Prevalence of Self-reported Neurologic and Ocular Symptoms in Early Syphilis Cases

Abstract

Background: Neurosyphilis, a complication of syphilis, can occur at any stage of infection. Measuring the prevalence of neurosyphilis is challenging, and there are limited data on the prevalence of neurologic or ocular symptoms among patients with syphilis. We sought to describe the prevalence of neurologic and/or ocular symptoms among early syphilis (ES) cases and the clinical management of symptomatic cases enrolled in the STD Surveillance Network (SSuN) Neuro/Ocular Syphilis Surveillance project.

Methods: Persons diagnosed with ES were selected for interviews based on current health department protocols in 5 participating SSuN jurisdictions from November 2016 through October 2017. All interviewed ES cases were screened for self-reported neurologic and/or ocular symptoms. Additional clinical information on diagnostic testing and treatment for cases concerning for neurosyphilis/ocular syphilis was obtained from providers.

Results: Among 9123 patients with ES who were interviewed, 151 (1.7%; 95% confidence interval [CI], 1.4%-1.9%) reported ≥ 1 neurologic or ocular symptom. Of the 53 (35%) who underwent lumbar puncture, 22 (42%) had documented abnormal cerebrospinal fluid, of which 21 (95%) were treated for neurosyphilis/ocular syphilis. Among the remaining 98 symptomatic patients with no documented lumbar puncture (65%), 12 (12%) were treated for and/or clinically diagnosed with neurosyphilis/ocular syphilis.

Conclusions: We observed a low prevalence of self-reported neurologic and/or ocular symptoms in interviewed ES cases. Approximately one-third of ES cases who self-reported symptoms underwent further recommended diagnostic evaluation. Understanding barriers to appropriate clinical evaluation is important to ensuring appropriate management of patients with possible neurologic and/or ocular manifestations of syphilis.

Keywords: complicated syphilis; early syphilis; neurosyphilis; ocular syphilis; prevalence.

Figure 1.

Clinical management of early syphilis cases self-reporting ≥ 1 neurologic or ocular symptom, STD Surveillance Network (SSuN), November 2016–October 2017 (n = 151). The bar graph and corresponding table demonstrate the diagnostic and clinical management outcomes among interviewed symptomatic early syphilis cases within the 5 SSuN jurisdictions participating in the enhanced Neuro/Ocular Syphilis Surveillance Project and include the following: the proportion that had lumbar puncture (LP) performed, the proportion that had documentation of abnormal cerebrospinal fluid (CSF) results (among those who underwent an LP), the proportion that were treated for neurosyphilis (NS) or ocular syphilis (OS) with a regimen recommended by the Centers for Disease Control and Prevention (among those with abnormal CSF), and the proportion that were given a clinical diagnosis of NS and/or OS (among those treated). Abnormal CSF consistent with NS/OS was defined as the presence of 1 of the following criteria: (1) reactive Venereal Disease Research Laboratory test; (2) leukocyte count > 5 cells/μL in human immunodeficiency virus (HIV)–seronegative persons or > 20 cells/μL in HIV-seropositive persons; or (3) protein > 45 mg/dL and reactive CSF fluorescent treponemal antibody absorption test.