Systemic lupus erythematosus and other connective tissue disorders
Intravenous drug use
Age (elderly person)
Reproduced with pemmission from Roos KL: Syphilitic meningitis. In Roos KL (ed): Meningitis: 100 Maxims in Neurology London, Amold, 1997, pp 171-181.
with neurosyphilis have a positive VDRL test. A CSF examination should be performed in patients with a reactive MHA-TP or FTA-ABS. The diagnosis of neurosyphilis is made in the presence of a reactive serological test with either neurological manifestations consistent with neurosyphilis or CSF evidence of a lymphocytic pleocytosis and an elevated protein concentration, and/or a positive CSF- VDRL test. Most clinicians treat patients for neurosyphilis when they have a positive serological test and a CSF lymphocytic pleocytosis with an elevated protein concentration whether the CSF-VDRL is reactive or not. A reactive cSf-VDRL establishes the diagnosis but a nonreactive test does not exclude the diagnosis. Screening for the presence of syphilis in HIV-1-infected individuals should be performed by the serum FTA-ABS test as the nontreponemal tests for syphilis may be falsely negative in HIV-infected individuals. A loss of reactivity to the treponemal tests in individuals infected with HIV-1 with advanced immunosuppression occurs.  In HIV-infected individuals with neurosyphilis, the CSF should demonstrate a lymphocytic pleocytosis and an elevated protein concentration. When the CSF-VDRL is negative, a CSF FTA-ABS or CSF MHA-TP should be obtained. The lack of CSF FTA-ABS or CSF MHA-TP reactivity excludes a diagnosis of neurosyphilis. The CSF FTA-ABS and CSF MHA-TP are not routinely recommended for the screening of neurosyphilis in non-HIV-infected individuals because reactivity of these tests on CSF does not establish the diagnosis of neurosyphilis.^
Management. Primary, secondary, and latent syphilis are treated with benzathine penicillin; neurosyphilis is treated with intravenous aqueous crystalline penicillin G 2 to 4 million units every 4 hr for 10 to 14 days. An alternate regimen is procaine penicillin, 2.4 million units intramuscularly daily with probenecid, 500 mg orally four times a day, both for 10 to 14 days. Patients with a history of penicillin allergies should be skin tested and desensitized if necessary. y , y The frequency with which intravenous antibiotics are unsuccessful in the therapy of neurosyphilis is extremely low. In those instances in which a progression of clinical disease or persistence of a CSF lymphocytic pleocytosis or a reactive CSF-VDRL is present, re-treatment of the patient with an additional 24 million units/d for 10 days is reasonable. The initial CSF pleocytosis will resolve 6 months after penicillin therapy in 80 percent of patients. Serial CSF-VDRL titers should decrease with treatment. Re-examination of the CSF should occur in HIV-infected patients with neurosyphilis.
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