Neurosyphilis: symptoms, treatment, diagnosis, signs

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When the syphilis pathogen enters the nervous tissue, it produces characteristic symptoms that make it possible to distinguish this case as a separate disease. This is neurosyphilis, well known to modern medicine, but remains one of the most difficult pathologies in terms of diagnosis and treatment. In recent years, there has been an increase in cases of this disease in the world, and its clinical manifestations differ in each case depending on the area affected and the intensity of the course. More often, the development of pathology occurs in the second or third stage of a syphilitic infection, when its causative agent, Treponema pallidum, spreads throughout the body along with the bloodstream.

What is neurosyphilis?

Syphilis is a sexually transmitted infectious disease caused by the bacterium Treponema pallidum (treponema pallidum). Syphilis infection usually occurs through the mucous membranes of the genitals or mouth, but subsequently the disease can affect almost all body systems. Neurosyphilis occurs when the infection affects the brain and spinal cord. How often do people get syphilis?
It is a mistake to think that syphilis is a thing of the past. In 2012, the World Health Organization (WHO) reported 5.6 million syphilis infections in men and women aged 15 to 49 years. However, quite often the infection is not treated properly and leads to serious complications.

The American Medical Association examined 233 patients with syphilis. Neurosyphilis was diagnosed in 21% of these patients (50 people).

In Russia, from 2010 to 2014, the increase in the number of cases of neurosyphilis was 73%.

Symptoms of late syphilis

The meningovascular form of neurosyphilis is disguised as vascular disorders. Symptoms include:

moderate headaches;
dizziness, weakness;
paralysis, paresis, speech disorders;
symptoms of ischemic stroke - loss of consciousness, coma, impaired brain function.

Tabes dorsalis manifests itself as progressive paralysis with pain in areas corresponding to the level of damage to the spinal cord. Possible:

dagger pains simulating attacks of angina, renal or hepatic colic;
numbness, a feeling of “goosebumps” on the skin, tingling in the soles, areas corresponding to the level of the lesion;
dysfunction of the pelvic organs - impotence, urinary and fecal incontinence;
impairment of tactile and pain sensitivity in areas corresponding to the level of the lesion;
unsteadiness of gait, hearing loss, progressive decrease in visual acuity;
arthrosis, arthritis, osteoporosis are possible due to tissue nutritional disorders;
because of them, ulcers also appear on the skin of the feet and legs, teeth, hair, nails fall out, sweat glands die off;
paralysis of the lower and upper limbs occurs 10-20 years after infection with syphilis.

Gumma of the brain is a tumor-like formation of scarred and necrotically altered nervous tissue. When it occurs, it can grow, leading to symptoms similar to those of a brain tumor. The changes are irreversible; usually, surgical treatment is performed for partial improvement. Since gummas most often form at the base of the brain, paralysis, dysfunction of the cranial nerves, and possibly intracranial pressure due to impaired circulation of the cerebrospinal fluid are possible. The outcome of progressive gumma is complete paralysis.

After 10-20 years, the disease turns a person into a weak-minded freak, unable to perform basic actions, take care of himself, a bedridden and hopeless patient. This is what advanced, untreated neurosyphilis looks like; symptoms, progressing, make the diagnosis obvious. Such a person will live, but not for long and very badly.

Fortunately, thanks to the widespread introduction of tests for syphilis, such forms of the disease are extremely rare. According to the rules, screening for this infection is carried out annually during a clinical examination at the place of residence or upon hiring. This is especially relevant, since there are known cases of syphilis infection through everyday life, when seeking the services of a cosmetologist or stylist. A single scratch made by an inattentive hairdresser on an infected instrument can cause illness. 1-2 spirochetes are enough for infection.

Ways of transmission of syphilis

The main way of contracting syphilis is through sexual intercourse. You can get infected through vaginal, anal and oral sex.

It is also possible to transmit syphilis through a needle (when using the same syringe with a syphilitic) or through a blood transfusion (if a healthy person receives a blood transfusion from a sick donor). This type of syphilis infection is extremely rare, as donated blood is now carefully tested before transfusion.

It is important to remember that anyone who is sexually active can get sick. Those at risk for syphilis are:

patients with HIV infection and AIDS;
sex workers and their clients;
people who have unprotected sex;
drug addicts;
people undergoing pre-infection prophylaxis (daily intake of special medications by HIV-positive patients. Such prophylaxis prevents HIV from spreading in the body and minimizes the risk of infection through sexual intercourse or a syringe, but does not protect against sexually transmitted diseases, including syphilis).

Congenital neurosyphilis Newborns can become infected with syphilis from their mother. The bacterium enters the fetal blood through the placenta. The risk of infection of the child is high if pregnancy occurs in the third year after the woman becomes infected with the infection. Congenital syphilis is characterized by skin rashes (red blisters and rashes), cracks around the mouth, and nosebleeds. Possible convulsions and fits, deafness. Children over two years of age experience vision problems and ulcers around the mouth and nose. The spinal cord is affected, teeth and bones grow poorly. If the infected mother seeks treatment in time, taking medication (penicillin) will also cure the fetus. If treatment is started late (less than 4 weeks before birth), the possibility of infection of the fetus increases.

Diagnosis of the disease

If a patient experiences any of the listed symptoms, he needs to make an appointment with a neurologist. The doctor will carry out the necessary diagnostic measures, which include:

visual examination;
lumbar puncture;
collection of cerebrospinal fluid;
serological blood test;
computer and magnetic resonance imaging of the brain.

The risk group traditionally includes patients with ordinary syphilis, who need to visit a neurologist regularly to prevent complications.

If the patient complains of symptoms associated with deteriorating vision, he is scheduled to consult an ophthalmologist with further examination of the fundus.

Reasons for the development of neurosyphilis

The main danger of syphilis is that in the early stages of development, which sometimes last for many years, it may practically not manifest itself at all, and after that it completely goes underground - the latent phase. At the same time, all the symptoms disappear, and here lies the main danger of the disease. Sometimes, after many years, undiagnosed or undertreated syphilis makes itself known - tertiary syphilis develops. Tertiary syphilis can affect almost all human organs and systems, including the heart, kidneys, liver, bones, joints, eyes and skin. When the infection affects the central nervous system, neurosyphilis develops. In this case, the patient faces paralysis, memory loss and dementia.

Types of neurosyphilis

Experts identify several types of neurosyphilis, each of which has specific symptoms:

latent - does not have a pronounced clinical picture, can only be detected during the analysis of cerebrospinal fluid;
early - formed against the background of primary or secondary syphilis in the first few years after infection and affects the blood vessels and lining of the brain;
late - occurs 7-8 years after the pathogens of syphilis enter the body, destroying brain fibers and nerve cells directly.

Neurosyphilis is particularly dangerous because it is usually detected suddenly and immediately affects most of the central nervous system.

Classification

The disease is divided into two forms: early and late. This division is very arbitrary, since symptoms of damage to the nervous system can appear only many years after infection. In HIV patients, on the contrary, neurosyphilis progresses quickly.

In addition, treponema pallidum can affect one part of the human body and not affect others. Such selectivity leads to the fact that the symptoms are always different and it is impossible to give a clear prognosis of the course of the disease.

