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ORIGINAL CONTRIBUTIONS
Year : 1990  |  Volume : 56  |  Issue : 3  |  Page : 208-210

Cerebro-spinal fluid examination in early syphilis after treatment with penicillin




Correspondence Address:
S Talwar


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Source of Support: None, Conflict of Interest: None


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  Abstract 

In case s having early syphilis, cerebro-spinal fluid:(CSF) was examined 6 months following pencillin treatment in 1173 cases of which 1 case showed some abnormality. In 1288 cases, CSF examination done at 30 months or later revealed abnormality in 3 cases. The initial diagnosis in these cases was primary syphilis in 2 cases and secondary syphilis in the remaining 2 and these cases had initially been treated with 2.4 MU of benzathine penicillin. These 4 cases were now diagnosed as cases of asymptomatic nourosyphifis and retreated with 9 MU Of procaine penicillin. AU these cases were cured following retreatment. Considering this small number (0.17%), it is considered unessential to examine CSF as a routine in early -syphilis.' However in cases where the clinical or serological response to treatment is not satisfactory, CSF examination is advisable.


Keywords: CSF, Early syphilis.


How to cite this article:
Talwar S, Tutakne M A. Cerebro-spinal fluid examination in early syphilis after treatment with penicillin. Indian J Dermatol Venereol Leprol 1990;56:208-10

How to cite this URL:
Talwar S, Tutakne M A. Cerebro-spinal fluid examination in early syphilis after treatment with penicillin. Indian J Dermatol Venereol Leprol [serial online] 1990 [cited 2019 Nov 13];56:208-10. Available from: http://www.ijdvl.com/text.asp?1990/56/3/208/3526


Neurosyphilis is one of the dreaded complications of untreated syphilis. CSF accurately reflects the activity of the disease process in the nervous system. Examination of the CSF in early syphilis is therefore done to defect neurological involvement since early treatment of neurosyphilis carries a far better prognosis. This recommendation was made before the discovery of penicillin for the treatment of syphilis, but this practice has continued in spite of use of penicillin. We have tried to evaluate if CSF examination is worthwhile following treatment with penicillin.


  Materials and Methods Top


The records of patients having early syphilis treated between January 1976 to July 1981 were screened. Of the 2869 cases treated during this period, 2754 cases were treated with 2.4 MU of benzathine penicillin, 91 cases (secondary and early latent) witr 4.8 MU of benzathine penicillin in two divided doses at one week interval and 24 cases with 6-9 MU of procaine penicillin in a daily dose of 0.6 MU for 10-15 days. As a routine each patient treated for syphilis was placed on surveillance for 3 months. During surveillance, the VDRL test was done at 2 months intervals for the first 6 months, followed by 3-months intervals for the next one year and then at 6-month intervals for the following year. The CSF examination in these patients was done for cells, protein, globulin and Wasserman reactionNDRL test at 6 months and 30 months after treatment as per the guidelines on surveillance[1],[2] The criteria of cure were taken as, (a) no clinical evidence of syphilis, (b) sero-negativity to antilipoidal test, and (c) normal CSF. Patients with abnormal CSF during surveillance were treated again as cases of neurosyphilis and placed on a fresh surveillance of 30 months.


  Results Top


One thousand four hundred and twenty nine patients were fully followed up after treatment, of which 89.10% were cured while 10.90% required retreatment. Among the cases requiring retreatment; 83 cases were sero resistant, 4 had neurosyphilis and 2 had a clinical relapse. At 6 months follow-up, CSF was examined in 1173 patients, of which 1 case revealed an abnormality [Table - 1]. This was a case of primary syphilis who also had a sero-relapse. He was now labeled as a case of asymptomatic neurosyphilis and retreated with 9 MU of procaine penicillin. A fresh surveillance of 30 months showed no further relapse. At 30 months, CSF was examined in 1288 patients, of which 3 cases showed abnormality. One of these cases had primary syphilis where serology remained unchanged till18 months following treatment. Thereafter he did not report for follow up. At 36 months, his blood VDRL test was positive in 1:32 dilution and CSF was abnormal. The second case had secondary syphilis who had shown a reduction in seroreactivity from 1:32 to 1:8 dilution 18 months after treatment. Thereafter he was lost to follow­up, but at 36 months his VDRL was positive in 1:128 dilution and CSF was found abnormal. The possibility of reinfection in these cases during their non-reporting cannot be ruled out. Retreatment with 9 MU of procaine penicillin cured these patients as per fresh surveillance of 30 months. The third case had secondary syphilis with a duration of 10 months. Following treatment his blood VDRL remained positive throughout in a low dilution. He was given retreatment with 9 MU ol-procaine penicillin and had no reactivity during the next 4 years.


