Spirochetal Infections: Neurosyphilis

Asymptomatic neurosyphilis is defined by the presence of spinal fluid abnormalities in the absence of neurologic signs and symptoms.

Syphilitic meningitis is defined by the appearance of meningeal signs and symptoms, including headache, nausea, vomiting, stiff neck, and cranial nerve abnormalities. Spinal fluid analysis in syphilitic meningitis reveals an increased opening pressure, a lymphocytic pleocytosis, a normal or slightly decreased glucose concentration, and an elevated protein concentration. The serum rapid plasma reagin (RPR) is usually positive.

Meningovascular syphilis is defined by the appearance of focal neurologic signs due to an inflammatory arteritis involving small and medium-size arteries in association with signs of meningeal inflammation. Vascular syphilis may also involve the arterial blood supply to the spinal cord.

General paresis (dementia paralytica) is a chronic progressive meningoencephalitis with a peak incidence 10 to 20 years after primary infection. Initially, there is a slow deterioration in cognitive functioning and personality changes, but as the disease progresses there is loss of appendicular strength, abnormality of the pupils, dysarthria, tremor, and loss of bowel and bladder control. Tabes dorsalis develops 10 to 20 years after primary infection and is characterized at onset by episodic lancinating pain in the lower extremities. As the disease progresses, there is loss of proprioceptive and vibratory sensation due to neuronal degeneration and infiltration of inflammatory cells in the dorsal column and posterior spinal nerve roots of the spinal cord. Tabes dorsalis is also characterized by loss of the pupillary reaction to light, with preservation of pupillary constriction to accommodation—the Argyll Robertson pupillary abnormality. Due to lumbosacral nerve root dysfunction, lower extremity areflexia, impotence, and loss of urinary continence may develop.

Gummatous Neurosyphilis. CNS gummas are rare but present as space-occupying lesions.

The diagnosis of neurosyphilis is made by a combination of serologic tests and spinal fluid analysis. The serologic tests are typically the Venereal Disease Research Laboratory (VDRL) or the RPR although the Treponema pallidum hemagglutination assay is more specific. A diagnosis of neurosyphilis is made by the detection of a reactive CSF VDRL. When the CSF VDRL is nonreactive, but there is a positive serologic test and an elevated CSF white blood cell count and protein concentration, treatment for neurosyphilis is recommended. Neurosyphilis is treated with intravenous aqueous penicillin G.

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