Early form

The early form corresponds to damage to the membranes and base of the brain (syphilitic meningitis) or the blood vessels of the meninges (meningovascular neurosyphilis). Syphilitic meningitis manifests itself within 2 years after infection. If during this time the tests did not show it, neurosyphilis will not manifest itself. The period for the manifestation of symptoms of meningovascular neurosyphilis is 5–10 years.

Other early forms of neurosyphilis include:

syphilitic meningomyelitis (damage to the spinal cord);
hypertrophic pachymeningitis (thickening of the dura mater);
gummas of the brain and spinal cord (avascular formations);
syphilitic lesions of the peripheral nervous system (damage to nervous tissue outside the brain and spinal cord);
cerebrospinal form of syphilis (damage to the white matter of the brain).

Late form

The late form of neurosyphilis, which occurs 15–25 years after infection, is characterized by dementia, headaches, brain fog, memory loss, muscle wasting and changes in gait stability.

During this period, the patient may develop:

tabes dorsalis (atrophy of the posterior parts of the spinal cord);
progressive paralysis (psychosis due to brain damage);
amyotrophic spinal syphilis (damage to the nerve cells of the spinal cord, leading to immobilization);
Erb's spastic spinal palsy (paralysis of the lower limbs).

Features of the clinic and diagnosis of early neurosyphilis at the present stage.

The incidence of syphilis of the nervous system increases by approximately 15-25% per year.

Currently, there are no pathognomonic symptoms in the diagnosis of early neurosyphilis and its clinical forms.

There are early neurosyphilis and late neurosyphilis. This division of neurosyphilis is conditional: early neurosyphilis can develop many years after contracting syphilis, along with this, especially with HIV infection, there are known cases of early manifestations of taboparalysis and tabes dorsalis.

Currently, early neurosyphilis is classified as:

1) asymptomatic neurosyphilis;

2) syphilitic meningitis

3) meningovascular neurosyphilis.

O.K. Shaposhnikov and I.I. Mavrov provide an expanded clinical classification:

1) hidden or latent syphilitic meningitis;

2) basal meningitis or meningoneuritic form of syphilitic meningitis;

3) acute generalized or manifest syphilitic meningitis;

4) syphilitic hydrocephalus;

5) syphilitic meningomyelitis;

6) early meningovascular syphilis.

Thus, a number of positions remain controversial – whether there is early neurosyphilis or whether it is neurosyphilis in general, whether asymptomatic early neurosyphilis should be isolated or not.

The widespread use of antibiotic therapy has resulted in a noticeable pathomorphosis of syphilis, which currently occurs with atypical and asymptomatic lesions of the nervous system.

Asymptomatic neurosyphilis. This form is characterized by the absence of clinical neurological symptoms. Diagnosis is based on a study of cerebrospinal fluid, which reveals elevated protein levels, positive RW and VDRL. Changes in one or more of these indicators are found in 20-30% of patients with untreated syphilis after 2 years of the disease. The risk of progression of asymptomatic neurosyphilis and its transition to symptomatic is 2-3 times higher in people of the Caucasian race compared to the Negroid race and 2 times higher in men than in women

Latent or asymptomatic syphilitic meningitis.

The most common form of early neurosyphilis. With primary syphilis, asymptomatic meningitis is detected in 4% of cases, with secondary fresh syphilis - in 15-25%, with secondary recurrent - in 30-50%.

As a rule, there are no clinical symptoms. Sometimes headaches and dizziness occur. The diagnosis of latent meningitis in patients with early syphilis is established by changes in the cerebrospinal fluid.

The meningoneuritic form of syphilitic meningitis or basal meningitis occurs in 10-20% of all cases of early neurosyphilis. It proceeds subacutely. Mild meningeal symptoms are noted: headache, worse at night, dizziness, sometimes nausea, vomiting. One of the manifestations of basal meningitis is damage to the cranial nerves - primarily the visual and auditory nerves.

In the eyeball, iritis (iridocyclitis) often develops, accompanied by pain, photophobia, lacrimation, pericorneal injection of the sclera, blurred vision and chorioretinitis.

When the optic nerve is involved in the process (usually one-sided), central vision deteriorates, visual fields narrow, patients note the appearance of dark spots and “floaters” in front of the eyes.

With neuritis of the auditory nerve, bone conduction primarily decreases (bone-air dissociation), which is pathognomonic for early neurosyphilis and may remain the only symptom, even with a negative Wassermann reaction.

Vestibular disorders in syphilis reflect the obligatory involvement of the central parts of the analyzer - dizziness in the form of rocking, the floor floating away from under the feet, the absence of a vestibular illusion of counter-rotation.

Acute generalized syphilitic meningitis and syphilitic hydrocephalus are extremely rare. Syphilitic meningomyelitis occurs 1-3 years after infection. There is a decrease or disappearance of tendon reflexes. In this case, paralysis of the lower extremities develops with dysfunction of the pelvic organs. Symptoms appear early and quickly regress with specific treatment. Early meningovascular syphilis is characterized by moderate involvement of the meninges in the process. The clinical picture is quite diverse: headache, intermittent focal disturbances of cerebral circulation with episodes of dysarthria and anarthria, alternating seizures, memory impairment, damage to cranial nerves, sensory disturbances, hemiparesis.

Based only on clinical manifestations, it is impossible to give a conclusion with a high degree of certainty about a specific lesion of the nervous system. Therefore, special emphasis is placed on laboratory diagnostics, designed to resolve controversial issues about the involvement of the nervous system in the syphilitic process.

The generally accepted characteristics of the cerebrospinal fluid are: the number of cellular elements, the total amount of protein, the results of the globulin reactions of Pandi, Nonne-Apelt, the Lange reaction with colloidal gold, a complex of serological reactions (CSR), RIF-c, RIF-10. Normally, cytosis in the cerebrospinal fluid does not exceed 6 × 106/l, and the protein level does not exceed 0.45 g/l.

When the condition of the cerebrospinal fluid was assessed by the number of cellular elements, the total amount of protein, globulin and colloid reactions and the Wassermann reaction, pathological cerebrospinal fluid was detected in 17.3-31% of patients with syphilis.

With the introduction of sensitive serological tests (RIF, RIT) into practice, the frequency of registration of pathological changes in the cerebrospinal fluid increased to 45.8-68.3%.

The sensitivity of the Wasserman reaction with cerebrospinal fluid for neurosyphilis using cardiolipin antigen is 63%, treponemal antigen - 84%, antigen from atypical forms of cultural Treponema pallidum - 92%.

False-positive results of serological reactions with cerebrospinal fluid are observed in cases of artifactual erythrocytrachia and may also be due to:

1) diseases caused by pathogens with a similar antigenic structure (yaws, bejel, pinta, rickettsia, treponema of the oral cavity and genitals, leptospira);

2) technical errors when setting up the reaction.

It should be taken into account that HIV infection can significantly change serological reactions in syphilis, which may also affect the results of cerebrospinal fluid testing. Negative CSF DCS results do not exclude neurosyphilis.

A specific test widely used today abroad is the fluorescent treponemal antibody absorption test (RIF-abs). This test is used as the “ gold standard”.

In Russia, RIF, in relation to cerebrospinal fluid, is used in the RIF-ts variant, that is, with undiluted cerebrospinal fluid.

However, the group of RIF tests is difficult to implement. Each result must be read and evaluated by a highly qualified specialist, which excludes automation and the formulation of reactions with a large number of sera.

