new challenges to both the diagnosis and treatment of otologic and neurotologic disease in HIV-positive patients will confront the audiologist and otolaryngologist. Recommendations for the safety of the examining audiologist and treating physician are given.