AM Report 1/30/17: Neurosyphilis

Which Asymptomatic patients should you screen for syphilis?

–HIV
–MSM
–Partner with syphilis
–High risk sexual behavior/history of incarceration or commercial sex work
–Pregnancy (r/o congenital syphilis)

Testing for Syphilis (Treponemal vs. Non-Treponemal)

BOTH type of tests required due to risk of false positives and false negatives (eg: immunosuppression/early disease)
-Can use direct visualization tests like DFA or Darkfield Microscopy but SEROLOGY is the most common method of testing.

Non-Treponemal testing

-Based on reactivity of serum of infected patients to a cardiolipin-cholesterol-lecithin antigen but non-specific
-Positive results are reported as a TITER (eg: 1:32) and wane over time with treatment 

RPR (Rapid Plasma Reagin)
–VDRL (Veneral Disease Research Laboratory)
–TRUST (Toluidine Red Unheated Serum Test)

Treponemal testing

-Directly evaluating for antibodies against Treponemal antigens(higher specificity)!
-Qualitative only (no titers!)  and remain positive for life

–FTA-ABS (Fluorescent Treponemal antibody absorption)
–TPPA (T.Pallidum particle agglutination assay)
EIA (Enzyme immunoassay)
–CIA (Chemiluminsence immunoassay)

At VMC, our policy is to do a Treponemal test (EIA) and confirm with a Non-Treponemal test (RPR with titer)

What if you suspect Neurosyphilis

-Must do LP and classically see elevated lymphocytes and protein on CSF
(+) VDRL in CSF is highly specific for neurosyphilis but poor sensitivity (can be negative in up to 70 % of cases!)
–If negative VDRL, can check FTA-ABS (higher sensitivity/poor specificity)

Clinical manifestations of Neurosyphilis

EARLY neurosyphilis

  • Asymptomatic! (+) CSF VDRL
  • Meningitis, cranial neuropathies
  • Syphilitic gummas (can occur any
  • Ocular syphilis/Oto-syphilis

LATE neurosyphilis

  • General paresis (General paralysis of the insane)-10 % of psych admissions prior to 1928
  • Tabes Dorsalis (posterior columns/dorsal roots)- + Argyll-Robertson pupil

Treatment of Neurosyphilis

  • Aqueous IV Pencillin G 4 million units q4h x 10-14d

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