The hemagglutination reaction with cerebrospinal fluid used abroad is TRHA. In this case, the RPGA index is used, calculated by the formula.

Progress in many areas of biology and medicine is largely associated with the widespread use of quantitative immunological methods, among which the most widely used are solid-phase versions of radioimmunoassay (RIA) and enzyme-linked immunosorbent assay (ELISA).

In addition, identifying immunoglobulins in the cerebrospinal fluid using radial immunodiffusion in a gel and determining the concentration of free light chains using electrophoresis with immunoblotting can also help in making a diagnosis of neurosyphilis.

Polymerase chain reaction to detect specific DNA sequences of pathogenic treponemes in cerebrospinal fluid was used in 1990.

The specificity of the method for cerebrospinal fluid samples is 71%. The question remains unclear whether the presence of treponemal DNA reflects the presence of viable treponemes or whether these are remnants of the genetic material of destroyed microorganisms.

Summarizing the literature data concerning the use of routine serological diagnostic methods (RIFc, and serological reactions with cardiolipin antigens), allows us to simplify the algorithm for their interpretation in the study of CSF: a negative test result in RIFc. allows to exclude damage to the central nervous system; positive result in RIFts. does not confirm damage to the central nervous system; a negative result in reactions with cardiolipin antigen does not exclude damage to the central nervous system; positive reactions with cardiolipin antigen highly likely indicate a specific lesion of the central nervous system. It is not difficult to imagine the challenges clinicians face when considering the need to jointly evaluate the results of multiple serological methods. Considering the possibility of obtaining distorted results (false positive and false negative) in each of the tests, laboratory confirmation of the diagnosis of neurosyphilis becomes completely difficult to implement and does not meet the requirements of today.

In the treatment of neurosyphilis, priority is given to methods that facilitate the penetration of the antibiotic through the blood-brain barrier in treponemocidal concentration.

An increase in the concentration of penicillin in the cerebrospinal fluid is promoted by: an increase in body temperature, the introduction of histamine, hyaluronidase, lidase, aminophylline, probenecid.

Inflammation of the meninges reduces the rate of antibiotic elimination. Increasing doses of parenterally administered penicillin leads to an increase in the level of antibiotic in the cerebrospinal fluid, but not proportionally. The peak concentration of the antibiotic in the cerebrospinal fluid is observed 2-4 hours after parenteral administration.

Using magnetic resonance imaging (MRI) of the brain and spinal cord, a topical diagnosis, the form of neurosyphilis is determined and differential diagnosis is carried out between neurosyphilis and various other neurological diseases, in particular, neoplasms, strokes of nonspecific etiology.

Establishing a diagnosis of neurosyphilis is impossible without conducting a cerebrospinal fluid examination, taking into account 4 indicators: cytosis, protein, CSR, RIF (RIF with whole cerebrospinal fluid).

A dermatovenerologist who monitors the patient after completion of treatment engages a neurologist consultant to examine the patient once every 6 months (as needed). The dermatovenerologist also organizes consultations with other specialists.

The first control study of cerebrospinal fluid is carried out 6 months after the end of the course of therapy, then once every 6 months within 3 years after diagnosis.

Cytosis quickly responds to specific therapy, therefore, a sharp decrease in the number of cells is a criterion for the adequacy of the treatment. Protein often decreases much more slowly and may remain abnormal for 2 years. It is extremely important to reduce protein slowly, albeit slowly. CSR in the cerebrospinal fluid may remain positive for 1 year after treatment, but with a tendency to decrease. RIF remains positive in the cerebrospinal fluid for a long time, and therefore cannot be used as a criterion for cure.

Carrying out control punctures once every 6 months is necessary for two reasons:

According to various authors, after adequate specific treatment, clinical and serological relapse of neurosyphilis is possible in approximately 30 cases;
CSF examination data are a criterion for prescribing an additional course of specific therapy.

Khodosevich E.V. Candidate of Medical Sciences, I.N. Telichko Doctor of Medical Sciences Professor

Symptoms of syphilis

The incubation period of syphilis lasts from a month to six months, after which you can find out about the presence of infection by finding characteristic ulcers (chancroid) on the body. They are the first striking symptom and correspond to the primary stage of the disease.

A syphilitic rash on the palms, soles or other parts of the body, characteristic of secondary syphilis, appears 2-3 months after infection. By this time, the pathogen has already entered the bloodstream, and the rash is the immune system’s response to the disease affecting various organs and tissues. People with secondary syphilis may have a fever, they may feel body aches, and their lymph nodes may be noticeably enlarged.

Then comes an asymptomatic period, which can last for many years. However, the absence of symptoms does not mean recovery. Eventually, syphilis may return, causing extensive damage to the skin, bones, and nervous system (neurosyphilis).

Symptoms of early neurosyphilis

The following symptoms are characteristic of early latent neurosyphilis:

fatigue, muscle weakness;
severe and moderate headaches, “heaviness in the head”;
tinnitus, hearing loss, dizziness;
memory impairment.

Acute syphilitic meningitis is accompanied by severe symptoms:

severe headaches;
dizziness, tinnitus;
severe vomiting without nausea, not associated with food intake or dietary errors;
fever, high temperature;
pathological reflexes;
convulsions;
deterioration of vision, narrowing of visual fields, facial asymmetry, drooping eyelids, deviation of the tongue to the side when cranial nerves are involved in the inflammatory process.

When brain tissue is involved in the process, strokes, paralysis, and paresis of the lower and upper extremities are possible.

Symptoms of neurosyphilis

The disease has no clearly defined symptoms. They vary depending on which structures of the central nervous system are affected by the infection. For example, the patient may suffer from insomnia, headaches, dizziness and seizures. Neurosyphilis can cause visual impairment, lead to gait instability and paralysis (Fig. 1), and articulation disorders.

Figure 1. Joint deformity due to tabes spinal cord. Source: Robert Sumpter/CDC

Symptoms at different stages

Clinical manifestations of neurosyphilis are divided into 4 stages.

First stage

For the earliest stage, there are no obvious symptoms of meningitis, but the patient may experience:

exhaustion and fatigue,
increased forgetfulness,
irritability,
headache,
sleep problems.

Second stage

At the second stage, symptoms appear that confirm the presence of meningitis - inflammation of the soft and hard membranes of the brain and spinal cord.

Damage to the meninges

The mild form of syphilitic meningitis is characterized by:

headache,
dizziness,
minor visual and hearing impairments.

Exacerbation of syphilitic meningitis

Acute meningitis is much more severe. It corresponds to:

Strong headache,
dizziness,
noise in ears,
nausea and vomiting,
increase in body temperature to 38℃,
neck muscle tension.

Basal meningitis

This type of meningitis occurs in approximately 10% of all cases of early neurosyphilis. It is characterized by the usual symptoms of meningitis (headache, dizziness), but they are not so pronounced. Often, with basal meningitis, the optic and auditory nerves are affected, resulting in a person losing hearing and vision.

Damage to the dura mater of the brain

The hard membranes of the brain are rarely affected by syphilis separately from the soft membranes. Often this development of the disease becomes a complication caused by the destruction of bone tissue. Among the symptoms:

excessive excitability or depression,
pain when pressing on the bones of the skull,
headache,
seizures,
paralysis,
neck muscle tension.

