Neurosyphilis in the modern era

Abstract

Objective: To review the nature of the presentation of neurosyphilis, the value of diagnostic tests, and the classification of the disease. Methods: A retrospective review was carried out of the records of patients who had been identified as possible cases of neurosyphilis by a positive FTA-abs test in the CSF. The review extended over 10 years at a single hospital which served a population of mixed ancestry in a defined catchment area in the Western Cape province of South Africa. Patients were placed in predefined diagnostic categories, and clinical, radiological, and laboratory features were assessed. Results: 161 patients met diagnostic criteria for neurosyphilis: 82 presented with combinations of delirium and dementia and other neuropsychiatric conditions, and the remainder had typical presentations such as stroke (24), spinal cord disease (15), and seizures (14). The average age of presentation ranged from 35.9 to 42.6 years in the different categories of neurosyphilis. Of those followed up, 77% had residual deficits from their initial illness. Cerebrospinal fluid (CSF) VDRL was positive in 73% of cases. Conclusions: The diagnosis of neurosyphilis can be made with reasonable certainty if there is an appropriate neuropsychiatric syndrome associated with a positive CSF VDRL. If the VDRL is negative, a positive FTA-abs in an appropriate clinical setting, associated with raised CSF cell count, protein, or IgG index, is a useful method of identifying neurosyphilis. Tabes dorsalis has become uncommon, but this is likely to be the only manifestation of neurosyphilis that has been altered during the antibiotic era.

Neurosyphilis and psychosis

“…It is widely accepted that a positive Cerebrospinal fluid (CSF) VDRL with a consistent clinical picture confirms the diagnosis. However, in one study it was shown that 27% of patients had negative CSF VDRL but the flourescent treponemal antibodyabsorption (FTA-Abs) test was positive (Timmermans & Carr, 2004). The patient's CSF VDRL was negative and the next step ideally would be to send for FTA-Abs test.…”

Indicações da punção liquórica nos portadores de sífilis

“…6 Essa última manifestação se tornou incomum após o início da era dos antibióticos. 20 Pode ainda apresentar deterioração cognitiva progressiva com episódios de delírio semelhante ao mal de Alzheimer, 7,21 como também quadro focal agudo similar a um íctus, ou como quadro multifocal recidivante que lembra a esclerose múltipla. 7 Alguns indivíduos mostram distúrbios psiquiátricos associados, como depressão, mania, psicose indistinguível de esquizofrenia e transtornos de personalidade.…”

“…Então, o diagnóstico depende dos testes sorológicos e do exame do LCR. 6,7,20,22 É descrito que a análise liquórica pode ser benéfica em portadores da sífilis primária. 21 Estudos avaliando portadores de sífi-lis latente ou de duração desconhecida observaram VDRL positivo no líquor, confirmando neurolues entre 16,2 e 21% dos doentes.…”

“…Se o VDRL for negativo, o FTA-abs (fluorescent treponemal antibody absorption test) positivo associado com aumento liquórico das células, das proteínas ou do IgG, é método usual para identificar a doença. 20,25 O CDC (Center for Disease Control, EUA) e outros órgãos recomendam que os indivíduos com titulações plasmáticas não decrescentes por duas ou mais diluições em três meses pós-tratamento para sífilis primária ou secundária devem ser avaliados por falha de tratamento e a punção lombar estará indicada. 14 As seqüelas severas observadas após falha terapêutica descrita em alguns doentes soropositivos indicam a importância de seguimento rigoroso.…”

Meningovascular neurosyphilis with basilar artery thrombosis, a case report and literature review

“…En 1999, según la Organización Mundial de la Salud (OMS), la incidencia mundial era de 12 millones de casos, 3 de ellos en Latinoamérica y África (1,2). No obstante, dado el advenimiento de técnicas de diagnóstico confiables y el tratamiento efectivo con penicilinas, sus manifestaciones terciarias neurológicas han cambiado; la parálisis general progresiva y la tabes dorsal son poco frecuentes hoy en día (3,4) y, por el contrario, las manifestaciones neurosiquiátricas se vienen presentando más a menudo (5).…”