From the Guidelines
Neurosyphilis should be treated with aqueous crystalline penicillin G 18-24 million units per day, administered as 3-4 million units IV every 4 hours or continuous infusion, for 10-14 days, as this regimen has been shown to be effective in treating the infection and preventing long-term neurological damage. This treatment approach is supported by the Centers for Disease Control and Prevention's guidelines for the treatment of sexually transmitted diseases, including syphilis 1. The guidelines recommend that patients with neurosyphilis or syphilitic eye disease, such as uveitis, neuroretinitis, and optic neuritis, should be treated with this regimen, and that a CSF examination should be performed to identify those with abnormalities who should have follow-up CSF examinations to assess treatment response.
Some key points to consider in the management of neurosyphilis include:
- All patients with syphilis should be tested for HIV, as coinfection can affect treatment outcomes 1
- Patients with syphilitic eye disease should be managed in collaboration with an ophthalmologist, and a CSF examination should be performed to identify those with abnormalities 2
- Clinical manifestations of neurosyphilis can vary widely, and early diagnosis through CSF analysis is crucial to prevent long-term neurological damage 1
- The infection can occur at any stage of syphilis, even years after initial infection, which is why thorough screening and treatment of early syphilis is essential for prevention 2
In terms of follow-up care, patients with neurosyphilis should undergo regular CSF examinations at 6-month intervals until cell count normalizes and serologic tests show improvement 1. This will help to ensure that the treatment is effective and that any potential complications are identified and managed promptly. Overall, the key to successful treatment of neurosyphilis is early diagnosis and prompt treatment with effective antibiotics, such as penicillin, to prevent long-term neurological damage.
From the Research
Definition and Treatment of Neurosyphilis
- Neurosyphilis is an infection of the central nervous system caused by Treponema pallidum, a spirochete capable of infecting almost any organ or tissue in the body, leading to neurological complications due to the infection 3.
- The first-line treatment for neurosyphilis is aqueous crystalline penicillin, but in cases of penicillin allergy, other regimes of antibiotic therapy can be used 3.
- Intravenous penicillin G is the recommended treatment for all forms of neurosyphilis and for syphilitic eye disease 4.
Alternative Treatment Options
- Procaine penicillin 1.2 million U intramuscularly daily for 20 days is as effective as a dosage schedule that requires admission to hospital for intravenous administration 5.
- Daily procaine penicillin is a well-accepted outpatient regimen with excellent compliance (88% overall) and minimal side effects 6.
- Oral doxycycline has been used as an alternative treatment option for early neurosyphilis, with similar rates of clinical and serological response and seroreversion compared to procaine G penicillin 7.
Diagnosis and Testing
- Diagnosis of neurosyphilis depends on serologic tests and cerebrospinal fluid (CSF) examination 4.
- CSF examination should be performed to evaluate for neurosyphilis in all patients with positive serum syphilis serology and neurologic, ophthalmic, or tertiary disease, or in those who have failed therapy, and in HIV-infected patients with late latent syphilis or syphilis of unknown duration 4.
Special Considerations
- Syphilis facilitates transmission of HIV (and vice versa), and thus all patients diagnosed with syphilis should be offered HIV testing 4.
- Patients with concomitant human immunodeficiency virus infection may require special consideration in treatment, as they may be at higher risk of progression to neurosyphilis 6.