Alteration in the Natural History of Neurosyphilis by Concurrent Infection with the Human Immunodeficiency Virus

Abstract

Within the past 18 months, we have seen four cases of neurosyphilis at our institution (two of meningovascular syphilis, one of acute syphilitic meningitis, and one of asymptomatic neurosyphilis) in young homosexual men with serologic evidence of exposure to human immunodeficiency virus (HIV). Two of the four patients had neurosyphilis despite previous adequate therapy for early syphilis with benzathine penicillin. Meningovascular syphilis developed in one patient within four months after a primary infection, in a manner consistent with an accelerated course of syphilitic infection. These findings suggest the possibility that HIV infection may alter the natural course of syphilis because of the profound defects in cell-mediated immunity it causes. The possible potentiating effects of HIV on Treponema pallidum infection suggest the need for lumbar puncture in the evaluation of HIV-seropositive patients with syphilis, as well as modifications of the currently recommended treatment regimens for primary, secondary, and latent syphilis and neurosyphilis in this patient population. Neurosyphilis should probably be added to the growing list of infectious complications of the acquired immunodeficiency syndrome (AIDS) and may be the first such complication to appear.

Pearls & Oy-sters: Neurosyphilis presenting as mesial temporal encephalitis

“…1 In patients with concomitant HIV infection, neurosyphilis may progress in an aggressive and often atypical manner. 1,6 It has been suggested that the course of syphilis in HIV-infected men may be altered as a result of potentiating effects of HIV on the T pallidum Follow-up brain MRI Improvement in the T2 and fluid-attenuated inversion recovery signal abnormality within the frontal and medial temporal lobes compared to the prior study. Progression of mesial temporal lobe atrophy is also seen.…”

Neurosyphilis Presenting Unilateral Oculomotor Nerve Palsy and Bilateral Pupil Involvement

“…Pupil abnormalities are prevalent in roughly 45-53% of neurosyphilis [6]. The most common pupil abnormalities include bilaterally small pupils who react briskly to near stimuli, called Argyll Robertson pupils, or bilaterally large tonic pupils [6][7][8]. We observed Argyll Roberson pupils with unilaterally large tonic pupil through this case.…”

Experience of Meningovascular Syphilis in Human Immunodeficiency Virus Infected Patient

“…The incidence of syphilis among HIV-positive individuals is difficult to estimate, but seroprevalence studies have shown evidence of previous exposure to Treponema pallidum in 3% to 35% of HIV-positive patients 3,4,12) . Concurrent HIV infection may alter the progression of syphilis by increasing the propensity of the disease to progress to neurosyphilis, decreasing the latency period before the onset of neurosyphilis, increasing the severity of the manifestations of neurosyphilis, or rendering standard therapy for primary and secondary syphilis inadequate 13) . Asymptomatic neurosyphilis is common during untreated primary and secondary syphilis 16,19) and during latent syphilis in HIV patients 12) .…”