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Neurological Findings in Early Syphilis: a Comparison Between HIV Positive and Negative Patients

Received April 10, 2013; Revised July 4, 2013; Accepted July 10, 2013.

Alejandra González-Duarte1 and Zaira Medina López2
1 Department of Neurology and Psychiatry, National Institute of Medical Science and Nutrition Salvador Zubirán, Mexico City
2Central Military Hospital, Mexico City, Mexico

Department of Neurology and Pshychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15 Sección XVI, Tlalpan 01400, Mexico City, Mexico. E-mail: [email protected]

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Abstract 

After a decade of steady decline, syphilis has reemerged within the past few years and it is seeping back into the HIV negative population. We describe herein 16 consecutive cases of neurosyphilis and compare its clinical characteristics. Of the 16 patients, 14 (87%) were men. Mean age at onset was 43 years old (range: 23-82). Twelve patients (75%) were HIV positive; stage was B2 in 2 patients, B3 and C2 in one patient each, and C3 in 8 patients. The clinical presentation was meningitis in 6 (40%), stroke in 3 (18%), ocular manifestations in 4 (27%), and psychiatric manifestations in 2 (13%) cases. Five additional patients had ocular involvement after a formal ophthalmologic examination. High venereal disease research laboratory test (VDRL) titers in serum and cerebrospinal fluid (CSF) were found. Patients in C3 stage of HIV had less CSF pleocytosis (<5 cells/mm3) than patients in earlier stages (P=0.018). Disease onset was earlier in patients older than 50 years old with HIV (P=0.049). We found that meningitis, ocular manifestations and stroke were the most common clinical findings in early syphilis. Moreover, stroke included the carotid and cerebrobasilar vascular territories. CSF VDRL continues to be a crucial test in all idiopathic cases of meningitis, stroke and uveitis, regardless of the HIV status or CSF pleocytosis. Except for less pleocytosis, there were no important differences between HIV positive and HIV negative patients.

Conclusions 

CSF-VDRL was positive in all patients despite being positive only in 62% of the serum samples. Proteins are usually mild to moderately high, and pleocytosis can be absent in patients with neurosyphilis. When further tested, the main clinical manifestations were ophthalmologic. HIV status did not grant a worse prognosis, non-the-less, because neurosyphilis was more often in HIV patients, we consider that all patients with neurosyphilis and ophthalmologic disease should be tested for HIV.

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