When the hard membranes of the spinal cord are damaged, in turn, the following are observed:

pain in the back of the head and neck,
pain in the area of the ulnar and median nerves,
sensory disturbances and paralysis.

Spinal cord lesion

The spinal cord can be affected by the disease, starting with the earliest forms of neurosyphilis. With acute inflammation of the spinal cord membranes, the patient may feel pain in the back along the spine - in the area of the sacrum, shoulder blades, and neck. When pressed, the pain intensifies.

The most common type of spinal cord lesion due to syphilis is syphilitic meningomyelitis. Among its symptoms:

convulsions,
loss of elasticity of the neck muscles,
paralysis of arms and legs,
amyotrophy,
retention of stool and urine.

Third stage

The third stage of neurosyphilis includes vascular lesions of the brain and spinal cord. In this case, the membranes of the brain are also affected by the disease, which means that along with the characteristic vascular symptoms, symptoms of meningitis are also observed.

Damage to cerebral vessels

Damage to large vessels leads to strokes of varying severity. Strokes, in turn, can cause:

paralysis,
decreased intelligence,
mental disorders,
seizures,
rave,
hallucinations.

Meningovascular neurosyphilis

With meningovascular neurosyphilis, the following may be observed:

headache,
dizziness,
noise in ears,
insomnia,
visual impairment,
behavior change,
memory loss,
increased nervousness,
loss of consciousness.

It is also possible: weakness of the muscles of the arms and legs, urinary and fecal incontinence, paralysis of the lower extremities.

Fourth stage

The fourth stage of neurosyphilis is the rarest. Its main symptom is the formation of gummas, tumors separated from the main brain tissue.

Gumma brain

If gummas form in the brain, symptoms may include:

increased intracranial pressure,
loss of hearing and vision.

Gummas in the spinal cord can cause:

paresis of the limbs (disruption of communication between the nervous system and the muscles of the legs, resulting in the feeling that the legs “do not obey”),
urinary and fecal incontinence.

Tabes dorsalis

In the case of tabes dorsalis, the dorsal roots and cords of the spinal cord are destroyed. Symptoms of tabes dorsalis:

sharp pain in the legs and back,
tingling and burning in the legs,
gait disturbance,
poor stability
poor coordination
incontinence or, conversely, retention of urine and feces,
penile dysfunction,
elongation of the face with a sad expression,
the pupils do not react to light (Argyll-Robertson pupils).

Erb's spastic spinal palsy

Erb's spastic spinal palsy is characterized by:

change in gait (shuffling gait, knees moving towards each other),
the appearance of mass reflexes (too sharp response of muscles and tendons to stimuli).

Progressive paralysis

Progressive paralysis is characterized by a constant increase in signs of dementia. It is characterized by:

psychosis, which is manifested by personality changes,
bad memory
deviations in behavior,
hallucinations,
emotional depression,
epilepsy,
tremor,
muscle dysfunction,
speech disorder,
urination, fecal incontinence.

Taboparalysis

Taboparalysis is a combination of symptoms of tabes dorsalis and progressive paralysis. Neurological complications in this case include both weakened reflexes and paresis, as well as manifestations of dementia that worsen over time.

Sometimes neurosyphilis does not reveal itself in any way, then laboratory diagnosis is necessary. To determine the presence of asymptomatic neurosyphilis, the doctor conducts a cerebrospinal fluid (CSF) test. The disease is indicated by elevated protein levels, a positive Wasserman reaction (RW) or a positive RPR test (rapid plasma reagin test). Sometimes the patient complains of headache and dizziness.

Syphilis - symptoms and treatment

How long after contact do the first signs appear?

The first symptoms of syphilis appear on average after 21 days, but the period can extend up to three months.

External signs of syphilis

Primary syphiloma (chancroid) is a symptom of the primary period of syphilis, a sign of which is erosion or ulceration that occurs at the site of penetration of pale treponema into the skin or mucous membranes. The formation of a chancre begins with the appearance of a small red spot, after a few days it turns into a nodule with a crust, when rejected, a painless erosion or ulcer of an oval or round shape with clear boundaries is exposed.

Dimensions of chancre:

ordinary - 1-2 cm in diameter;
dwarf - from 1 to 3 mm;
giant - from 2 to 5 cm.

Most often, chancre is single, but with repeated sexual intercourse with an infected partner, multiple rashes may appear. Multiple chancres include “bipolar” chancre, in which ulcers occur simultaneously on different parts of the body, and “kissing” chancre on contacting surfaces.

In 90-95% of cases, the chancre is located in any area of the genital organs. The fact that it is often found at the base of the penis indicates that the condom is not fully effective in preventing syphilis. Very rarely, chancre can appear inside the urethra, in the vagina and on the cervix. An atypical form of chancre in the genital area is indurative edema in the form of extensive painless thickening of the foreskin or labia majora.

Outside the genital organs, chancres are most often found in the area of the mouth (lips [10], tongue [11], tonsils), less often in the area of the fingers (chancre-felon) [5], breast [3], pubis, and navel. Casuistic cases of the appearance of chancre in the chest area [12] and eyelids have been described.

Folman's syphilitic balanitis [14] is a clinical variant of chancre, the sign of which is spots with scales on the head of the penis, combustiform chancre - resembling a superficial burn, herpetiform chancre - in the form of a group of pinpoint microerosions [15], hypertrophic - simulating skin carcinoma [16] .

Syphilitic lymphadenopathy (enlarged lymph nodes) is a symptom of the primary and secondary periods of syphilis.

Syphilitic roseola (spotted syphilide) is a manifestation of the secondary early congenital and, less commonly, tertiary period of syphilis, occurring in 50-70% of patients.

Late roseola (erythema) of Fournier is a rare manifestation of tertiary syphilis, usually occurring 5-10 years after infection. It is characterized by the appearance of large pink spots, often grouped into bizarre shapes [17]. Unlike roseola, with secondary syphilis the spots peel off and leave behind atrophic scars [18].

Papular syphilide is a symptom of secondary and early congenital syphilis; it appears with relapse of the disease in 12-34% of cases. It is a rash of isolated dense nodules (papules) of a hemispherical shape with a smooth surface from pink-red to copper or bluish in color. There is no itching or pain, but if you press on the center of the papule, patients note sharp pain (Jadassohn's symptom).

Condyloma lata - observed in 10% of patients. The warty surface of the papules, which almost always merge into large conglomerates, is weeping, eroded and often covered with a gray foul-smelling coating. There is severe pain during sexual intercourse and defecation. In rare cases, condylomas lata can be located under the armpit, under the mammary glands, in the folds between the toes, or in the recess of the navel [5].

Pustular syphilide can most often be found in patients who abuse alcohol and drugs, are infected with HIV, and have hemato-oncological diseases [13].

Syphilitic alopecia (baldness) is characterized by untreated secondary and early congenital syphilis. Usually appears in 4-11% of cases a few weeks after the appearance of the primary rash (fresh roseola) and spontaneously regresses after 16-24 weeks [4].

Pigmentary syphilide ( change in skin color) is a manifestation of secondary syphilis in the first 6-12 months after infection. Clinically, it is an alternation of pigment and depigment spots (mesh form), and at first only hyperpigmentation of the skin is noted. Depigmented (white) round spots with a diameter of 10-15 mm in the neck area (spotted form) are traditionally called the “necklace of Venus”, and in the forehead area - the “crown of Venus” [15]. Without treatment, the rash spontaneously regresses within 2-3 months. More rare is the “marble” or “lace” form.

