Neurosyphilis medical therapy: Difference between revisions
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:**If [[Penicillin#Benzylpenicillin .28penicillin G.29|aqueous crystalline penicillin G]] is contraindicated, then [[Penicillin G procaine|procaine penicillin]] is an alternative (administered daily with [[probenecid]] for two weeks). | :**If [[Penicillin#Benzylpenicillin .28penicillin G.29|aqueous crystalline penicillin G]] is contraindicated, then [[Penicillin G procaine|procaine penicillin]] is an alternative (administered daily with [[probenecid]] for two weeks). | ||
:**Intramuscular ceftriaxone for 14 days is also shown to be an alternative effective. | :**Intramuscular ceftriaxone for 14 days is also shown to be an alternative effective. | ||
=== Pre-Medical Check up === | |||
Considerations in the management of patients who have neurosyphilis before starting medications include | |||
* All persons who have syphilis should be tested for [[HIV|HIV.]] | |||
* Screen for penicillin allergy. | |||
* Pregnancy | |||
===Pharmacotherapy === | ===Pharmacotherapy === | ||
| Line 17: | Line 23: | ||
* Alternative regimen (1): [[Penicillin#Procaine benzylpenicillin|Procaine penicillin]] 2.4 million units IM once daily, plus [[probenecid]] 500 mg orally four times a day, both for 10-14 days.<ref name="urlSexually Transmitted Diseases Treatment Guidelines, 2010" /> | * Alternative regimen (1): [[Penicillin#Procaine benzylpenicillin|Procaine penicillin]] 2.4 million units IM once daily, plus [[probenecid]] 500 mg orally four times a day, both for 10-14 days.<ref name="urlSexually Transmitted Diseases Treatment Guidelines, 2010" /> | ||
* Alternative regimen (2): [[Benzathine penicillin G]] 2.4 million units IM once per week for up to 3 weeks after regular course. | * Alternative regimen (2): [[ceftriaxone]] 2 g daily either IM or IV for 10-14 days<ref name="pmid3764632">Hook EW, Baker-Zander SA, Moskovitz BL, Lukehart SA, Handsfield HH (1986) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=3764632 Ceftriaxone therapy for asymptomatic neurosyphilis. Case report and Western blot analysis of serum and cerebrospinal fluid IgG response to therapy.] Sex Transm Dis 13 (3 Suppl):185-8. PMID: [http://pubmed.gov/3764632 3764632]</ref><ref name="pmid14573840">Shann S, Wilson J (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14573840 Treatment of neurosyphilis with ceftriaxone.] Sex Transm Infect 79 (5):415-6. PMID: [http://pubmed.gov/14573840 14573840]</ref> | ||
** Penicillin allergic condition | |||
* Alternative regimen (3): [[Benzathine penicillin G]] 2.4 million units IM once per week for up to 3 weeks after regular course. | |||
**To approximate for [[Syphilis pathophysiology#Latent syphilis|late latent disease]] and to address concerns about slowly dividing [[Treponema Pallidum|treponemes]]. | **To approximate for [[Syphilis pathophysiology#Latent syphilis|late latent disease]] and to address concerns about slowly dividing [[Treponema Pallidum|treponemes]]. | ||
==== Pregnancy: ==== | ==== Pregnancy: ==== | ||
| Line 45: | Line 38: | ||
*Several small observational studies conducted in HIV-infected patients with neurosyphilis suggest that [[ceftriaxone]] 1-2 g IV daily for 10-14 days might be effective as an alternate agent.<ref name="pmid1442850">Dowell ME, Ross PG, Musher DM, Cate TR, Baughn RE (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1442850 Response of latent syphilis or neurosyphilis to ceftriaxone therapy in persons infected with human immunodeficiency virus.] Am J Med 93 (5):481-8. PMID: [http://pubmed.gov/1442850 1442850]</ref><ref name="pmid15117503">Smith NH, Musher DM, Huang DB, Rodriguez PS, Dowell ME, Ace W et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15117503 Response of HIV-infected patients with asymptomatic syphilis to intensive intramuscular therapy with ceftriaxone or procaine penicillin.] Int J STD AIDS 15 (5):328-32. [http://dx.doi.org/10.1258/095646204323012823 DOI:10.1258/095646204323012823] PMID: [http://pubmed.gov/15117503 15117503]</ref><ref name="pmid18532887">Ghanem KG, Moore RD, Rompalo AM, Erbelding EJ, Zenilman JM, Gebo KA (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18532887 Antiretroviral therapy is associated with reduced serologic failure rates for syphilis among HIV-infected patients.] Clin Infect Dis 47 (2):258-65. [http://dx.doi.org/10.1086/589295 DOI:10.1086/589295] PMID: [http://pubmed.gov/18532887 18532887]</ref> | *Several small observational studies conducted in HIV-infected patients with neurosyphilis suggest that [[ceftriaxone]] 1-2 g IV daily for 10-14 days might be effective as an alternate agent.<ref name="pmid1442850">Dowell ME, Ross PG, Musher DM, Cate TR, Baughn RE (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1442850 Response of latent syphilis or neurosyphilis to ceftriaxone therapy in persons infected with human immunodeficiency virus.] Am J Med 93 (5):481-8. PMID: [http://pubmed.gov/1442850 1442850]</ref><ref name="pmid15117503">Smith NH, Musher DM, Huang DB, Rodriguez PS, Dowell ME, Ace W et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15117503 Response of HIV-infected patients with asymptomatic syphilis to intensive intramuscular therapy with ceftriaxone or procaine penicillin.] Int J STD AIDS 15 (5):328-32. [http://dx.doi.org/10.1258/095646204323012823 DOI:10.1258/095646204323012823] PMID: [http://pubmed.gov/15117503 15117503]</ref><ref name="pmid18532887">Ghanem KG, Moore RD, Rompalo AM, Erbelding EJ, Zenilman JM, Gebo KA (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18532887 Antiretroviral therapy is associated with reduced serologic failure rates for syphilis among HIV-infected patients.] Clin Infect Dis 47 (2):258-65. [http://dx.doi.org/10.1086/589295 DOI:10.1086/589295] PMID: [http://pubmed.gov/18532887 18532887]</ref> | ||
==Follow-Up== | |||
:Follow-up for neurosyphilis Among HIV-Infected Persons.<ref name="pmid18715154">Marra CM, Maxwell CL, Tantalo LC, Sahi SK, Lukehart SA (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18715154 Normalization of serum rapid plasma reagin titer predicts normalization of cerebrospinal fluid and clinical abnormalities after treatment of neurosyphilis.] Clin Infect Dis 47 (7):893-9. [http://dx.doi.org/10.1086/591534 DOI:10.1086/591534] PMID: [http://pubmed.gov/18715154 18715154]</ref> | |||
:*If [[Lumbar puncture#Diagnostics|CSF pleocytosis]] was present initially, a [[Syphilis laboratory findings#CSF analysis|CSF examination]] should be repeated every 6 months until the cell count is normal.<ref name="pmid18715154" /><ref name="pmid15034833">Marra CM, Maxwell CL, Tantalo L, Eaton M, Rompalo AM, Raines C et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15034833 Normalization of cerebrospinal fluid abnormalities after neurosyphilis therapy: does HIV status matter?] Clin Infect Dis 38 (7):1001-6. [http://dx.doi.org/10.1086/382532 DOI:10.1086/382532] PMID: [http://pubmed.gov/15034833 15034833]</ref> | |||
* | |||
:*Follow-up CSF examinations also can be used to gauge response after therapy. | :*Follow-up CSF examinations also can be used to gauge response after therapy. | ||
:*Limited data suggest that changes in CSF parameters may occur more slowly in HIV-infected patients, especially those with more advanced [[immunosuppression]].<ref name="pmid15034833">Marra CM, Maxwell CL, Tantalo L, Eaton M, Rompalo AM, Raines C et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15034833 Normalization of cerebrospinal fluid abnormalities after neurosyphilis therapy: does HIV status matter?] Clin Infect Dis 38 (7):1001-6. [http://dx.doi.org/10.1086/382532 DOI:10.1086/382532] PMID: [http://pubmed.gov/15034833 15034833]</ref><ref name="pmid18525260">Ghanem KG, Moore RD, Rompalo AM, Erbelding EJ, Zenilman JM, Gebo KA (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18525260 Neurosyphilis in a clinical cohort of HIV-1-infected patients.] AIDS 22 (10):1145-51. [http://dx.doi.org/10.1097/QAD.0b013e32830184df DOI:10.1097/QAD.0b013e32830184df] PMID: [http://pubmed.gov/18525260 18525260]</ref> | |||
