German guidelines on the diagnosis and treatment of neurosyphilis

Abstract

Introduction: In view of the importance of neurosyphilis and the difficulties encountered in diagnosing it, the S1 guideline "Neurosyphilis" has been published by the German Society for Neurology (DGN) in accordance with the stipulations of the Association of the Scientific Medical Societies in Germany (AWMF). The present article is an abridged translation of that German guideline.

Main recommendations: (a) Neurosyphilis can manifest as early neurosyphilis (meningitis, meningovascular neurosyphilis or syphilitic gummas) or late neurosyphilis (tabes dorsalis, general paresis). (b) The following diagnostic criteria help to establish the presence of probable neurosyphilis (always point iv, accompanied by any two of points i to iii): (i) subacute or chronic neuro-psychiatric symptoms; (ii) increased cerebrospinal fluid (CSF) cell count or signs of blood-CSF barrier disruption; (iii) positive effect of anti-neurosyphilis antibiotic therapy on clinical course and CSF findings; (iv) positive TPHA/TPPA or FTA test in serum. (c) The diagnosis of neurosyphilis is confirmed by the subsequent detection of intrathecal production of antibodies against Treponema pallidum. (d) In neurosyphilis, treatment with intravenous penicillin or ceftriaxone for 14 days is recommended. (e) The following parameters can be used to assess a therapeutic effect: clinical findings, serum VDRL, and CSF cell count.

Conclusion: The German guideline on the diagnosis and treatment of neurosyphilis is a practical tool to support clinicians in diagnosing and treating patients with neurosyphilis. This article is an abridged translation of this guideline (Klein MW, J.; Angstwurm, K.; Esser, S.; Hahn, K.; Matschke, M.; Scheithauer, S.; Schoefer, H.; Sturzenegger, M.; Wildemann, B. Neurosyphilis, S1-Leitlinie. Deutsche Gesellschaft für Neurologie, Leitlinien für Diagnostik und Thearpie in der Neurologie 2020).

Fig. 1

Work-up in patients with suspected neurosyphilis. (1) Confirmation of a positive test using a confirmatory test is recommended (see text). (2) In patients with HIV, a discrete disruption of the blood–brain barrier may occasionally be seen. Also, a slightly increased cell count can be the result of the HIV infection itself. (3) If suspicion of neurosyphilis persists, treatment should be considered. (4) The VDRL test is recommended to create a basis for future follow up investigations. For details see text. TPPA = Treponema pallidum agglutination test; TPHA = T. pallidum hemagglutination test; TPLA = T. pallidum latex agglutination test, ITpA = intrathecal T. pallidum antibodies; AI = CSF/serum antibody index; VDRL = Venereal Disease Research Laboratory