Syphilitic tonsillitis is a symptom of secondary syphilis, a sign of which is the appearance of roseola and (or) papules on the mucous membrane of the mouth, pharynx, and soft palate. If the papules are localized on the vocal cords, a characteristic “hoarse” voice appears. Sometimes syphilitic tonsillitis is the only clinical manifestation of the disease, and then it is dangerous in terms of the possibility of sexual (during oral sex) and domestic infection due to the high content of treponemes in the elements of the rash.

Syphilitic onychia (thickening and brittleness of the nail plates) and paronychia (inflammation of the periungual fold) occur at all stages of syphilis and with early congenital syphilis [16].

Tuberous syphilide (tertiary papule) is the main symptom of the tertiary period of syphilis, which can appear as early as 1-2 years from the moment of infection. But as a rule, it occurs after 3-20 years. It is characterized by the appearance of isolated brownish-red seals up to 5-10 mm in size, which rise above the skin level and have a smooth and shiny surface. The outcome of the existence of a tubercle is always the formation of a scar.

Syphilitic gumma (gummy syphilide) characterizes the tertiary period and late congenital syphilis. In this case, a mobile, painless, often single node with a diameter of 2 to 5 cm appears in the subcutaneous tissue. Gummas can occur in muscle and bone tissue, and on internal organs. Most often they are localized in the mouth, nose, pharynx and pharynx, resulting in perforation of the hard palate with food entering the nasal cavity and a “nasal” voice, deformation of the cartilaginous and bone parts of the nasal septum with the formation of a “saddle” and “lornette” nose [18 ].

Symptoms of neurosyphilis

Ocular and pupillary symptoms result from damage to the optic and oculomotor nerves. These include: progressive loss of vision, ptosis - drooping eyelid, anisocoria - small pupils ("prostitute's eyes"), unequal pupil sizes (Baillarger's symptom), Argyll Robertson pupil - narrowing pupils when the patient focuses on a close object, and not narrowing in directed bright light, oblique deflection - in which one eye moves downward while the other deflects upward [16].
Labyrinthine deafness is a manifestation of neurosyphilis and late congenital syphilis due to damage to the auditory nerve.
Tabetic arthropathy occurs in patients with late neurosyphilis and is most often manifested by unilateral enlargement and slight hyperemia (redness) of the joints of the foot and knee (Charcot's joint), which are subsequently deformed with the possible appearance of ulcerative skin defects.
Ataxic gait is staggering while walking with eyes closed due to decreased joint-muscular sensitivity.
Instability in the Romberg position is a symptom of neurosyphilis, in which it is impossible to maintain balance in a standing position with your feet together and your arms extended along the body or forward with your eyes closed.

Symptoms of visceral syphilis (from the internal organs) depend on the localization of the process [16].

Yellowness of the skin and sclera occurs with syphilitic hepatitis.

Vomiting, nausea, weight loss - with gastrosyphilis.
Pain in muscles (myalgia), joints (arthralgia), bones - with syphilitic hydrarthrosis and osteoperiostitis.
Cough with sputum - with syphilitic bronchopneumonia.
Pain in the heart - with syphilitic aortitis (mesaortitis).

Characteristic is the so-called “syphilitic crisis” - paroxysmal pain in the area of the affected organs [8].

Symptoms of early congenital syphilis:

syphilitic pemphigus;
syphilitic rhinitis;
diffuse papular infiltration;
osteochondritis of long bones;
Parrot's pseudoparalysis is a symptom of early congenital syphilis, in which there is no movement of the limbs, but nerve conduction is preserved;
Sisto's symptom - the constant cry of a child - is a sign of developing meningitis.

Symptoms of late congenital syphilis:

Parenchymal keratitis is characterized by clouding of the cornea of both eyes and is observed in half of the patients.
Clutton's joint (syphilitic gonitis) is a bilateral hydrarthrosis in the form of redness, swelling and enlargement of the joints, most often the knees.
The buttock-shaped skull is characterized by enlargement and protrusion of the frontal and parietal tubercles, which are separated by a longitudinal depression.
The Olympic forehead is an unnaturally convex and high forehead.
The Ausitidian symptom is thickening of the sternal end of the right clavicle.
DuBois's sign is a shortened (infantile) little finger.
Saber shin is a characteristic symptom of late congenital syphilis in the form of an anterior bend of the tibia, resembling a saber.
Hutchinson's teeth - dystrophy of the permanent upper middle incisors in the form of a screwdriver or barrel with a semilunar notch on the free edge.

Gaucher diastema - widely spaced upper incisors.
Corabelli's cusp is the fifth additional cusp on the chewing surface of the first upper molar.

Can syphilis be asymptomatic?

The latent stage of syphilis is a period when there are no visible signs of syphilis. Without treatment, an infected person continues to have syphilis, even if there are no symptoms.

Early latent syphilis is called syphilis in which the infection occurred within the last 12 months, late latent syphilis - more than 12 months ago. Latent syphilis can last for years [27].

Diagnostics

A venereologist diagnoses neurosyphilis. Since the symptoms and forms of the disease are different, the patient can also be referred for examination to a neurologist, urologist, ENT specialist and gastroenterologist. Cardiac or neurological symptoms are a reason to be tested for syphilis.

The doctor makes a diagnosis of neurosyphilis, taking into account three mandatory parameters: the clinical picture, positive test results for syphilis and changes in the cerebrospinal fluid.

Important! All patients diagnosed with syphilis must also be tested for HIV infection. And HIV-infected people need to be regularly tested for syphilis. According to statistics, about half of patients diagnosed with neurosyphilis are HIV-positive.

Laboratory diagnostics determines how much the syphilitic process has penetrated the nervous system. To do this, serological tests of blood and cerebrospinal fluid (cerebrospinal fluid) are performed. These tests detect antibodies produced by the immune system in response to a pathogen entering the body.

CSF is taken for analysis using a lumbar puncture. The procedure consists of inserting a special needle into the spinal canal in the lumbar region.

Important! Lumbar puncture is a safe procedure. The puncture is carried out below the spinal cord, therefore, under standard conditions for performing a lumbar puncture, damage to the spinal cord is excluded.

Serological tests (or tests) include non-treponemal and treponemal tests.

When conducting non-treponemal tests, samples taken from the patient reveal antibodies that are formed in response to lipids of the treponemal membrane. Such tests are screening and are rapid tests.

Non-treponemal tests include:

RSKk - reaction of complement fixation with cardiolipin antigen;
RPR (Rapid Plasma Reagins) - rapid plasma reagin test;
RMP - microprecipitation reaction.

Results from nontreponemal tests can be obtained quickly and are easy to perform but often produce false results. Therefore, they are prescribed in conjunction with more complex and accurate treponemal tests, in which the antigen is the treponema pallidum itself.

Treponemal tests include:

RIF—immunofluorescence reaction with whole cerebrospinal fluid;
RIBT (or RIT) - immobilization reaction of Treponema pallidum;
ELISA - enzyme-linked immunosorbent assay;
RSKt - reaction of complement fixation with treponemal antigen;
RPHA - passive hemagglutination reaction;
IB - immunoblotting.

