Cerebrospinal fluid examination may be useful in diagnosing neurosyphilis in asymptomatic HIV+ patients with syphilis

Abstract

ARTICLE Cerebrospinal fluid examination may be useful in diagnosing neurosyphilis in asymptomatic HIV+ patients with syphilisEl examen del líquido céfalo raquídeo puede ser útil en el diagnóstico de neurosífilis en pacientes VIH + asintomáticos con sífilis Whether lumbar puncture should be indicated for diagnosing neurosyphilis in patients who are coinfected with the human immunodeficiency virus (HIV) and Treponema pallidum (T. pallidum) but do not have any symptoms or neurological signs is a matter for discussion 1,2 . The European guidelines recommend lumbar puncture in cases of symptomatic patients (neurological, ophthalmological or otological symptoms) and asymptomatic HIV-positive patients with Venereal Disease Research Laboratory (VDRL) test results greater than or equal to 1/32 in serum and CD4 less than or equal to 350. These guidelines suggest that lumbar puncture should not be compulsory but that it could be indicated in cases of late latent syphilis or syphilis of undetermined duration 3 . In 2002, the Centers for Disease Control and Prevention (CDC) recommended lumbar puncture for patients with late latent syphilis or syphilis of undetermined duration. This recommendation was later revised to include reactive VDRL ≥ 1/32 in serum and CD4 cell counts ≤ 350 cells/ml. Since 2010, CDC has not been recommending lumbar puncture for asymptomatic patients. AbstrACtLumbar puncture in neurologically asymptomatic HIV+ patients is still under debate. There are different criteria for detecting neurosyphilis through cerebrospinal fluid (CSF), especially in cases that are negative through the Venereal Disease Research Laboratory (VDRL), regarding cellularity and protein content. However, a diagnosis of neurosyphilis can still exist despite negative VDRL. Treponema pallidum hemagglutination assay (TPHA) titers and application of the TPHA index in albumin and IgG improve the sensitivity, with a high degree of specificity. Thirty-two patients were selected for this study. VDRL was positive in five of them. The number of diagnoses reached 14 when the other techniques were added. It was not determined whether cellularity and increased protein levels were auxiliary tools in the diagnosis. According to our investigation, CSF analysis using the abovementioned techniques may be useful in diagnosing neurosyphilis in these patients.Keywords: neurosyphilis, HIV positive, VDRL, TPHA in CSF, TPHA indexes. resumo La punción lumbar (PL) en pacientes VIH+ neurológicamente asintomáticos es controversial. Existen diferentes criterios para detectar en el líquido cefalorraquídeo (LCR) neurosífilis (NS): el examen Venereal Disease Research Laboratory (VDRL) en primer lugar, en caso de negatividad: la celularidad y el tenor de proteinas. Sin embargo el diagnóstico de NS puede ser sostenido a pesar de la negatividad de las técnicas mencionadas. La titulación del Treponema pallidum hemagglutination assay (TPHA) y la aplicación del índice de TPHA en Albúmina e Ig G mejoran la sensibilidad asociando elevado grado de especificidad. 32 pacien...

The Great Impostor: Transaminitis Masking the Coinfection of Syphilis and Human Immunodeficiency Virus

“…In addition, they state that there are some “soft” indications such as self-reported symptoms (e.g., headaches, blurry vision, and hearing loss), which may not be easily validated on physical exam. Some experts agree that neurosyphilis in HIV-positive patient can be detected more consistently if the CD4 count is less than or equal to 350 cells/ml and RPR or VDRL is greater than or equal to 1 : 32 [17]. Based on the clinical findings, our patient underwent a lumbar puncture because he had several days of bilateral frontal headaches without neurological deficits and serum RPR titers greater than 1 : 32, as well as unknown duration of syphilis infection.…”

Management of neurosyphilis: time for a new approach?

“…Recent approaches include the use of quantitative CSF : serum ratios of treponemal antibodies (i.e. FTA‐ABS) with higher ratios presumed to be indicative of intrathecal antibody production . These approaches attempt to improve sensitivity also by estimating permeability of the blood brain barrier with an albumin quotient.…”

“…While these techniques, and others, appear to improve the sensitivity of existing CSF serology they are considerably more labour intensive than existing techniques and are yet to be validated or widely applied. CSF cytokine and chemokine profiling of patients with neurosyphilis has led to an expanding library of novel markers that correlate with CNS inflammatory responses and invasion of the CNS . A prospective study looking at the utility of CSF levels of chemokine CXCL 13 and T. pallidum DNA PCR to improve diagnostic accuracy in patients with suspected neurosyphilis has recently begun recruiting in Shanghai (Clinical Trials Registry number ChiCTR‐DDD‐16009591).…”

“…FTA-ABS) with higher ratios presumed to be indicative of intrathecal antibody production. 18 These approaches attempt to improve sensitivity also by estimating permeability of the blood brain barrier with an albumin quotient. While these techniques, and others, appear to improve the sensitivity of existing CSF serology they are considerably more labour intensive than existing techniques and are yet to be validated or widely applied.…”

“…CSF cytokine and chemokine profiling of patients with neurosyphilis has led to an expanding library of novel markers that correlate with CNS inflammatory responses and invasion of the CNS. [18][19][20] A prospective study looking at the utility of CSF levels of chemokine CXCL 13 and T. pallidum DNA PCR to improve diagnostic accuracy in patients with suspected neurosyphilis has recently begun recruiting in Shanghai (Clinical Trials Registry number ChiCTR-DDD-16009591). Validation of these indicators will be difficult and further work is required before these tests can be confidently incorporated into any existing neurosyphilis diagnostic algorithm.…”