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Volume 331:1469-1473 December 1, 1994 Number 22 Next

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ABSTRACT

Background Infection with the human immunodeficiency virus (HIV) may affect both the natural course of syphilis and the response to treatment. We examined the response to treatment with high-dose penicillin G in HIV-infected patients with symptomatic neurosyphilis.

Methods Neurosyphilis was defined by reactivity in serum treponemal tests for syphilis, neurologic manifestations consistent with neurosyphilis, and a positive Venereal Disease Research Laboratory (VDRL) test on cerebrospinal fluid. We identified 11 HIV-infected patients with symptomatic neurosyphilis; 5 had been treated previously for early syphilis with penicillin G benzathine. Patients were treated with 18 million to 24 million units of penicillin G per day administered intravenously for 10 days. Cerebrospinal fluid was examined approximately 6 and 24 weeks after treatment, when the polymerase chain reaction and rabbit inoculation were used to detect Treponema pallidum.

Results In four of the seven patients studied 24 weeks after treatment, the serum titers on rapid plasma reagin (RPR) testing decreased by at least two doubling dilutions, and four patients had reductions in the cerebrospinal fluid titers on VDRL testing or reverted to nonreactive results. In two patients there was no normalization or improvement in serum titers on RPR testing or cerebrospinal fluid titers on VDRL testing, cell counts, or protein concentrations. One patient relapsed with meningovascular syphilis six months after therapy. T. pallidum was detected by the polymerase chain reaction in cerebrospinal fluid from 3 of 10 patients before treatment, but in none of the 10 post-treatment specimens.

Conclusions In patients with early syphilis who are also infected with HIV, therapy with penicillin G benzathine may fail, and neurosyphilis may develop. The regimen of high-dose penicillin recommended for neurosyphilis is not consistently effective in patients infected with HIV.

Source Information

From the Department of Medicine, Grady Memorial Hospital, Emory University School of Medicine, Atlanta (S.M.G., M.E.E., S.T.); the Sexually Transmitted Disease Laboratory, Center of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta (R.G., S.L.); and the Departments of Medicine (S.A.L., C.M.M.) and Pathology (J.K.), University of Washington, Seattle. Presented in part at the 33rd Interscience Conference on Antimicrobial Agents and Chemotherapy, New Orleans, October 17-20, 1993.

Address reprint requests to Dr. Gordon at the Cleveland Clinic Foundation, Department of Infectious Disease, 9500 Euclid Ave., S32, Cleveland, OH 44195.

Full Text of this Article

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Neurosyphilis in Patients with Human Immunodeficiency Virus Infection
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