Another spirochaete, Treponema pallidum, may also cause acute meningitis. Although rare, such cases are occurring more frequently in association with HIV infection.130,131 It occurs within two years of primary infection and presents acutely with headache, vomiting, pyrexia, and neck stiffness. Cranial nerve palsies and epileptic seizures are not infrequent. CT scan appearances are of non-specific meningeal enhancement and the CSF contains a predominantly mononuclear pleocytosis, raised protein, and normal sugar. The diagnosis is confirmed by finding a positive CSF VDRL test.

Acute syphilitic meningitis is managed with the parenteral administration of large doses of procaine penicillin for 17-21 days,132 with corticosteroids given for the first 24 hours to diminish the possibility of inducing a Jarisch-Herxheimer reaction. It is necessary to follow up cases closely to ensure that serological changes and CSF revert to normal and to treat any reinfection rapidly.

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