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Neurosyphilis – Causes, Symptoms and Treatment

Neurosyphilis is a serious infection of the nervous system caused by the bacterium Treponema pallidum. It develops as a complication of untreated syphilis and can damage the brain and spinal cord.

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Things worth knowing about "Neurosyphilis"

Neurosyphilis is a serious infection of the nervous system caused by the bacterium Treponema pallidum. It develops as a complication of untreated syphilis and can damage the brain and spinal cord.

What is Neurosyphilis?

Neurosyphilis refers to an infection of the central nervous system (CNS) caused by the bacterium Treponema pallidum, the pathogen responsible for syphilis. It occurs when a syphilis infection is left untreated or inadequately managed, allowing the bacteria to spread to the brain, meninges, or spinal cord. Although neurosyphilis can arise at any stage of syphilis, it is most commonly associated with late-stage or tertiary syphilis.

Causes and Risk Factors

Neurosyphilis is always caused by a prior infection with Treponema pallidum, a spiral-shaped (spirochete) bacterium. Transmission typically occurs through unprotected sexual contact or from mother to child during pregnancy (congenital syphilis).

Untreated or inadequately treated syphilis infection
Immune suppression, particularly in individuals with HIV infection
Limited access to medical care
Delayed initiation of antibiotic treatment after initial infection

Forms of Neurosyphilis

Neurosyphilis is classified into several distinct clinical forms:

Asymptomatic Neurosyphilis

In this form, there are no neurological symptoms, but abnormalities are detected in the cerebrospinal fluid (CSF). It is the most common form and is often identified incidentally during routine testing.

Meningeal Neurosyphilis

Inflammation of the meninges (meningitis) causes headache, neck stiffness, nausea, and sensitivity to light. This form typically presents in early syphilis.

Meningovascular Neurosyphilis

Inflammatory changes in cerebral blood vessels can lead to stroke, often affecting unusually young patients without typical cardiovascular risk factors.

Parenchymatous Neurosyphilis

Direct damage to brain or spinal cord tissue. This includes two major subtypes:

General paresis (also known as paralytic dementia): personality changes, dementia, psychosis, and seizures
Tabes dorsalis: degeneration of the posterior spinal cord columns, causing stabbing pain, gait disturbances, bladder dysfunction, and loss of reflexes

Ocular Syphilis

Eye involvement causing visual disturbances and, in severe cases, blindness.

Symptoms

The symptoms of neurosyphilis are highly variable and may resemble other neurological or psychiatric conditions, making diagnosis challenging:

Persistent headache and neck stiffness
Personality and behavioral changes
Memory impairment and cognitive decline
Stroke-like symptoms (sudden paralysis, speech difficulties)
Visual disturbances or hearing loss
Shooting or stabbing pains (characteristic of tabes dorsalis)
Gait disturbances and loss of coordination
Bladder and bowel dysfunction
Seizures

Diagnosis

Diagnosing neurosyphilis requires a combination of clinical assessment, serological blood tests, and cerebrospinal fluid (CSF) analysis obtained through lumbar puncture.

Blood serology: Detection of antibodies against Treponema pallidum (e.g., TPPA, FTA-ABS, VDRL tests)
CSF analysis: Elevated white blood cell count (pleocytosis), increased protein levels, and a positive VDRL test in the CSF are considered diagnostic
MRI of the brain: Identifies inflammatory changes, infarcts, or cortical atrophy
Neurological and neuropsychological examinations

Treatment

Neurosyphilis is treated with high-dose intravenous Penicillin G, which remains the first-line therapy. Prompt treatment can halt the progression of disease, but existing neurological damage may be irreversible.

High-dose intravenous Penicillin G: 18 to 24 million units per day for 10 to 14 days, administered in divided doses every 4 hours
For patients with penicillin allergy: Ceftriaxone intravenously as an alternative (under specialist guidance)
Follow-up lumbar punctures after treatment to confirm therapeutic success
Symptomatic management of neurological complications (e.g., physiotherapy, pain management)

Early diagnosis and treatment are critical, as neurological damage that has already occurred is often permanent.

Prevention

The best way to prevent neurosyphilis is to diagnose and treat syphilis early. Regular screening is especially important for high-risk groups, including people with multiple sexual partners and individuals living with HIV. Consistent use of condoms significantly reduces the risk of transmission.

References

World Health Organization (WHO): Guidelines for the Treatment of Treponema pallidum (Syphilis). Geneva, 2016.
Marra C.M.: Neurosyphilis. Continuum (Minneapolis, Minn.), 2015; 21(6): 1714-1728. PubMed PMID: 26633783.
Ropper A.H., Samuels M.A., Klein J.P.: Adams and Victor's Principles of Neurology. 11th edition. McGraw-Hill Education, 2019.

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