[Clinical characteristics and therapy of neurosyphilis in patients who are negative for human immunodeficiency virus].
BACKGROUND
Neurosyphilis is still a significant medical problem in developing countries and its occurrence in HIV infection is the reason for a growing number of new cases in developed countries [1-4]. Personality changes are the commonest symptom of late neurosyphilis [5]. Neurologic deficits are usually due to syphilitic vasculitis with lacunar infarctions [6]. The laboratory confirmation of neurosyphilis must depend on a cluster of tests (Venereal Disease Research Laboratories--VDRL; Fluorescent Treponemal Antibody-Absorption--FTA-ABS; Treponema Pallidum Immobilization--TPI or Nelson-Mayer). The diagnosis of active neurosyphilis also requires an inflammatory cerebrospinal fluid (CSF) test [4].


METHODS
A retrospective study of hospitalized neurosyphilitic patients at the Institute of Neurology, Belgrade, Serbia, was carried out. Between 1990 and 1996 seven cases were found: five males and two females, aged from 22 to 66 years, mean 56 years. All were in tertiary stage and HIV negative. None of them reported previous veneral disease and only one reported meningitis. In all patients neurological examination, VDRL and TPI in blood and CSF, CT or MRI of the brain, Mini Mental State (MMS) test [11] and psychiatric evaluation were performed. To patients with active disease 24 million units of crystalline penicillin were administered, in divided daily doses in continuous intravenous infusions for three weeks.


RESULTS
Symptoms. Five patients (71%) had gait disturbances, four (57%) headache, three (43%) hearing loss, speech complaints, forgetfulness, mood changes, and two (29%) seizures and stroke-like episodes. Malaise, diplopia, visual loss, vertigo, loss of sphincter control and paresthesia were noticed in one patient (14%). Neurologic findings. Five patients (71%) had pupillary changes. In four (57%) of them we found hemiparesis, gait disturbances and signs of cerebellar involvement, in three (43%) hearing loss, dysarthria, paraparesis, hypesthesia for light touch, mood disorders (depression in two, hypomania in one), mild cognitive decline and tremor of the tongue and hands. Lesion of the second and the sixth cranial nerve, position sense and positive release signs were recorded in one patient (14%). Gonarthrotic changes were observed in two (29%) patients. Cerebrospinal fluid. Elevated cell count and high protein level were detected in four (57%) patients. Three had also positive oligoclonal bands. Serological tests. In six patients (86%) serological tests for syphilis were positive (VDRL and/or Nelson-Mayer Test) in serum and in three (43%) in CSF. Results in one patient were negative both regarding serum and CSF, as he was treated for secondary syphilis in his twenties (now 65 years old) presumably as a "burnt out" case with neurologic sequelae. Neuroimaging. CT and MRI of the brain showed cortical and subcortical reduction in the brain parenchyma in four (57%) and multiischaemic changes in two (29%) patients. Therapy. Crystalline penicillin was administered to five patients with no side effects. Improvement of mood and cognitive status were noted in three patients, improvement of neurologic status in two subjects and arrest of progression in two patients.


CONCLUSIONS
None of our patients reported previous venereal disease. They complained of impaired gait, headache, hearing loss, speech difficulties, forgetfulness, and mood changes. Pupillary changes, hemiparesis, gait disturbances and cerebellar signs, hearing loss, dysarthria, paraparesis, hypesthesia, mood disorders, mild cognitive decline and tremor of the tongue and hands were found during the examination. Pupillary signs are the most important symptoms because they can point to neurosyphilis. A two-step approach is recommended for establishing the diagnosis of syphilis with simple nontreponemal tests for screening purpose, and specific treponemal tests for its confirmation [21]. In our patients all but one were positive for syphilis in serum-tests and/or CSF. (ABS
Pavlović
D M
DM
Institute of Neurology, Clinical Centre of Serbia, Belgrade.
Milović
A M
AM
D000328:Adult; D000368:Aged; D005260:Female; D018023:HIV Seronegativity; D006801:Humans; D008297:Male; D008875:Middle Aged; D009494:Neurosyphilis / Q000175:diagnosis* / Q000188:drug therapy*; D012189:Retrospective Studies