From the Guidelines
The earliest manifestations of neurosyphilis typically occur within weeks to months after initial syphilis infection and include asymptomatic neurosyphilis, syphilitic meningitis, and meningovascular syphilis. The clinical presentation of these early manifestations can vary, with asymptomatic neurosyphilis showing no clinical symptoms but having abnormal cerebrospinal fluid findings, such as mononuclear pleocytosis and elevated protein levels 1.
Key Features of Early Neurosyphilis
- Asymptomatic neurosyphilis: abnormal cerebrospinal fluid findings without clinical symptoms
- Syphilitic meningitis: headache, neck stiffness, cranial nerve palsies, and occasionally seizures
- Meningovascular syphilis: stroke-like symptoms due to inflammation of blood vessels in the brain These early forms develop when Treponema pallidum invades the central nervous system, crossing the blood-brain barrier during primary or secondary syphilis stages.
Importance of Early Recognition
Early recognition of neurosyphilis is crucial, as treatment with intravenous penicillin G can prevent progression to more severe forms like general paresis or tabes dorsalis, which develop decades after initial infection and cause irreversible neurological damage. In patients with HIV infection, the clinical and prognostic significance of CSF abnormalities is unknown, and some specialists recommend CSF examination before treatment of early syphilis, with follow-up CSF examination following treatment in persons with initial abnormalities 1.
From the Research
Early Manifestations of Neurosyphilis
The earliest manifestations of neurosyphilis can vary, but some common presentations include:
- Asymptomatic meningitis, symptomatic meningitis, gumma, and meningovascular syphilis 2
- Ocular and otologic syphilis, which can occur at any time but often accompany the acute meningitis of early neurosyphilis 2
- Cranial nerve abnormalities, such as cranial nerve palsies, which can result from meningeal inflammation spreading to neighboring cranial nerves 3
- Syphilitic meningitis with cranial nerve involvement, and seizures 4
Clinical Presentation
The clinical presentation of early neurosyphilis can include:
- Meningitis, characterized by inflammation of the meninges, which can lead to symptoms such as headache, fever, and stiff neck 2, 5
- Cranial nerve abnormalities, such as facial nerve palsy, which can result in symptoms such as weakness or paralysis of the facial muscles 3
- Cerebrospinal accidents, such as strokes, which can occur as a result of meningovascular syphilis 5
Diagnosis and Treatment
The diagnosis of neurosyphilis requires meeting clinical, serologic, and cerebrospinal fluid (CSF) criteria, while the diagnosis of asymptomatic neurosyphilis relies on serologic and CSF criteria alone 2. The first-line treatment for neurosyphilis is aqueous crystalline penicillin, although other antibiotic regimens can be used in cases of penicillin allergy 6.