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  51th ICAAC
Chicago, IL
September 17-20, 2011
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Risk of Neurosyphilis With Early Syphilis in German Group With HIV
  51st Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), September 17-20, 2011, Chicago

Mark Mascolini

Almost 20% of HIV-positive people with early syphilis had neurosyphilis, according to results of an 80-person prospective study at the University Hospital Essen in Germany [1]. All but one study participant were men and almost all were gay men.

In recent years syphilis has emerged more frequently in gay men with and without HIV [2,3]. Because people coinfected with HIV and syphilis run a higher risk of progression to neurosyphilis, some guidelines recommend spinal puncture for people with newly diagnosed syphilis. Researchers at the University Hospital Essen planned this prospective study of people with newly diagnosed early primary or secondary syphilis to assess prevalence and signs of neurosyphilis in cerebrospinal fluid (CSF).

The investigators recruited 80 people with HIV and syphilis who agreed to spinal puncture to sample CSF for testing, including TPHA (Treponema pallidum hemagglutination assay), ITpA index (intrathecally produced T pallidum antibody index), VDRL (Venereal Disease Research Laboratory test for syphilis), and FTA-ABS-19s-IgM. The researchers also performed neurologic exams on all study participants.

All but 1 of 80 study participants were men, and 74 were men who have sex with men. Their age averaged 38.3 years (range 18 to 64), their CD4 count 478 (range 81 to 1164), and their viral load 293 copies (range below 37 to more than 500,000 copies). Twenty-four of 53 antiretroviral-treated people (45%) had detectable viral loads in plasma.

Time between HIV diagnosis and syphilis diagnosis averaged 57 months (range 0 to 272). Ten people (12.5%) had stage 1 syphilis, 63 (78.7%) had stage 2, and 7 (8.8%) had stage 1-2.

Fifty-four people (67.5%) had clinical symptoms of early syphilis, including 55% with exanthem (rash) and 14% with ulcus durum (an indolent firm ulcer). Fourteen people (17.5%) had neurosyphilis, indicated by a positive ITpA index. Only 4 of these 14 (5% of all participants) had neurologic symptoms, including cranial nerve pareses, ocular scotoma, and meningitis.

Of the 14 people with neurosyphilis, 4 had CDC stage A HIV infection, 8 had CDC stage B, and 2 had CDC stage C. Results so far have also failed to find correlations between early neurosyphilis incidence and CD4 count or viral load in plasma.

All IgM-Western blots were positive for syphilis. CSF TPHA averaged 1:64 (range 1:2 to 1:16,000), and 15 people (19%) had a positive FTA-ABS-19s-IgM in CSF. A decreased blood-CSF barrier explained neurosyphilis in 4 people (5%).

Clinicians treated early neurosyphilis with intravenous penicillin G for 21 days. People without early neurosyphilis received intramuscular penicillin for at least 14 days.

The researchers believe results of this ongoing study demonstrate that HIV infection may increase the risk of neurosyphilis.


1. Esser S, Riehemann A, Jablonka R, Von Heinegg E, Schadendorf D. Diagnosis of early neurosyphilis (NSI) by cerebrospinal fluid in HIV-infected patients with primary (LI) or secondary (LII) syphilis-infection. 51st Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC). September 17-20, 2011. Chicago. Abstract H1-1396.

2. Marcus U, Kollan C, Bremer V, Hamouda O. Relation between the HIV and the re-emerging syphilis epidemic among MSM in Germany: an analysis based on anonymous surveillance data. Sex Transm Infect. 2005;81:456-457.

3. Torrone EA, Bertolli JM, Li J, Sweeney PA, Jeffries WL 4th, Ham DC, Peterman TA. Increased HIV and primary and secondary syphilis diagnoses among young men--United States, 2004-2008. J Acquir Immune Defic Syndr. 2011 Aug 4. Epub ahead of print.