RMP has the highest diagnostic sensitivity among non-treponemal tests. Treponemal tests of cerebrospinal fluid ELISA, RPGA, IB, RIF, RIBT, in turn, show 100% sensitivity when analyzing for meningovascular syphilis.

The Ministry of Health of the Russian Federation recommends conducting two screenings during the initial examination: RMP (or its modification: RPR, TRUST, VDRL) and, in case of a positive result, also any treponemal test (RPGA, ELISA, DAC, RIF, RIT).

The Venereal Diseases Research Laboratories (VDRL) test is also known in world practice.

If necessary, to clarify the form of neurosyphilis, the doctor prescribes computed tomography and magnetic resonance imaging.

MODERN APPROACH TO DIAGNOSIS AND TREATMENT OF NEUROSYPHILIS

E. G. Kozhanova

V. A. Kutashov

GBOU VPO VSMU im. N.N. Burdenko Ministry of Health of Russia, Department of Psychiatry and Neurology, IDPO

Russia, Voronezh

Annotation.

Neurosyphilis is a chronic progressive specific lesion of the central, peripheral, autonomic nervous system, manifested by a specific process in the membranes and vessels of the brain and spinal cord, the formation of gummas, and the involvement of the primary substance of the brain and spinal cord in the pathological process in the late stages of the disease [1].

Currently, in Russia and abroad, the epidemiological situation is characterized by an increase in the registration of the number of cases of neurosyphilis. In the Russian Federation, the result of long-term consequences of the syphilis epidemic observed in the 90s of the 20th century was the formation of new cases of neurosyphilis due to latent, late and unspecified forms of syphilitic infection, which currently tend to increase. Late detection of lesions of the nervous system can contribute to the development of late forms of neurosyphilis, which necessitates the improvement of existing approaches to the diagnosis of neurosyphilis [2, 3].

This article discusses the etiology, pathogenesis of neurosyphilis, and features of the clinical course of this disease. The issues of instrumental and laboratory diagnostics, as well as treatment of syphilis of the central nervous system at different stages are discussed in more detail.

Keywords:

neurosyphilis, pathogenesis, clinical picture, diagnosis, treatment.

Etiology and pathogenesis.

All forms of neurosyphilis develop due to penetration of the syphilis pathogen Traeponema pallidum into the vessels, membranes and substance of the nervous tissue (hematogenously and lymphogenously). In the initial stages of the disease, hematogenous dissemination predominates: the pathogen enters the blood within a few hours after infection and is fixed in the endothelial cells of blood vessels, and from there in the lymphatic capillaries of the perineural spaces, nerve sheaths and, finally, in the subdural and subarachnoid spaces. Lymphogenic penetration is the main one, but occurs later and more slowly, while from the lymph nodes the pathogen enters the perineural zone of the peripheral nerves and spinal roots, and from there into the subdural and subarachnoid spaces. Finding itself in the soft meninges, already sensitized by a hematogenous generalized infection, treponema pallidum causes hyperergic inflammation in them with pronounced exudative phenomena. Then, as the reactivity of the reticuloendothelial tissue of the membranes changes, proliferative and cicatricial processes begin to predominate in the picture of inflammation. Along with the membranes, the infection affects the vessels of the nervous system, the perineurium and endoneurium of the roots and peripheral nerves, i.e. the entire mesenchymal apparatus of the nervous system. Over time, local immunity is developed and the mesenchyme loses its ability to retain Treponema pallidum, rendering it harmless. Then the latter penetrate the parenchyma of the central nervous system, causing degenerative changes. In this case, diseases develop with direct damage to the substance of the brain and spinal cord, in contrast to early forms characterized by damage to the membranes and vessels of the nervous system. Syphilitic meningitis can develop already in the primary (rare) and secondary periods. Characteristic neurological symptoms, united by the term “neurosyphilis,” develop with tertiary syphilis [4].

Classification of syphilis of the nervous system according to the ICD

A50.4 Late congenital neurosyphilis

A52.1 Neurosyphilis with symptoms

A52.2 Asymptomatic neurosyphilis

A52.3 Neurosyphilis, unspecified

Features of the clinical course of neurosyphilis.

A feature of the clinical course of neurosyphilis at the present stage is the low-symptomatic manifestations and atypical course of the disease. According to the literature, over the past decades there has been an evolution in the clinical picture and course of syphilis, which fits into the concept of “pathomorphosis”. Many authors have pointed out changes in the clinical picture of neurosyphilis in recent decades. J. Hotson, comparing the incidence of progressive paralysis and tabes dorsalis with the data of the “pre-penicillin period”, noted a decrease in the frequency of these forms of neurosyphilis by at least 10 times. As a possible reason for the decrease in the frequency of late manifest forms of syphilis, the authors consider not only the influence of active chemotherapy (the introduction of anti-syphilitic drugs - penicillin into the arsenal), but also the use of antibiotics by the population in connection with intercurrent diseases [2].

According to some modern foreign authors, when performing liquor diagnostics in patients with latent forms of syphilis, in 25-30% of cases a diagnosis of asymptomatic neurosyphilis is established; patients with neurosyphilis with a primary manifestation in the form of ischemic stroke are often found. Quite often there are reports of an increase in the number of patients with symptoms of mental disorders in late forms of neurosyphilis and damage to the optic nerve [2, 4, 5].

Clinical forms that occur during the first 3-5 years after infection are classified as early neurosyphilis. What they have in common is damage to tissues of mesenchymal (mesoderm) origin - blood vessels, meninges, which is why early neurosyphilis is also called meningovascular. Late neurosyphilis occurs 10-25 years after the initial infection. It affects the parenchyma of the brain and spinal cord, i.e. tissue of ectodermal origin, so-called parenchymal syphilis. The following clinical variants of early and late syphilis are distinguished:

Early neurosyphilis: syphilitic meningitis, meningoencephalitis, meningomyelitis, meningoencephalomyelitis, mono- and polyneuritis, endarteritis, gumma of the brain and spinal cord.

Late neurosyphilis: syphilitic myelopathy (tabes dorsalis), syphilitic encephalopathy (progressive paralysis), myatrophic spinal syphilis, Erb's spastic spinal palsy [4, 6].

Instrumental and laboratory diagnostics.

One of the features of the modern course of syphilitic lesions of the nervous system is the predominance of erased, atypical, asymptomatic and seronegative forms. This is associated with the altered reactivity of the human body and the evolution of the pathogenic properties of the pathogen itself. In such cases, a particularly thorough laboratory examination of blood and cerebrospinal fluid is required, which has always played a major role in the diagnosis of any form of syphilis. Due to the absence of a typical picture and pathognomonic clinical variants, serological examination becomes the leading method [4, 7].

In general, the diagnosis of neurosyphilis requires the presence of 3 criteria:

1. Positive non-treponemal and/or treponemal reactions in the study of blood serum.

2. Neurological syndromes characteristic of neurosyphilis.

3. Changes in the cerebrospinal fluid (positive serological reactions, inflammatory changes in the cerebrospinal fluid with cytosis over 10/μl and protein content over 0.6 g/l). Computed tomography, magnetic resonance imaging, magnetic resonance angiography of the brain for neurosyphilis, although they do not allow us to establish the specificity of the process, however, make it possible to determine its localization, size and serve mainly to exclude other diseases [2, 8].

