Is Neurosyphilis On the Rise?

Health officials weigh cases nationwide, especially among the HIV-positive

As syphilis cases among gay and bisexual men grow across the nation, health officials in five cities and Puerto Rico are investigating whether neurosyphilis, a type of syphilis infection that affects the brain and spinal cord, is becoming more common.

“We are trying to work out the parameters for investigating neurosyphilis cases to make sure we aren’t missing anything,” said Dr. Susan Blank, assistant commissioner of the city health department’s Bureau of Sexually Transmitted Disease Control.

Puerto Rico and the five cities—New York, Los Angeles, Chicago, San Diego, and Washington, D.C.—have all seen recent increases in syphilis among gay and bisexual men with many of those men also infected with HIV.

The HIV co-infection is a concern because it may make the standard syphilis treatment less effective. A patient could leave his doctor’s office thinking his syphilis had been cured only to later develop neurosyphilis, an infection of the spinal cord or brain.

“It has been shown that response to conventional therapy for syphilis in HIV-positive persons may be slowed, which is why follow-up is so important in these patients,” wrote Dr. Christopher Hall, a fellow at California’s state health department, in response to e-mail questions.

While the later stages of syphilis can take decades to develop, neurosyphilis can occur sooner.

“Some investigators have recovered the syphilis organism from the spinal fluid of patients appropriately treated for syphilis, even early on in syphilis infection,” Hall wrote.

Hall, Dr. Jeffrey D. Klausner, and Dr. Gail A. Bolan published an article on treating syphilis in HIV-positive patients in Current Infectious Disease Reports, a medical journal.

One study from the University of Washington found that a weakened immune system, such as those that can be found in people with HIV, was associated with a higher risk for neurosyphilis. No other study has found that association.

“There is no clear evidence, to date, that HIV infection puts one at substantially greater risk for developing clinically evident neurosyphilis,” Hall wrote.

Health departments are still concerned enough that they want to take a closer look for neurosyphilis cases.

“Are we just seeing it faster because there is some HIV connection here?” Blank said. “The other reason to take a look-see on this is it may affect the messages that we give to the public.”

Health departments may need to start telling HIV-positive patients that they should follow up any treatment for syphilis with testing to be sure the bug has been wiped out.

New York City has seen a small number of neurosyphilis cases recently, though increasingly, they are only among men which may mean they are linked to recent increases in syphilis among gay and bisexual men here.

In 2000, there were 17 cases, six in 2001, five in 2002, 15 in 2003 and there are five reported cases to date in 2004. In 2000, the cases were almost evenly divided between men and women. In 2001, two-thirds of the cases were among men, all the 2002 cases were among men, 12 men and three women had neurosyphilis in 2003, and all the 2004 cases are among men.

“The thing that is notable here, if you look at our data from 2000, about half of the cases were among men,” Blank said. “Since then the male to female ratio is about 1.5 to 1, then in 2004 the cases were all male.”

A June issue of the Bay Area Reporter, a San Francisco gay newspaper, disclosed that a 47-year-old, HIV-positive man in that city died from neurosyphilis last September. The man had been treated for syphilis 25 years earlier.

In 2003, San Francisco had 18 cases of neurosyphilis, according to the newspaper. There were 16 in 2002, six in 2001, seven in 2000, and four in 1999. The newspaper did not report the gender of the cases.

The federal Centers for Disease Control and Prevention has long recommended that doctors check the spinal fluid of HIV-positive patients for syphilis if they are unsure when the patient with syphilis was first infected with the disease, according to Blank.

Hall wrote that what is most important for treating syphilis in HIV-positive patients is that they be checked for any symptoms of neurosyphilis.

“Of great importance, all HIV-positive persons with syphilis should be aggressively evaluated for neurological signs and symptoms, even in the early stages of syphilis,” he wrote. “If any are present, the spinal fluid should be tested.”

The evaluation after treating syphilis should also be aggressive.

“Follow-up for syphilis—which is always important—is critical in HIV co-infected patients,” Hall wrote. “Such a person should be seen back in the first month, and blood markers for syphilis should be followed at three, six, nine, 12, and 24 months after treatment. Many believe that if follow-up were taken more seriously by clinicians and patients alike, treatment failures, which are few, would be caught and later consequences, such as neurosyphilis, would be headed off.”

People seeking a syphilis test or information can contact GMHC at 212.367.1100, the health department at 212.427.5120, or the Michael Callen-Audre Lorde Community Health Center at 212.271.7200

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