Neurosyphilis: Symptoms and Treatment

Neurosyphilis is a specific infection of the nervous system, consisting in the penetration of the causative agent of syphilis into the nerve tissue. Clinical manifestations can be very diverse, they depend on the stage of the disease. Neurosyphilis can occur in any period of syphilitic infection, but is more common in the secondary and tertiary periods. Diagnosis is based on clinical manifestations, given serological research methods. The treatment is based on antibiotics of the penicillin series. If the disease is not treated, it can go on for many years. Sometimes a complete cure is impossible. In the modern world, neurosyphilis is much less common than in the last century. This is due to improved diagnostics and mass surveys of the population, earlier treatment, as well as a change in tropism (the ability to selectively affect) the pathogen to the nervous tissue.

In this article, we describe the main symptoms of this illness and treatment, which is usually prescribed by doctors.

Causes. Is neurosyphilis contagious? How can I get infected?

Neurosyphilis always occurs against the background of such a venereal disease as syphilis. The causative agent is pale treponema - Treponema pallidum. Infectiousness depends on the stage of syphilis at the time of contact. Isolate primary, secondary and tertiary syphilis (neurosyphilis can accompany all three stages). Primary syphilis in the presence of a solid chancre and secondary in the presence of specific eruptions are always contagious. This coincides with the so-called early syphilis: up to 5 years from the time of infection. Particularly high risk is the first 2 years. Tertiary syphilis is practically not contagious, since the pathogen is deep in the tissues, however, when the gum decays or ulceration, the risk of infection increases.

Contact with a patient with neurosyphilis is dangerous not by neurosyphilis itself, but by the concomitant venereal process in the body. This means that the pale treponema does not come from the nervous system itself, but with neurosyphilis the causative agent can be contained in semen, and in vaginal discharge, and in blood, and even in saliva, whence it penetrates to a healthy man.

Ways of infection:

• Sexual - the main way of transmission of infection. Penetration of the pathogen occurs through microdamages in the skin and mucous membranes. And the type of sexual contact does not matter: you can get infected with both anal and oral sex (sometimes even the risk of infection is higher). Using a condom reduces the risk of infection, but does not reduce it to zero. Even a single sexual contact with a patient carries a 50% risk of infection;
• blood transfusion (transfusion of contaminated blood, using a single syringe for injections from drug addicts or one tank with narcotic substances, with dental manipulations and etc .;
• household - a very rare, but still possible way. To infect syphilis by household means, very close household contact with the patient is necessary. It is possible to transfer through wet towels, common utensils, using a razor or toothbrush with a sick person. A kiss can also cause infection;
• transplacental - transfer from mother to fetus. The risk is very high;
• professional - this applies to medical personnel who are in contact with body fluids: blood, sperm, saliva. Infection is possible with obstetrics, autopsies, surgical interventions.

Thus, we can summarize: contact with a patient with neurosyphilis always carries a certain risk. If the neurosyphilis proceeds along with the primary or secondary form of syphilis, the risk of infection is very high. If neurosyphilis is a manifestation of the tertiary form of syphilis, then the risk of infection is minimal.

Symptoms

Allocate an early, late and congenital neurosyphilis.
Early neurosyphilis develops in the first 5 years of the disease, more often in the first 2 years. It is also called mesenchymal, since the vessels and membranes are primarily affected, and the nervous tissue suffers again.
Late neurosyphilis occurs after 5 years of having a syphilitic infection in the body. This neurosyphilis is parenchymal, the nerve cells and fibers are directly affected.
Congenital neurosyphilis occurs in the first year of life as a result of transplacental transmission of pale treponema from mother to child.

Early neurosyphilis

Classification of early neurosyphilis:

• asymptomatic (latent) neurosyphilis;
• syphilitic meningitis;
• meningovascular syphilis (cerebral and spinal).

Asymptomatic neurosyphilis can be called an accidental finding. This condition, when there are no clinical manifestations, and the diagnosis is established only on the basis of specific changes in the cerebrospinal fluid (cerebrospinal fluid): an increase in the number of lymphocytes, or lymphocytic pleocytosis, an increase in protein content and positive serological reactions. It is characteristic for primary and secondary syphilis, often develops in the first 12-18 months of infection. The outcome of this form of the disease can be clinically manifested neurosyphilis (i.e. deterioration conditions and the appearance of symptoms of damage to the nervous system) or spontaneous sanation of the cerebrospinal fluid (which happens less often).

