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Neurosyphilis present in 90% of HIV-positive patients with early syphilis in Warsaw
Michael Carter, 2016-02-09 07:50:00
majority of early syphilis cases in patients with HIV in Warsaw had neurological
involvement, Polish investigators report in HIV
Medicine. There was a significant relationship between HIV viral load and
the risk of neurosyphilis. Lumbar puncture was used to diagnose neurosyphils,
but because this procedure is unpopular with patients and involves risks, the
investigators recommend that all HIV-positive patients diagnosed with early
syphilis should receive antibiotic therapy that has good penetration into the central
nervous system (CNS).
Incidence of the
sexually transmitted infection syphilis is high among patients with HIV,
most especially among men who have sex with men (MSM), and incidence has risen since 2000.
European guidelines for
the management of syphilis suggest that patients with HIV may have an increased
risk of early neurosyphilis and that this may be asymptomatic.
of especial concern for individuals with HIV as it could exacerbate the
cognitive decline that has been associated with HIV infection in some research.
A recent report found a relationship between neurosyphilis and HIV viral load
in cerebrospinal fluid (CSF), whereas another identified a link between viral
load and subsequent cognitive decline.
Guidelines recommend that patients with high
syphilis titres (1/32) should be investigated for neurosyphilis.
research findings and guidelines in mind, Polish investigators designed a
prospective study to assess the frequency of neurosyphilis among HIV-positive
patients diagnosed with early syphilis and to assess the association between
neurosyphilis and HIV-related factors, such as CD4 cell count, HIV viral load
and treatment with antiretroviral therapy (treatment vs. no treatment).
place between 2008 and 2012 at an outpatient clinic in Warsaw.
During this time,
191 HIV-positive individuals were diagnosed with early syphilis. Of these, 93%
has high syphilis titres. Neurological examination using lumbar puncture was
offered to all patients but only 59 (33%) consented. A further 13 patients with
low titres and symptoms of neurosyphilis were also recruited to the study.
All 72 patients
were male, their median age was 33 years and 89% were MSM. Just over half the
patients (51%) were taking HIV therapy at the time syphilis was diagnosed.
Median CD4 cell count and viral load were 521 cells/mm3 and 24,500
confirmed neurosyphilis in 90% of patients.
No relationship was
found between neurosyphilis risk and CD4 cell count. However, among patients
with neurological involvement, there was a significant relationship between
pleocytosis – increased white blood count – and serum viral load above 1000
copies/ml (p = 0.045). Neurosyphilis was also significantly associated the
absence of HIV therapy (p = 0.0328).
confirmed neurosyphilis were treated with antibiotic therapy with good CNS
“A very high
proportion of confirmed neurosyphilis seen in patients with relatively low
serum...titres may suggest that CNS involvement should be suspected regardless
of…titre,” conclude the authors. “Taking into account updated indications and
risks associated with lumbar puncture, it may be preferable to use treatments
with good CNS penetration in all HIV-positive patients diagnosed with syphilis.”