What should a neuro exam template for suspected neurosyphilis include?

Neurological Examination Template for Suspected Neurosyphilis

When evaluating a patient for suspected neurosyphilis, perform a comprehensive neurological examination focusing on the specific deficits that characterize this disease, including cognitive dysfunction, cranial nerve palsies, motor and sensory deficits, and signs of meningeal irritation. 1, 2

Mental Status and Cognitive Assessment

Expected Abnormalities in Neurosyphilis:

• Cognitive impairment: Assess orientation, memory (immediate, recent, and remote), attention, and executive function—patients may present with subacute cognitive decline progressing to dementia, particularly in general paresis 3, 4
• Behavioral changes: Document personality changes, disinhibition, poor judgment, or psychiatric symptoms that may precede overt cognitive decline 4
• Level of consciousness: Note any altered mental status ranging from confusion to obtundation, especially in acute presentations 3
• Speech and language: Evaluate for dysarthria, aphasia, or word-finding difficulties that may indicate cortical involvement 4

Cranial Nerve Examination

Expected Abnormalities:

• CN II (Optic): Test visual acuity, visual fields, pupillary responses, and perform fundoscopy—look for optic neuritis, neuroretinitis, or papilledema 1
• CN III, IV, VI (Oculomotor, Trochlear, Abducens): Assess extraocular movements for diplopia or ophthalmoplegia, which may indicate cranial nerve palsies 1
• CN V (Trigeminal): Test facial sensation and motor function (jaw clench)—may show sensory deficits or weakness 1
• CN VII (Facial): Evaluate facial symmetry and strength—facial nerve palsy can occur 1
• CN VIII (Vestibulocochlear): Perform hearing assessment and Weber/Rinne tests—auditory symptoms including hearing loss or tinnitus are common in neurosyphilis 1, 2
• CN IX, X (Glossopharyngeal, Vagus): Test palatal elevation, gag reflex, and voice quality 1
• CN XI, XII (Accessory, Hypoglossal): Assess shoulder shrug and tongue movement 1

Motor Examination

Expected Abnormalities:

• Muscle strength: Test all major muscle groups bilaterally—look for focal weakness or hemiparesis, particularly in meningovascular syphilis with stroke 5, 6
• Muscle tone: Assess for rigidity, spasticity, or hypotonia—parkinsonian features may be present 4
• Involuntary movements: Observe for tremor, myoclonus, or choreiform movements 4
• Gait: Evaluate for ataxia, wide-based gait, or the characteristic stamping gait of tabes dorsalis 5, 6
• Coordination: Perform finger-to-nose and heel-to-shin testing—cerebellar signs may be present 6

Sensory Examination

Expected Abnormalities:

• Light touch and pain: Test in all dermatomes—may reveal sensory deficits, particularly in tabes dorsalis 5, 6
• Proprioception: Assess joint position sense—impaired in tabes dorsalis 5, 6
• Vibration: Test with tuning fork at bony prominences—often diminished in posterior column involvement 5, 6
• Romberg test: Positive Romberg sign indicates posterior column dysfunction, classic in tabes dorsalis 5, 6

Reflex Examination

Expected Abnormalities:

• Deep tendon reflexes: Test biceps, triceps, brachioradialis, patellar, and Achilles reflexes—may be diminished or absent in tabes dorsalis, or hyperactive with upper motor neuron involvement 5, 6
• Plantar response: Assess Babinski sign—extensor response indicates corticospinal tract involvement 6
• Pupillary reflexes: Look for Argyll Robertson pupils (small, irregular pupils that accommodate but do not react to light)—classic but uncommon finding in neurosyphilis 5, 6

Meningeal Signs

Expected Abnormalities:

• Neck stiffness: Assess for nuchal rigidity—present in syphilitic meningitis 1, 5
• Kernig's sign: Test for meningeal irritation 5
• Brudzinski's sign: Evaluate for meningeal inflammation 5

Ophthalmologic Examination

Expected Abnormalities:

• Slit-lamp examination: Essential when ocular symptoms present—uveitis is frequently associated with neurosyphilis and requires CSF examination 1, 2
• Fundoscopy: Look for papilledema, optic atrophy, or chorioretinitis 1, 6

Seizure Activity

Expected Abnormalities:

• Document any seizure history or witnessed seizure activity: Seizures may occur, particularly in patients with temporal lobe involvement or meningoencephalitis 3

Critical Clinical Pitfalls to Avoid

• Do not overlook temporal lobe abnormalities on imaging: Young patients presenting with subacute cognitive impairment, seizures, and bilateral temporal lobe hyperintensities on MRI should raise immediate suspicion for neurosyphilis, even without classic findings 3
• Never skip CSF examination in patients with ocular manifestations: Syphilitic uveitis or any ocular symptoms are frequently associated with neurosyphilis and mandate lumbar puncture 1, 2
• Do not dismiss atypical presentations in HIV-infected patients: Neurosyphilis should be in the differential diagnosis of any neurologic disease in HIV-positive persons, particularly those with CD4 count ≤350 cells/mL or RPR titer ≥1:32 1, 2
• Always test for HIV in all patients with suspected neurosyphilis: The diseases facilitate transmission of each other, and HIV status affects management decisions 1, 2, 5

Documentation Requirements

Document all positive and pertinent negative findings systematically, as this examination will guide the decision for CSF examination and subsequent treatment with aqueous crystalline penicillin G 18-24 million units per day IV for 10-14 days 1, 2