Syphilitic meningitis is more common among young people with syphilis. Symptoms of this condition are headache, nausea and vomiting, which do not bring relief, positive meningeal signs (rigidity of the occipital muscles, symptoms of Brudzinsky, Kernig). Body temperature usually does not increase. The intracranial pressure often increases, even a special clinical form is distinguished: acute syphilitic hydrocephalus (edema). Perhaps the defeat of the cranial nerves: visual, oculomotor, auditory, trigeminal, facial. This is manifested by visual impairment (areas of visual fields fall out), strabismus appears, neurosensory deafness develops. In the cerebrospinal fluid, lymphocytic pleocytosis and an increase in protein content are observed.

Meningovascular syphilis is a manifestation of cerebral circulation disorders associated with the damage to the brain vessels in the form of syphilitic vasculitis. Clinically, it can be a microfocal lesion of the brain tissue, with a variety of symptoms: increased reflexes, a violation of sensitivity, symptoms of oral automatism, a decrease attention and memory. And it can also lead to a vascular catastrophe in the form of a typical ischemic or hemorrhagic stroke.

Usually, a few weeks before the onset of the stroke itself, the patients develop headaches, dizziness, sleep deterioration, behavior changes, epileptic seizures are possible. Then, paresis develops (a decrease in muscle strength in the limbs), a speech disorder.

If the circulatory disturbance occurs in the vessels feeding the spinal cord, this leads to a spinal stroke. The patient develops weakness in the lower limbs, which gradually grows. Dysfunctions of the pelvic organs in the form of impaired urination (incontinence) and defecation. Sensitivity below the level of defeat is lost. Developed and trophic disorders: dryness and peeling of the skin, cold extremities, decubitus.

All these neurological signs are combined with positive serological reactions to syphilis in the blood and CSF.

Late neurosyphilis

Among the forms of late neurosyphilis are:

• meningovascular neurosyphilis (same species as in early neurosyphilis);
• progressive paralysis;
• spinal dorsalis (tabes dorsalis);
• atrophy of the optic nerve;
• gummy neurosyphilis.

Progressive paralysis- this, in fact, chronic meningoencephalitis. It develops in 5-15 years from infection with syphilis. The reason is the penetration of pale treponem into the cells of the brain with subsequent destruction. First, nonspecific changes in higher nervous activity are detected: attention and memory deteriorate, irritability appears.

Personality changes progress, and mental disorders join: inadequate behavior, depression, delusions and hallucinations. Violation of thinking can reach the degree of dementia (acquired dementia). Among the neurological symptoms, it should be noted the development of tremor of the tongue, fingers, change of handwriting, dysarthria. A characteristic phenomenon is Argyle Robertson's syndrome: narrow uneven pupils that do not react to light (do not narrow). However, the pupils' reaction to accommodation and convergence is preserved. In the stage of dementia, paralysis and disorders of the pelvic organs function, generalized epileptic seizures. The disease is steadily progressing and is lethal in a few months or years.

Dorsal articulation: this form of neurosyphilis develops when the posterior roots and posterior cords of the spinal cord are affected. Most often, lumbar and sacral roots are involved in the process, more rarely cervical spine. Clinically, there is a violation of deep sensitivity (joint-muscle feeling, vibration sensitivity), loss of Achilles and knee reflexes, instability in Romberg's posture, closing eyes. "Lamp-shaped" paroxysmal pain in the legs lasts from several minutes to several hours. Because of a violation of deep sensitivity, the gait changes: it becomes "stamping the legs in the knee joints are re-bent. Pupils change their form, reveal the syndrome of Argyl Robertson. Patients have so-called tabetic crises: attacks of pain in the abdomen, perineum, larynx. Possible development of atrophy of the optic nerve. Another characteristic feature of dorsal arteries is trophic joint disorders (Sharko joint or neurogenic arthropathy), trophic ulcers of the lower extremities. Possible violations of urination and impotence. In liquor there can be no change. Before the appearance of antibiotics, spin dry was the most common disease of the nervous system, today it is a rarity.

If the patient simultaneously exhibits manifestations of both progressive paralysis and dorsal dryness, then this is called "taboralysis".

Atrophy of the optic nerve can be an independent form of late neurosyphilis. At first, the process is one-sided, but it gradually captures another eye. Reduced visual acuity, patients complain of "fog" before their eyes, when viewed, the discs of the optic nerves look gray. In the absence of treatment, the patient is threatened with complete blindness.

Gummous neurosyphilisIs a manifestation of tertiary syphilis. Gunma are dense, rounded formations formed as a result of a specific inflammatory process caused by pale treponema. In the brain, gums are more often located on the base of the brain, squeezing the cranial nerves and leading to an increase in intracranial pressure. In the spinal cord, they are more often found in the cervical or mid-thoracic area, which is clinically manifested by paralysis of the lower extremities and pelvic disorders.