:*Limited data suggest that changes in CSF parameters may occur more slowly in HIV-infected patients, especially those with more advanced [[immunosuppression]].<ref name="pmid15034833">Marra CM, Maxwell CL, Tantalo L, Eaton M, Rompalo AM, Raines C et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15034833 Normalization of cerebrospinal fluid abnormalities after neurosyphilis therapy: does HIV status matter?] Clin Infect Dis 38 (7):1001-6. [http://dx.doi.org/10.1086/382532 DOI:10.1086/382532] PMID: [http://pubmed.gov/15034833 15034833]</ref><ref name="pmid18525260">Ghanem KG, Moore RD, Rompalo AM, Erbelding EJ, Zenilman JM, Gebo KA (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18525260 Neurosyphilis in a clinical cohort of HIV-1-infected patients.] AIDS 22 (10):1145-51. [http://dx.doi.org/10.1097/QAD.0b013e32830184df DOI:10.1097/QAD.0b013e32830184df] PMID: [http://pubmed.gov/18525260 18525260]</ref> | :*If the cell count has not decreased after 6 months or if the CSF is not normal after 2 years, re-treatment should be considered. | ||
:*If the cell count has not decreased after 6 months or if the CSF is not normal after 2 years, re-treatment should be considered. | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
{{WH}} | |||
{{WS}} | |||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Gynecology]] | [[Category:Gynecology]] | ||
[[Category:Bacterial diseases]] | [[Category:Bacterial diseases]] | ||
[[Category:Sexually transmitted diseases]] | [[Category:Sexually transmitted diseases]] | ||
[[Category:Emergency mdicine]] | |||
[[Category:Up-To-Date]] | [[Category:Up-To-Date]] | ||
[[Category:Infectious disease]] | [[Category:Infectious disease]] | ||
[[Category:Urology]] | [[Category:Urology]] | ||
[[Category:Neurology]] | [[Category:Neurology]] | ||
Latest revision as of 22:58, 29 July 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]
Overview
Medical therapy is recommended for all patients diagnosed with neurosyphilis. Penicillin is the treatment of choice for neurosyphilis. CNS involvement can occur during any stage of syphilis. However, CSF laboratory abnormalities are common in persons with early syphilis, even in the absence of clinical neurological findings. Syphilitic uveitis or other ocular manifestations frequently are associated with neurosyphilis and should be managed according to the treatment recommendations for neurosyphilis.
Management of Neurosyphilis
For patients diagnosed with neurosyphilis including ocular or auditory syphilis with or without positive CSF results, aqueous crystalline penicillin G is the treatment of choice.[1]
- The recommended regimen is intravenous administration of penicillin every 4 hours or continuously for 10-14 days.
- Oral antibiotics are not recommended for the treatment of neurosyphilis.
- If aqueous crystalline penicillin G is contraindicated, then procaine penicillin is an alternative (administered daily with probenecid for two weeks).
- Intramuscular ceftriaxone for 14 days is also shown to be an alternative effective.
- The recommended regimen is intravenous administration of penicillin every 4 hours or continuously for 10-14 days.
Pre-Medical Check up
Considerations in the management of patients who have neurosyphilis before starting medications include
- All persons who have syphilis should be tested for HIV.
- Screen for penicillin allergy.
- Pregnancy
Pharmacotherapy
- Preferred regimen (1): Aqueous crystalline penicillin G 18-24 million units per day, administered as 3-4 million units IV every 4 hours or continuous infusion, for 10-14 days.[2]
- Alternative regimen (1): Procaine penicillin 2.4 million units IM once daily, plus probenecid 500 mg orally four times a day, both for 10-14 days.[2]
- Alternative regimen (2): ceftriaxone 2 g daily either IM or IV for 10-14 days[3][4]
- Penicillin allergic condition
- Alternative regimen (3): Benzathine penicillin G 2.4 million units IM once per week for up to 3 weeks after regular course.
