Current CDC guidelines recommend lumbar puncture in syphilis patients with signs or symptoms of neurologic disease.
As part of a study of cerebrospinal fluid (CSF) abnormalities in syphilis, 410 HIV-infected individuals with untreated syphilis underwent lumbar puncture and a structured history that assessed the presence of new: headache, stiff neck, photophobia, vision loss, ocular inflammation, hearing loss, sensory loss, or gait incoordination. Severity was graded from 0 (absent) to 3 (severe). A symptom was considered present if it was graded as ≥2 in severity. Neurosyphilis was defined as a reactive CSF-VDRL. Association between categorical variables was assessed by chi-square or fisher exact test and by logistic regression. P-values <0.05 were considered significant. Diagnostic specificity and sensitivity were calculated using standard formulae.
Participants were mostly white (73.4%) men (99.5%) with early syphilis (70.2%). Median RPR titer was 1:64 (IQR 1:16-1:256). Symptom frequency was: headache (18.5%), stiff neck (3.9%), photophobia (4.0%), vision loss (13.5%), ocular inflammation (4.4%), hearing loss (5.9%), sensory loss (0.7%) and gait incoordination (0.2%). CSF-VDRL was reactive in 69 (16.8%). Headache, stiff neck, photophobia and gait incoordination were not more common in those with a reactive CSF-VDRL. However, compared to those without each individual symptom, the odds of a reactive CSF-VDRL were significantly higher in those with vision loss (6.77 [95% CI 3.60-12.70], P<0.001) or hearing loss (3.28 [1.36-7.92], P=0.008); and bordered on significantly higher for those with ocular inflammation (2.58 [0.93-7.13], P=0.07) and sensory loss (10.03 [0.90-112.19], P=0.06). Taking into account serum RPR titer and antiretroviral use, the odds of a reactive CSF-VDRL remained significantly higher in those with vision or hearing loss. While the specificity of these 4 symptoms for neurosyphilis was high, the sensitivity was low (Table).
In HIV-infected individuals with syphilis, new headache, stiff neck, photophobia and gait incoordination were not more common in those with neurosyphilis, while vision or hearing loss, ocular inflammation and sensory loss were. While the latter 4 symptoms had high specificity, they were very insensitive. Lack of neurologic symptoms in HIV-infected patients with syphilis should not reassure clinicians that their patients do not have neurosyphilis.