Spirochaetal infection neurosyphilis

The initial event in neurosyphilis is meningitis. Of all untreated patients 25% develop an acute symptomatic syphilitic meningitis within 2 years of the primary infection.

ACUTE SYPHILITIC MENINGITIS: Three clinical forms are recognised:

The majority are asymptomatic and revealed only by lumbar puncture if performed.

1. Asymptomatic

2. Aseptic meningitis — fever rash in 50% of cases, malaise, neck stiffness.

3. Acute basal meningitis — hydrocephalus cranial nerve palsies (especially 7th, 8th) papilledema.

lymphocytosis, 100-1000 cells/mm3 elevated protein (0.5-2 g/1), glucose reduced, Rcagin tests positive.

latent period

Symptomatic meningitis responds to penicillin. Treatment during either the primary infection or the secondary stage prevents the late manifestations.

If untreated non-neurological late manifestations e.g. aortitis.

REMAINS LATENT

late neurological complications -». meningovascular syphilis - 5-10 years -». spinal syphilis 10-15 years optic atrophy 10-15 years general paresis 15-20 years tabes dorsalis 15-20 years

after the primary infection

Late neurological complications occur in only 7% of untreated cases.

These forms are exceptionally rare and the clinical syndromes mentioned above seldom occur in a 'pure' form. MENINGOVASCULAR SYPHILIS

'Early' late manifestation resulting in an obliterative endarteritis and periarteritis.

Presents as a 'stroke' in a young person - hemisphere, brain stem or spinal. Granulations around the base of the brain may produce cranial nerve palsies or even hydrocephalus.

CSF - lymphocytes 100/mm3, protein J, gammaglobulin T> positive serology. Penicillin arrests progression.

SPINAL SYPHILIS

Chronic meningitis with subpial damage to the spinal cord.

Presents as a progressive paraplegia, occasionally with radicular pain and wasting in upper limbs - ERB's PARAPLEGIA. CSF - as meningovascular syphilis. Penicillin arrests progression.

OCULAR MANIFESTATIONS

Meningitis around optic nerve with subpial necrosis may be the only manifestation of late syphilis. Presents as a constriction of the visual fields with a progressive pallor of the optic disc:

- if both eyes are affected, the vision is rarely saved.

- if only one eye is involved, treatment with penicillin will save the other. Neuroretinitis, uveitis and chorioretinitis occur, especially in HIV patients.

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