- To approximate for late latent disease and to address concerns about slowly dividing treponemes.
Pregnancy:
- Pregnant patients who are allergic to penicillin should be desensitized and treated with penicillin.
Neurosyphilis Among HIV-Infected Persons:
- HIV-infected patients with neurosyphilis should be treated according to the recommendations for HIV-negative patients with neurosyphilis.
- HIV-infected, penicillin-allergic patients who have neurosyphilis should be managed according to the recommendations for penicillin-allergic, HIV-negative patients with neurosyphilis.
- Several small observational studies conducted in HIV-infected patients with neurosyphilis suggest that ceftriaxone 1-2 g IV daily for 10-14 days might be effective as an alternate agent.[5][6][7]
Follow-Up
- Follow-up for neurosyphilis Among HIV-Infected Persons.[8]
- If CSF pleocytosis was present initially, a CSF examination should be repeated every 6 months until the cell count is normal.[8][9]
- Follow-up CSF examinations also can be used to gauge response after therapy.
- Limited data suggest that changes in CSF parameters may occur more slowly in HIV-infected patients, especially those with more advanced immunosuppression.[9][10]
- If the cell count has not decreased after 6 months or if the CSF is not normal after 2 years, re-treatment should be considered.
References
- ↑ http://www.cdc.gov/std/tg2015/syphilis.htm#Neurosyphilis Accessed on September 27, 2016
- ↑ 2.0 2.1 "Sexually Transmitted Diseases Treatment Guidelines, 2010". Retrieved 2012-12-19.
- ↑ Hook EW, Baker-Zander SA, Moskovitz BL, Lukehart SA, Handsfield HH (1986) Ceftriaxone therapy for asymptomatic neurosyphilis. Case report and Western blot analysis of serum and cerebrospinal fluid IgG response to therapy. Sex Transm Dis 13 (3 Suppl):185-8. PMID: 3764632
- ↑ Shann S, Wilson J (2003) Treatment of neurosyphilis with ceftriaxone. Sex Transm Infect 79 (5):415-6. PMID: 14573840
- ↑ Dowell ME, Ross PG, Musher DM, Cate TR, Baughn RE (1992) Response of latent syphilis or neurosyphilis to ceftriaxone therapy in persons infected with human immunodeficiency virus. Am J Med 93 (5):481-8. PMID: 1442850
- ↑ Smith NH, Musher DM, Huang DB, Rodriguez PS, Dowell ME, Ace W et al. (2004) Response of HIV-infected patients with asymptomatic syphilis to intensive intramuscular therapy with ceftriaxone or procaine penicillin. Int J STD AIDS 15 (5):328-32. DOI:10.1258/095646204323012823 PMID: 15117503
- ↑ Ghanem KG, Moore RD, Rompalo AM, Erbelding EJ, Zenilman JM, Gebo KA (2008) Antiretroviral therapy is associated with reduced serologic failure rates for syphilis among HIV-infected patients. Clin Infect Dis 47 (2):258-65. DOI:10.1086/589295 PMID: 18532887
- ↑ 8.0 8.1 Marra CM, Maxwell CL, Tantalo LC, Sahi SK, Lukehart SA (2008) Normalization of serum rapid plasma reagin titer predicts normalization of cerebrospinal fluid and clinical abnormalities after treatment of neurosyphilis. Clin Infect Dis 47 (7):893-9. DOI:10.1086/591534 PMID: 18715154
- ↑ 9.0 9.1 Marra CM, Maxwell CL, Tantalo L, Eaton M, Rompalo AM, Raines C et al. (2004) Normalization of cerebrospinal fluid abnormalities after neurosyphilis therapy: does HIV status matter? Clin Infect Dis 38 (7):1001-6. DOI:10.1086/382532 PMID: 15034833
- ↑ Ghanem KG, Moore RD, Rompalo AM, Erbelding EJ, Zenilman JM, Gebo KA (2008) Neurosyphilis in a clinical cohort of HIV-1-infected patients. AIDS 22 (10):1145-51. DOI:10.1097/QAD.0b013e32830184df PMID: 18525260