What is the recommended treatment for a patient with syphilis (sexually transmitted infection) and hearing loss?

Treatment of Syphilis with Hearing Loss

A patient with syphilis and hearing loss should be treated as neurosyphilis with aqueous crystalline penicillin G 18-24 million units per day IV (administered as 3-4 million units every 4 hours or continuous infusion) for 10-14 days, regardless of CSF examination results. 1

Diagnostic Approach

Hearing loss in the context of syphilis mandates specific evaluation:

• Patients with syphilis presenting with auditory symptoms (hearing loss, tinnitus) require CSF examination to assess for neurosyphilis 1
• Many experts recommend treating auditory disease caused by syphilis as neurosyphilis regardless of CSF findings 1
• All patients with syphilis must be tested for HIV infection 1, 2

First-Line Treatment Regimen

The recommended neurosyphilis treatment protocol is:

• Aqueous crystalline penicillin G 18-24 million units per day IV, administered as 3-4 million units every 4 hours (or continuous infusion) for 10-14 days 1, 2
• Some specialists add benzathine penicillin G 2.4 million units IM weekly for up to 3 weeks after completing the IV regimen to provide comparable total duration of therapy 1

Alternative regimen (only if compliance can be ensured):

• Procaine penicillin 2.4 million units IM once daily PLUS probenecid 500 mg orally four times daily, both for 10-14 days 1
• Critical caveat: Procaine penicillin without probenecid does NOT achieve adequate CSF levels and is inadequate for neurosyphilis 3

Penicillin Allergy Management

For penicillin-allergic patients with neurosyphilis or otosyphilis:

• Desensitization followed by penicillin treatment is mandatory 1, 2
• Ceftriaxone 2 grams daily IV for 10-14 days may be considered, but data are extremely limited and cross-reactivity with penicillin exists 1, 3
• Skin testing to confirm penicillin allergy should be performed when reagents and expertise are available 1
• Never use alternatives like doxycycline or azithromycin for neurosyphilis or otosyphilis 1

Adjunctive Therapy Considerations

Regarding corticosteroids:

• Systemic steroids are frequently used as adjunctive therapy for otologic syphilis, but have NOT been proven beneficial 1
• Historical data show only 15% of patients maintained hearing gains one year after combined penicillin-steroid therapy 4

Follow-Up Protocol

Mandatory monitoring includes:

• If CSF pleocytosis was present initially, repeat CSF examination every 6 months until cell count normalizes 1
• If cell count has not decreased after 6 months, or CSF is not normal after 2 years, re-treatment should be considered 1
• Quantitative nontreponemal serologic tests at 6,12, and 24 months 1, 2, 5

Prognosis and Realistic Expectations

Hearing outcomes are variable:

• Approximately one-third of otosyphilis patients show audiogram improvement one year after treatment with high-dose IV penicillin 6
• Complete audiologic recovery is rare but possible with prompt treatment 7
• Enhanced speech discrimination may occur more commonly than pure tone threshold gains 4
• Delayed diagnosis and treatment significantly increase risk of irreversible hearing loss 7

Common Pitfalls to Avoid

• Do not treat auditory syphilis with standard early syphilis regimens (single-dose benzathine penicillin)—this is inadequate 1
• Do not skip CSF examination in patients with hearing loss, even if planning to treat as neurosyphilis, as baseline CSF parameters guide follow-up 1
• Do not use oral penicillin preparations—they are ineffective for any stage of syphilis 3
• Be aware that Jarisch-Herxheimer reaction may occur within 24 hours of initiating therapy 2, 3

Special Population: Pregnancy

If the patient is pregnant:

• Penicillin desensitization is absolutely mandatory if penicillin-allergic—no exceptions 2, 3, 5
• Penicillin is the only therapy proven to prevent maternal transmission and treat fetal infection 3, 5
• Women treated during second half of pregnancy risk premature labor from Jarisch-Herxheimer reaction and should seek immediate attention for contractions or decreased fetal movement 3