How is neurosyphilis treated?

Updated: Jul 17, 2018
  • Author: Richard P Knudsen, MD, FAAN, FAAP; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
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The earliest effort at treatment is key. Prevention, overall, from a public health standpoint, would be most appropriate. Identification of high-risk groups (eg, men who have sex with men [71] ) with educational programs would limit disease and consequent suffering. Vigilant screening of high-risk patients, including in the area of congenital syphilis, by the medical community remains essential.

Adequate treatment of neurosyphilis is based largely on achieving treponemicidal levels of penicillin (PCN) in the CSF. Treponema pallidum is highly susceptible to PCN, which is the drug of choice for all stages of syphilis. Serum levels of PCN should be maintained for many days because treponemes divide slowly in early syphilis (30-33 per hour in experimental settings) and PCN acts only on dividing cells. [72, 73, 74, 75, 76, 77, 78, 79, 80]

PCN acts by interfering with the synthesis of cell walls and is active only against organisms that, like T pallidum, synthesize their cell walls in growth and division. The intensity of therapy should be based on the presence or absence of CNS involvement and HIV infection. Future studies should address whether more intensive therapy for neurosyphilis is warranted in HIV-infected individuals, particularly those with low (< 200 cells/µL) peripheral blood CD4+ T-cell counts.

PCN has some ameliorative effect in every stage of neurosyphilis. Earlier forms of illness are better candidates for a response to antibiotic treatment. Meningovascular disease responds most dramatically. Intravenous PCN requires hospital admission, which involves loss of time from work, high cost, and risks of the hospital environment. For inpatient treatment, accurate diagnosis of neurosyphilis is imperative.

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