11/6/18 Goldstein Morning Report

Today in Goldstein Morning Report we presented a case of a 45 year old M with no PMH who was brought in for acute encephalopathy and witnessed seizures. On exam the patient was found to have multiple cranial neuropathies and labs were significant for a positive RPR (1:32). The patient had a lumbar puncture performed which showed 4 WBCs (lymphocytes), glucose 67 and protein 54 and CSF VDRL was found to be reactive.

Neurosyphilis
– Clinical signs of neurosyphilis include meningitis, stroke, acute/chronic encephalopathy, loss of vibration sense, cranial nerve dysfunction and auditory/ophthalmic abnormalities.
– The diagnosis of neurosyphilis is based on clinical suspicion, serologic tests and CSF analysis.
– Remember that CSF abnormalities can occur in early syphilis, and may not be clinically significant in the absence of neurologic signs/symptoms.
– In early neurosyphilis, serum nontreponemal (VDRL, RPR) and treponemal tests (FTA-ABS) are generally reactive, however in late neurosyphilis VDRL and RPR may be nonreactive and FTA-ABS should always be performed.
– CSF-VDRL is highly specific and a reactive test is diagnostic for neurosyphilis, however the sensitivity is much lower.

Diagnosis of neurosyphilis in an HIV- patient
– In patients with a nonreactive CSF-VDRL, treatment depends on further CSF findings.
—> If the CSF WBC>5, treat for neurosyphilis.
—> If the CSF WBC<5 but the CSF protein >45, treat for neurosyphilis.

Diagnosis of neurosyphilis in an HIV+ patient
– Similarly to HIV- patients, further CSF studies must be used to diagnosed neurosyphilis when the CSF-VDRL is negative. However HIV can cause a mild CSF pleocytosis and protein level (especially in those with CD4>200, detectable HIV RNA and not on ART).
–> If the CSF WBC >20, treat for neurosyphilis.
–> If the CSF WBC is 6-20, treat for neurosyphilis if the CD4<200, HIV RNA<50 and on ART
–> If the CSF WBC is ≤5, do not treat.

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