In the diagnosis of neurosyphilis, great importance is attached to immunological methods for studying CSF.

Non-treponemal tests.

In Russia, the non-treponemal complement fixation test (CFR) has been used for a long time to study CSF in the diagnosis of neurosyphilis. A comparative study of the diagnostic significance of various immunological tests in the study of CSF in patients with neurosyphilis showed higher results of the diagnostic efficiency of the microprecipitation reaction (MPR) of CSC.

Treponemal tests.

Due to the low sensitivity of non-treponemal tests, various treponemal tests are widely used in the diagnosis of NS. In Russia, for the specific diagnosis of syphilis, RIF with whole cerebrospinal fluid (RIFc) is used. In general, the significance of this reaction in the diagnosis of neurosyphilis is assessed quite highly. However, positive RIFc results may not necessarily be associated with neurosyphilis, since a positive reaction may be a consequence of the penetration of serum antitreponemal antibodies into the CSF when the permeability of the blood-brain barrier increases, as well as when blood enters the CSF during lumbar punctures, but negative RIFc results exclude neurosyphilis.

Many authors have reported the possibility of using enzyme-linked immunosorbent assay (ELISA) to diagnose neurosyphilis. In accordance with the current order of the Ministry of Health of the Russian Federation No. 87 dated May 26, 2001 “On improving the serological diagnosis of syphilis,” ELISA can be used to study CSF for the purpose of diagnosing neurosyphilis.

Also in Russia, when diagnosing neurosyphilis, in accordance with the current Russian Order of the Ministry of Health of the Russian Federation No. 87 dated May 26, 2001, the immobilization reaction of Treponema pallidum (RIBT) is used. According to some authors, positive results of RIBT with cerebrospinal fluid are highly likely to indicate syphilitic damage to the central nervous system, but negative results do not exclude the presence of neurosyphilis, which is explained by the low concentration of immobilisins in the CSF. In recent years, the use of RIBT has been limited due to the need to maintain a vivarium, the complexity of carrying out the reaction and recording the results. Abroad, RIBT is used only for research purposes.

Some foreign researchers have shown the possibility of using polymerase chain reaction (PCR) to detect Treponema pallidum nucleic acids in the CSF for the diagnosis of neurosyphilis, but the sensitivity of CSF PCR turned out to be low, and the method has not found wide practical application [2, 4, 7, 8].

Treatment.

Specific treatment of neurosyphilis is carried out with the aim of microbiological sanitation of the patient by creating a treponemocidal concentration of penicillin in the CSF - 0.018 mcg/ml. In accordance with clinical recommendations, treatment of patients with early neurosyphilis and treatment of patients with late neurosyphilis is provided. This therapy is based on the administration of 10 million units of benzylpenicillin sodium crystalline salt (BNSC) intravenously 2 times a day daily (or intravenous jet administration of BNSC, dividing the daily dose of 12 million - 24 million units into 6 injections) in early forms – 14 days, in late forms – 2 repeated courses of 14 days each with an interval of 2 weeks [7, 9, 10]. Noteworthy is the use of a water-soluble form of penicillin as the drug of choice - benzylpenicillin sodium crystalline salt. Currently, the use of BNSC is unanimously supported by all domestic and foreign researchers because of its ability to better (compared to durable penicillins) penetrate the blood-brain barrier (BBB) and sanitize the nervous system. The state of the BBB in syphilis (in the absence of provoking and comorbid factors) is characterized as “fluctuating” - from increased permeability in early neurosyphilis to normal or decreased permeability in the later (“burnt out”) stages.

An indicator of the state of the BBB in syphilis is the content of cells and protein in the CSF - an increase in protein-cellular parameters of the CSF corresponds to increased permeability of the BBB. In this regard, oral administration as a measure to prevent an exacerbation reaction of prednisolone 50-90 mg in the first 3-5 days of penicillin therapy or during the entire course of specific treatment seems debatable, since the membrane-stabilizing properties of glucocorticosteroids, which reduce the permeability of the BBB, are well known [4, 9, 10].

Currently, studies are being conducted on the combined use of osmodiuretics (mannitol) and penicillin under conditions of temporary osmotic “breakthrough” of the BBB, which allows achieving reliable sanitation of the central nervous system [9].

The response to treatment is considered adequate if after 6 months. after its completion, the number of cells in the CSF normalizes, and the protein concentration (if it was initially elevated) decreases. Subsequently, it is recommended to re-examine the CSF at 6-month intervals for 2 years. Throughout this period, the number of cells in the CSF should remain normal, and the protein concentration should steadily decrease.

The best effect is considered to be the absence of disease progression and the restoration of normal cellular composition and protein in the CSF. It is believed that the earlier penicillin therapy is started and the less pronounced the manifestations of parenchymal neurosyphilis at the time of treatment, the better the prognosis. Decreased vision, development of blindness, mental disorders, disorders of locomotor functions and the musculoskeletal system, as a rule, cause persistent disability in patients [9, 10].

Literature:

1. Diseases of the nervous system / N.N. Yakhno, D.R. Shtulman, P.V. Melnichuk. – M., 1995.

2. Neurosyphilis: epidemiology, pathogenesis, clinic, laboratory diagnostics / G.L. Katunin, L.E. Melekhina, N.V. Frigo. — Bulletin of dermatology and venereology. – 2013. – No. 5.

3. Syphilitic meningomyelitis / D.R. Shtulman (et al.) / Neurological Journal. – 1998. – No. 1.

4. Neurosyphilis / G.I. Mavlyutova, O.S. Kochergina, E.F. Rakhmatullina / Practical medicine. – 2014. – No. 2 (78).

5. Pathogenesis and modern features of the clinical picture of acquired syphilis. Modern problems of dermatovenerology, immunology and medical cosmetology / T.V. Krasnoselskikh, E.V. Sokolovsky. – 2010.

6. Neurosyphilis. From diagnosis to treatment. Part I. Epidemiology, pathogenesis, clinic. / M.V. Rodikov, V.I. Prokhorenkov / Bulletin of Dermatology and Venereology. – 2010. – No. 1.

7. Neurosyphilis. From diagnosis to treatment. Part II. Epidemiology, pathogenesis, clinic. / M.V. Rodikov, V.I. Prokhorenkov / Bulletin of Dermatology and Venereology. – 2010. – No. 2.

8. Neurosyphilis. Modern ideas about diagnosis and treatment / A.V. Samtsov. – St. Petersburg: SpetsLit. – 2006.

9. Concentration of penicillin in the cerebrospinal fluid in patients with neurosyphilis receiving standard therapy / M.V. Rodikov, V.I. Prokhorenkov / Russian Journal of Skin and Venereal Diseases. – 2008. – No. 2.

10. Neurosyphilis has returned / O.V. Kolokolov, A.L. Bakulev, A.M. Kolokolova, I.I. Sholomov. / Bulletin of medical Internet conferences, volume 2. – 2012. – No. 9.

About the author:

Kozhanova Evgenia Gennadievna

– intern of the Department of Psychiatry and Neurology of the Institute of Postgraduate Education of VSMU named after. N.N. Burdenko

e-mail

Kutashov Vyacheslav Anatolievich

– Doctor of Medical Sciences, Professor, Head of the Department of Psychiatry and Neurology, IDPO VSMU named after. N.N. Burdenko

e-mail

EG Kozhanova, VA Kutashov

CURRENT APPROACHES TO DIAGNOSIS AND TREATMENT OF NEUROSYPHILIS

Summary:

Neurosyphilis — a chronic, progressive specific involvement of the central, peripheral, autonomic nervous system, which manifests itself in the specific process membranes and blood vessels of the brain and spinal cord, forming Gunma involvement in the pathological process of the primary substance of the brain and spinal cord in the later stages of the disease.

