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See Serologic Tests for Syphilis, Primary Syphilis, above 1 Indications for a lumbar puncture It is most important to prevent neurosyphilis by prompt diagnosis, adequate treatment, and follow-up of early syphilis Indications for lumbar puncture vary depending on the stage of the disease and the patient s immune status In early syphilis (primary and secondary syphilis and early latent syphilis of less than 1 year duration), invasion of the central nervous system by T pallidum with cerebrospinal fluid abnormalities occurs commonly, but neurosyphilis rarely develops in patients who have received the standard therapy outlined above Thus, unless clinical symptoms and signs of neurosyphilis or ophthalmologic involvement (uveitis, neuroretinitis, optic neuritis, iritis) are present, a lumbar puncture in early syphilis is not recommended as part of the routine evaluation In latent syphilis, the decision to perform a lumbar puncture should be individualized Routine lumbar puncture for all patients is not indicated since the yield is low and findings rarely influence therapeutic decisions Cerebrospinal fluid evaluation is recommended, however, in the later stages of syphilis if neurologic or ophthalmologic symptoms and signs are present, if therapy other than with penicillin is to be given, if the patient is HIV positive (see next section), if there is evidence of treatment failure (see earlier discussion), or if there is evidence of active tertiary syphilis (eg, aortitis, iritis, optic atrophy, the presence of a gumma) Some experts also routinely recommend lumbar puncture for all persons with latent syphilis if the serum nontreponemal antibody titer is 1:32 2 Spinal fluid examination Cerebrospinal fluid findings in neurosyphilis are variable In classic cases, there is an elevation of total protein, lymphocytic pleocytosis, and a positive cerebrospinal fluid reagin test (VDRL) However, cerebrospinal fluid may be completely normal in neurosyphilis, and the VDRL may be negative In one study, 25% of patients with primary or secondary syphilis in whom T pallidum was isolated from cerebrospinal fluid had a normal cerebrospinal fluid examination In later stages of syphilis, normal cerebrospinal fluid analysis in the presence of infection can occur, but it is unusual Because false-positive reagin tests rarely occur in the cerebrospinal fluid, a positive test confirms the presence of neurosyphilis Because the cerebrospinal fluid VDRL may be negative in 30 70% of cases of neurosyphilis, a negative test does not exclude neurosyphilis The use of cerebrospinal fluid FTA-ABS in the diagnosis of neurosyphilis is not recommended It is a highly sensitive test but lacks specificity, and a high serum titer of FTA-ABS may result in a positive cerebrospinal fluid titer in the absence of neurosyphilis.



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8 Nervous system (neurosyphilis) Neurosyphilis (15 20% of late syphilitic lesions; often present with cardiovascular syphilis) can occur at any stage of disease and is also a progressive, disabling, and life-threatening complication Asymptomatic and meningovascular syphilis occur earlier (months to years after infection, sometimes coexisting with primary and secondary syphilis) than tabes dorsalis and general paresis (2 50 years after infection)

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