by Carolyn Chu, MD, MSc, AAHIVS, AAHIVM Chief Medical Officer

March 23, 2021

Featured Literature:

Quilter LAS, de Voux A, Amiya RM, et al. Prevalence of self-report neurologic and ocular symptoms in early syphilis cases.  Clin Infect Dis. 2021 May 15; 72(6): 961-967.  doi: 10.1093/cid/ciaa180.  PMID: 32103243.

Although public health surveillance data suggest an overall low prevalence of reported neurosyphilis cases (<2%), neurosyphilis and ocular syphilis clusters have recently been observed in multiple urban areas. The STD Surveillance Network (SSuN) Enhanced Neuro/Ocular Syphilis Surveillance project was established in 2016 to help address gaps in surveillance of early syphilis (ES) cases with neurologic and/or ocular manifestations. This study aimed to: (a) characterize prevalence of self-reported symptoms among reported ES cases in select participating jurisdictions (Florida Department of Health; Multnomah County Health Department; New York City Department of Health and Mental Hygiene; Philadelphia Department of Public Health; and Washington State Department of Health); and (b) describe clinical management of identified cases. 13,071 ES cases were reported across participating jurisdictions between November 1, 2016 and October 31, 2017. 9,123 (70%) were interviewed and received enhanced screening involving a standardized neurosyphilis and ocular syphilis data collection tool to supplement routine health department activities and case investigation protocols. Of interviewed cases, > 80% identified as male and men who have sex with men, and almost half were living with HIV. 151 (1.7%) reported at least 1 neurologic or ocular symptom: headache was most common, followed by blurry vision, vision changes, and tinnitus; stroke-like symptoms were least common. 35% of symptomatic cases underwent lumbar puncture (LP), with subsequent documentation of abnormal CSF results in 42%. Among cases with abnormal CSF, 95% received a CDC-recommended regimen for neurosyphilis or ocular syphilis treatment. Of symptomatic cases with no documented LP, 12% were ultimately treated for and/or clinically diagnosed with neurosyphilis or ocular syphilis. Of cases reporting at least 1 ocular symptom, one-third had documented ophthalmologic examination (of which less than half had abnormal findings such as uveitis, optic neuritis, or retinitis). Of cases reporting only ocular symptoms, 37% underwent LP, of which 53% had abnormal CSF results.

Author’s Commentary:

If syphilis rates continue to rise, providers might anticipate an increase in persons presenting with complications such as neurosyphilis and ocular syphilis. This report helps characterize neurologic and/or ocular symptoms among cases of early syphilis based on a limited sample of health departments participating in a sentinel surveillance project. Nearly 20% of symptomatic cases reported serious, debilitating manifestations. Notably, only one-third had documented CSF analysis. HIV and syphilis have a long-standing association; therefore, HIV providers should continue having a low threshold for performing thorough neurologic assessments and further testing/evaluation as indicated. Effective and timely coordination involving local resources, processes, and providers is instrumental to ensure patients receive recommended evaluation and treatment.

The author has no conflicts of interest to disclose.

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