Neurosyphilis medical therapy
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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