Currently in Russia and abroad, the epidemiological situation is characterized by increasing registration numbers of cases of neurosyphilis. In the Russian Federation, the result of long-term effects of syphilis epidemic observed in the 90-ies of XX century was the emergence of new cases of neurosyphilis by hidden as of late and unspecified forms of syphilitic infection, which currently have a tendency to grow. Untimely detection of lesions of the nervous system may contribute to late forms of neurosyphilis, which causes the need to improve existing approaches to the diagnosis of neurosyphilis.

This article discusses the etiology, pathogenesis of neurosyphilis, the clinical course of the disease. In more detail questions of instrumental and laboratory diagnostics, as well as at different stages of the treatment of central nervous system syphilis.

Keywords:

neurosyphilis, pathogenesis, clinical manifestations, diagnosis, treatment.

References:

1. Diseases of the nervous system / NN Yahno, DR Shtulman, PV Melnychuk. - M., 1995.

2. Neurosyphilis: epidemiology, pathogenesis, clinic, laboratory diagnostics / GL Katunin, LE Melekhina, NV Frigo. — Journal of Dermatology and Venereology. - 2013. - No. 5.

3. Syphilitic meningomyelitis / DR Shtulman (et al.) / Neurology journal. - 1998. - No. 1.

4. Neurosyphilis / GI Mavlyutova, OS Kochergina, EF Rakhmatullina / Practice of medicine. - 2014. - No. 2 (78).

5. Pathogenesis and modern clinical features of acquired syphilis. Modern problems of dermatology, immunology and medical cosmetology / TV Krasnoselskikh, EV Sokolovsky. — 2010.

6. Neurosyphilis. From diagnosis to treatment. Part I. The epidemiology, pathogenesis, clinic. / MV Rodikov, VI Prohorenkov / Journal of Dermatology and Venereology. - 2010. - No. 1.

7. Neurosyphilis. From diagnosis to treatment. Part II. Epidemiology, pathogenesis, clinical features. / MV Rodikov, VI Prohorenkov / Journal of Dermatology and Venereology. - 2010. - No. 2.

8. Neurosyphilis. Modern views on the diagnosis and treatment / AV Samtsov. —St. Petersburg: SpetsLit. — 2006.

9. The concentration of penicillin in the cerebrospinal fluid of patients with neurosyphilis receiving standard therapy / MV Rodikov, VI Prohorenkov / Russian Journal of Skin and Venereal Diseases. - 2008. - No. 2.

10. Neurosyphilis back / OV Kolokolov, AL Bakulev, AM Kolokolova, II Sholomov. / Medical Internet Conferences Bulletin, Part 2. - 2012. - No. 9.

Treatment of neurosyphilis

Penicillin antibiotics are used to treat syphilis. Treponema pallidum has not yet developed resistance to them, so the antibiotic is the main remedy prescribed by the doctor.

The antibiotic is administered intravenously or intramuscularly. Hormones and corticosteroids are used as adjuvant therapy.

Penicillins can cause allergic reactions in the form of swelling or rash. Possible side effects are nausea, vomiting, and diarrhea.

Important! Preparations based on bismuth and iodine were used before the discovery and widespread use of penicillin. Now they are practically not used: both drugs cause complications.

After completing a course of antibiotics, you need to take control tests for syphilis in the third and sixth months. Even if the result is negative, doctors recommend getting tested every year for three years after treatment.

The doctor also prescribes a course of penicillin for pregnant women. Lack of treatment during pregnancy can lead to premature birth or intrauterine fetal death.

Even if a child was born without signs of neurosyphilis, it is recommended to have him examined.

For analysis, the child’s blood and the mother’s blood are taken, as well as biomaterial from the placenta or umbilical cord and from the skin of the newborn. If an infection is detected, the child also receives penicillin intravenously or intramuscularly.

Treatment

The treatment course is developed based on the diagnostic results and the patient’s health condition. The main drug in this case is penicillin, which can be replaced by other antibiotic drugs. The patient is also recommended to take:

corticosteroids;
glycine;
vitamin complexes;
nootropics to stimulate brain activity;
medicines to strengthen blood vessels and stimulate blood circulation;
restorative drugs.

This combination enhances the therapeutic effect and helps to more quickly eliminate the symptoms of the disease.

Consequences, prognosis

Neurosyphilis can be treated with antibiotics, but many of its effects are irreversible.

In severe forms of the disease, signs of successful treatment are usually limited to only partial restoration of body functions.

The exception is mild forms of the disease: asymptomatic neurosyphilis and meningitis neurosyphilis, identified in the early stages. In this case, the cure is complete.

Meningovascular syphilis often causes acute cerebrovascular accident (stroke). The extent and timing of recovery after cerebrovascular accident are individual in each case.

Congenital syphilis is characterized by high mortality. According to WHO, it has become one of the leading causes of death in newborns in 2021. In total, 200,000 deaths were recorded.

Important! Neurosyphilis, like syphilis, does not contribute to the development of immunity from re-infection.

Diagnosis of neurosyphilis

Early neurosyphilis is diagnosed based on characteristic symptoms with positive tests for infection. To identify the disease, the Wasserman reaction, Treponema pallidum immobilization test (TPI), enzyme-linked immunosorbent assay (ELISA), and polymerase chain reaction (PCR) are widely used.

Late neurosyphilis is more difficult to determine, since in more than half of the cases the pathogen is absent in free form in the patient’s blood. Waserman and RIBT reactions can be negative. MRI and MSCT data record nonspecific changes in the brain. However, a qualified specialist is able to distinguish them from other similar symptoms. Positive tests for syphilis in the past can help in diagnosis.

Most forms of neurosyphilis are diagnosed by analyzing the cerebrospinal fluid. There are large numbers of leukocytes and lymphocytes in it and the absence of pronounced symptoms of meningitis is a characteristic symptom of neurosyphilis.

Prevention

Prevention of syphilis comes down to preventing infection. To reduce the risk of infection, you should:

Have protected sex (condoms do not provide a 100% guarantee against contracting sexually transmitted diseases). If you change partners frequently, undergo examinations at least once a year.
Be in a monogamous relationship with one trusted partner.
If you suspect an infection, immediately consult a doctor for examination.

Proper prevention and taking care of your own health will help prevent the disease or cope with its consequences.

Complications and prevention of neurosyphilis

If neurosyphilis is not detected in time, the patient faces serious health problems. Here are just a few diseases that develop in the absence of proper treatment:

paraparesis of the lower extremities;
hearing loss;
dementia;
meningeal and parenchymal gummas.

Since the disease develops on the basis of ordinary syphilis, the following preventive measures can be recommended to prevent it:

take everything necessary to avoid accidentally becoming infected with syphilis;
If the body is affected by Treponema pallidum, regularly visit a doctor and monitor the condition of the body.

In order to be sure that there are no syphilis pathogens in the body, it is best to regularly (once a year) take a blood test in specialized laboratories.