Congenital neurosyphilis

Currently, this form of the disease is extremely rare, since all pregnant women are examined for syphilis several times during pregnancy. If intrauterine infection does occur, the clinical manifestations are the same as in adults, except for dorsal dryness. There are distinctive signs that allow one to suspect congenital neurosyphilis: it is hydrocephalus and a triad Getschinsohn: keratitis, deafness, deformation of the upper central incisors (barrel-shaped teeth with a semilunar recess in edge). There can only be individual signs from the triad. Treatment leads to the cessation of the infectious process, but the neurologic symptoms of congenital neurosyphilis persist for life.

Diagnostics

Diagnosis of neurosyphilis complex: requires a thorough neurologic examination and serological blood tests, general and serological examination of cerebrospinal fluid (carrying out lumbar puncture). Since the clinical picture of the neurosyphilis is very diverse, and recently erased, atypical forms of the disease are increasingly encountered, then only simultaneous pathological changes in blood tests, cerebrospinal fluid with appropriate neurological symptoms allow to establish diagnosis.
In the serodiagnosis of neurosyphilis two groups of tests are used: treponemal and non-treponemal. The latter are used as screening methods. To the non-treponemal is the Wasserman reaction (complement binding reaction with lipid antigens), microprecipitation with cardiolipin antigen.

These studies can be carried out with blood serum, and with cerebrospinal fluid. However, non-treponemal tests do not have a high degree of accuracy and can give false positive and false negative results. Therefore, in addition to them, specific treponemal tests are used to establish the diagnosis. These include RIF (the reaction of immunofluorescence), RIBT (reaction of immobilization of pale treponemes or RIT). It is necessary to know that the RIF remains positive all life after the transferred syphilis.

Thus, in order to establish the diagnosis of neurosyphilis, the patient should have 3 criteria: positive non-treponemal and / or treponemal tests in the study serum, changes in cerebrospinal fluid (lymphocytic pleocytosis, increase in protein content, positive serological tests for syphilis), neurological symptoms.

As additional research methods, CT or MRI can be used (especially for detecting gum or differential diagnostics with other diseases of the nervous system), consultation of the oculist for the purpose of examination of the fundus.

Treatment

For the treatment of neurosyphilis, an antibiotic penicillin is used. The treatment regimen and dosages depend on the clinical form and the stage of the process.

The most effective is the intravenous injection of the sodium salt of benzylpenicillin by , 0, 00 to , 0, 00 units6 times a day for 10-14 days. If intravenous administration is not possible for some reason, then use intramuscularly novocaine salt benzylpenicillin 2400000 units per day in combination with oral administration of probenecid 500 mg orally 4 times a day in for 10-14 days. Probenecid is used to maintain a high concentration of penicillin in the blood with intramuscular injection. This is necessary to ensure the penetration of the antibiotic into the nerve tissue.
After such two-week courses, the treatment is continued as follows: once a week intramuscularly injected benzathine-benzylpenicillin 2400000 units for three weeks.

At the beginning of the treatment, the patient may experience a temporary deterioration in the state of health in the form of headache, fever, chills, tachycardia, muscle pain, and lowering blood pressure. These symptoms go away within a day after the appointment of corticosteroids or non-steroidal anti-inflammatory drugs.
If there is an intolerance to antibiotics of the penicillin series, then ceftriaxone, chloramphenicol, is used to treat neurosyphilis.

The effectiveness of the treatment of neurosyphilis is assessed by the regression of neurologic symptoms and improvement in the indices of the cerebrospinal fluid. The lumbar puncture and the investigation of the cerebrospinal fluid are carried out immediately after the penicillin therapy, then every 6 months for 2 years. If there is no normalization of the cerebrospinal fluid, then a second course of antibiotic therapy is recommended.
The patient is considered cured, if in 2 years the parameters of the cerebrospinal fluid do not have deviations.
Along with antibiotics in the complex, vitamins, iron preparations, vascular (cavinton, nicotinic acid, trental), nootropics (piracetam, glycine) are used as restorative agents.

Effects

Early forms of neurosyphilis usually respond well to treatment, complete recovery is possible. Sometimes after meningovascular syphilis, there may be residual phenomena in the form of paresis, dysarthria, dysfunction of the pelvic organs, which can cause disability.

Late forms of neurosyphilis poorly respond to treatment. Neurological symptoms often remain with the patient for life and also cause disability.

Progressive paralysis earlier led to a fatal outcome. Today, the use of penicillin can mitigate the symptoms and stop the progress of the disease. The suckling of the spinal cord is practically incurable, neurological symptoms do not have the reverse development.

Congenital syphilis always causes neurological defects that impede the normal development of the child's body, and deafness and hydrocephalus lead to disability.

XIII Moscow Assembly "Health of the Capital presentation on "Neurosyphilis as an interdisciplinary problem".
Prepared by e. m., Prof. N. AND. Syuch, Cand. M. FROM. A. Polevshchikova