Syphilis/CSF analysis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

Clinical signs of neurosyphilis (i.e., cranial nerve dysfunction, meningitis, stroke, acute or chronic altered mental status, loss of vibration sense, and auditory or ophthalmic abnormalities) warrant further investigation and treatment for neurosyphilis.

Laboratory testing is helpful in supporting the diagnosis of neurosyphilis; however, no single test can be used to diagnose neurosyphilis in all instances.

Cerebrospinal fluid (CSF) abnormalities are common in persons with early syphilis.

Diagnosed by finding high numbers of leukocytes in the CSF or abnormally high protein concentration in the setting of syphilis infection.

VDRL in cerebrospinal fluid (CSF-VDRL), which is highly specific but insensitive, is the standard serologic test for CSF. Although some advocate using the FTA-ABS test to improve sensitivity.

When reactive in the absence of substantial contamination of CSF with blood, it is considered diagnostic of neurosyphilis; however in early syphilis, it can be of unknown prognostic significance.^[1]

Most other tests are both insensitive and nonspecific and must be interpreted in relation to other test results and the clinical assessment. Therefore, the laboratory diagnosis of neurosyphilis usually depends on various combinations of reactive serologic test results, CSF cell count or protein, and a reactive CSF-VDRL with or without clinical manifestations.

HIV Co-infection

There is anecdotal evidence that the incidence of neurosyphilis is higher in HIV patients, and some have recommended that all HIV-positive patients with syphilis should have a lumbar puncture to look for asymptomatic neurosyphilis.^[2]

Among persons with HIV infection, the CSF leukocyte count usually is elevated (>5 white blood cell count [WBC]/mm3); using a higher cutoff (>20 WBC/ mm3) might improve the specificity of neurosyphilis diagnosis.^[3]

The CSF-VDRL might be non-reactive even when neurosyphilis is present.

Therefore, additional evaluation using FTA-ABS testing on CSF can be considered. The CSF FTA-ABS test is less specific for neurosyphilis than the CSF-VDRL but is highly sensitive; neurosyphilis is highly unlikely with a negative CSF FTA-ABS test.^[4]

Resources

Sexually transmitted diseases treatment guidelines, 2010^[5]

Association of Public Health Laboratories (APHL). Laboratory Diagnostic Testing for Treponema pallidum. Expert Consultation Meeting Summary Report, January 13--15, 2009, Atlanta, GA

CDC: Guidelines for the laboratory diagnosis of gonorrhea, chlamydia and syphilis

References

↑ Lukehart SA, Hook EW, Baker-Zander SA, Collier AC, Critchlow CW, Handsfield HH (1988). "Invasion of the central nervous system by Treponema pallidum: implications for diagnosis and treatment". Annals of Internal Medicine. 109 (11): 855–62. PMID 3056164. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
↑ Walter T, Lebouche B, Miailhes P; et al. (2006). "Symptomatic relapse of neurologic syphilis after benzathine penicillin G therapy for primary or secondary syphilis in HIV-infected patients". Clin Infect Dis. 43 (6): 787–90. PMID 16912958.
↑ Marra CM, Maxwell CL, Smith SL, Lukehart SA, Rompalo AM, Eaton M, Stoner BP, Augenbraun M, Barker DE, Corbett JJ, Zajackowski M, Raines C, Nerad J, Kee R, Barnett SH (2004). "Cerebrospinal fluid abnormalities in patients with syphilis: association with clinical and laboratory features". The Journal of Infectious Diseases. 189 (3): 369–76. doi:10.1086/381227. PMID 14745693. Retrieved 2012-02-16. Unknown parameter |month= ignored (help)
↑ Jaffe HW, Larsen SA, Peters M, Jove DF, Lopez B, Schroeter AL (1978). "Tests for treponemal antibody in CSF". Archives of Internal Medicine. 138 (2): 252–5. PMID 343742. Retrieved 2012-02-16. Unknown parameter |month= ignored (help)
↑ Workowski KA, Berman S (2010). "Sexually transmitted diseases treatment guidelines, 2010". MMWR. Recommendations and Reports : Morbidity and Mortality Weekly Report. Recommendations and Reports / Centers for Disease Control. 59 (RR-12): 1–110. PMID 21160459. Retrieved 2012-02-16. Unknown parameter |month= ignored (help)

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[pmid3056164-1] Lukehart SA, Hook EW, Baker-Zander SA, Collier AC, Critchlow CW, Handsfield HH (1988). "Invasion of the central nervous system by Treponema pallidum: implications for diagnosis and treatment". Annals of Internal Medicine. 109 (11): 855–62. PMID 3056164. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)

[2] Walter T, Lebouche B, Miailhes P; et al. (2006). "Symptomatic relapse of neurologic syphilis after benzathine penicillin G therapy for primary or secondary syphilis in HIV-infected patients". Clin Infect Dis. 43 (6): 787–90. PMID 16912958.

[pmid14745693-3] Marra CM, Maxwell CL, Smith SL, Lukehart SA, Rompalo AM, Eaton M, Stoner BP, Augenbraun M, Barker DE, Corbett JJ, Zajackowski M, Raines C, Nerad J, Kee R, Barnett SH (2004). "Cerebrospinal fluid abnormalities in patients with syphilis: association with clinical and laboratory features". The Journal of Infectious Diseases. 189 (3): 369–76. doi:10.1086/381227. PMID 14745693. Retrieved 2012-02-16. Unknown parameter |month= ignored (help)

[pmid343742-4] Jaffe HW, Larsen SA, Peters M, Jove DF, Lopez B, Schroeter AL (1978). "Tests for treponemal antibody in CSF". Archives of Internal Medicine. 138 (2): 252–5. PMID 343742. Retrieved 2012-02-16. Unknown parameter |month= ignored (help)

[pmid21160459-5] Workowski KA, Berman S (2010). "Sexually transmitted diseases treatment guidelines, 2010". MMWR. Recommendations and Reports : Morbidity and Mortality Weekly Report. Recommendations and Reports / Centers for Disease Control. 59 (RR-12): 1–110. PMID 21160459. Retrieved 2012-02-16. Unknown parameter |month= ignored (help)

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