Neurosyphilis

Can be early (secondary) or late (tertiary) in the course of disease.

The management and investigation of neurosyphilis should be made with a Consultant in Genitourinary Medicine/ Infectious Diseases and a consultant neurologist.

Meningovascular: may be associated with early or late syphilis.

Parenchymatous: General paresis and/or tabes dorsalis.

Patients should have a thorough neurological examination to rule out focal neurology or papilloedema that may indicate raised intracranial pressure and relevant radiological imaging of the head requested if these signs are present prior to lumbar puncture. Neurological imaging must be considered if there are neurological signs or symptoms.

LUMBAR PUNCTURE
In order for CSF tests to be interpreted correctly the CSF should not be macroscopically contaminated with blood.
CSF tests should include:

1. Cell count
2. Total protein
3. Oligoclonal bands
4. A treponemal test
5. A non-treponemal test
6. TPHA index. This requires CSF albumin and CSF IgG (but not widely available)

If the CSF is abnormal then CSF examination should be repeated between 6 weeks and 6 months after treatment.

Prednisolone 40-60mg orally once daily for three days, starting anti-treponemal treatment 24 hours after commencing prednisolone.
For ENT or optic atrophy complicating syphilis infection, a longer prednisolone course may be considered. Refer for ENT/Ophthalmology Consultant opinion.

Procaine penicillin 2.4MU intramuscular once daily for 14 days
 (NB unlicensed medication, named patient form may be needed)
PLUS
Probenecid 500mg 4 times daily orally for 14 days
Or
Benzylpenicillin 10.8 - 14.4g daily given as 1.8g-2.4g intravenously every 4-6 hours for 14 days 
PENICILLIN ALLERGIC (or declines parenteral):
Doxycycline 200mg twice daily orally for 28 days

In tertiary neurosyphilis partner notification and follow-up as for late latent syphilis.