Chapter 5-12: Neurosyphilis in HIV-Positive Patients

TEXTBOOK PRESENTATION

Patients with neurosyphilis may be asymptomatic or have a number of clinical presentations, including aseptic meningitis, stroke-like symptoms, visual impairment, hearing loss, dementia, and various focal deficits.

DISEASE HIGHLIGHTS

1. Caused by the spirochete T pallidum

2. High-risk groups: MSMs, IDUs, and patrons of sex workers

3. Association of HIV and syphilis infection

   1. Studies document a high HIV coinfection rate in patients with syphilis: CDC reports that in 2016 among primary and secondary syphilis cases with known HIV-status, 47.0% of cases among MSM were HIV-positive, compared with 10.7% of cases among men who have sex with women, and 4.1% of cases among women.

      HIV infection in patients with syphilis is common, especially in MSMs.

   2. Neurosyphilis in HIV-infected less frequent (1%)

4. Syphilis commonly infects the CNS early in the course of disease in both HIV-infected and non–HIV-infected persons (25–33%).

5. The CNS infection is more often progressive in HIV-infected persons, increasing the need for detection in this group.

6. Infections develop in characteristic stages.

   1. Primary syphilis: syphilitic chancre

      1. Characterized by chancre: a 0.5- to 2-cm painless, indurated, well-circumscribed ulceration at the site of primary inoculation approximately 2–3 weeks after contact (Figure 5-7)

      2. Atypical presentations are common. Multiple chancres may be seen more often in HIV-infected patients.

      3. Lesion resolves with or without therapy.

   2. Secondary syphilis

      1. Symptoms usually start with a rash that is usually not itchy and may appear as the chancre is healing or up to several weeks later.

      2. The secondary syphilis rash is macular or maculopapular, and often involves the palms and/or soles, but may have an atypical aspect or be completely unnoticed (faint rash or darker skin) (Figure 5-8).

         Secondary syphilis should always be considered in the differential diagnosis of rash in sexually active patients.

      3. Other skin findings may be present:

         1. Mucosal patches are superficial erosions in the mouth and genital areas.

         2. Condyloma lata are large, moist, pink to gray/white raised lesions seen in perianal area, vulva, or scrotum.

      4. Other symptoms include fever, myalgias, sore throat, lymphadenopathy, headaches, and hair loss.

   3. Latent syphilis: 60–70% of untreated patients have no disease progression.

      1. Early latent syphilis: < 1 year duration

      2. Late latent syphilis: > 1 year duration

      3. Latent syphilis of unknown duration: no prior negative serology to determine duration

   4. Tertiary stage

      1. Develops in one-third of untreated patients

      2. Gummas (syphilitic granulomas with caseating necrosis) affect involved organs and usually develop over 4–10 years but may develop earlier in HIV-infected patients.

      3. Protean manifestations of tertiary syphilis include heart (aortic root and coronary artery involvement), eyes, skin, and CNS involvement

   5. Neurosyphilis

      1. May be asymptomatic (positive CSF findings) or symptomatic

      2. Neurosyphilis can develop early after syphilis infection in HIV-infected patients.

         1. Typical early symptoms include cranial nerve palsies, meningitis, or meningovascular symptoms (strokes secondary to arteritis). One report found visual symptoms in 51%; headache in 32%; and gait difficulty, hearing loss, meningismus, or altered mental status in < 5%.

         2. Early neurosyphilis develops in 1.7% of HIV-infected MSMs who acquire syphilis.

            ...