  Comments Top


Five to ten percent of untreated syphilis patients on follow up are known to develop clinically apparent neurosyphilis[3]. Treatment with penicillin in early syphilis is however, effective in preventing involvement or curing CNS syphilis[4]. Jefferise[5] examined CSF in 1379 patients of early and latent syphilis at least 1 year after penicillin treatment and all cases showed normal findings. Fernando[6] examined 231 patients treated with penicillin for early syphilis, and only 3 cases showed inconsequential spinal fluid abnormality. In our study out of 2461, only 4 cases showed abnormality. In all these cases, blood serology had also remained positive or was rising. Relapses are known to occur within two years of the disease[7], infrequently it may occur after 2 years. Possibility of reinfection in these cases cannot be ruled out. All our 4 cases with abnormal CSF were initially treated with 2.4 MU of benzathine penicillin or procaine penicillin revealed abnormality in CSF. Use of 4.8 MU of benzathine penicillin in secondary and early latent cases in the present study was prompted by observation of better results with higher doses in earlier studiese[8],[10]. VDRL in CSF can be negative in 35-57% of the cases of neurosyphilis[11]. Recently, using rabbit inoculation technique,  Treponema pallidum Scientific Name Search i>were isolated from 18 out of 43 patients with early syphilis and it was recommended to examine CSF[12]. This is contrary to the recent recommendations of WHO where examination of CSF was considered not necessary in early syphilis[13]. In view of the poor penetration of benzathine penicillin into CSF, crystalline penicillin has been recommended to achieve better results[14].

 
  References Top

1.Idsoe O, Guthe T and Willcox RR: Penicillin in the treatment of syphilis : the experience of three decades, Bull WHO, 1972;47 (suppl): 38.  Back to cited text no. 1    
2.King A, Nicol C and Rodin P: Venereal diseases, Fourthed, Cassel Limited, London, 1980; p 162.  Back to cited text no. 2    
3.Gjestland T: The Oslo study of untreated syphilis, Acta Dermato-Venereol, 1955; 35 (suppl 34): 22-368.  Back to cited text no. 3    
4.King AJ: Drugs in treatment of syphilis: Part l, Brit Med J, 1959; 1: 355-359.  Back to cited text no. 4    
5.Jefferiss FJG: Test of cure in treated early and latent syphilis, Brit J Vener Dis, 1963; 39: 139-142.  Back to cited text no. 5    
6.Fernando WL: CSF findings after treatment of early syphilis with penicillin, Brit J Vener Dis, 1968; 44: 134-135.  Back to cited text no. 6    
7.King A, Nicol C and Rodin P: Venereal Diseases, Fourthed, Cassel Limited, London, 1980; p 42.  Back to cited text no. 7    
8.Fiumara NJ: The treatment of secondary syphilis: An evaluation of 204 patients, Sex Tran Dis, 1977; 4: 96-99.  Back to cited text no. 8    
9.Durst RD: Dose related seroreversal in syphilis: Arch Dermatol, 1973; 108: 663-664  Back to cited text no. 9    
10.Musher D M : How much penicillin cures early syphilis? Ann Int Med, 1988; 109: 849-851.  Back to cited text no. 10    
11.Escober MR, Dalton HP and Allison ML: Fluorescent Antibody tests for syphilis using cerebrospinal fluid: Amer J Clin Pathol, 1970; 53: 886-890.  Back to cited text no. 11    
12.Lukehart SA, Hoow EW, Collier AC et al : Invasion of the central nervous system by Treponema pallidum : Implications for diagnosis and treatment, Ann Int Med, 1988; 109: 855-861.  Back to cited text no. 12    
13.WHO Expert Committee on venereal Diseases and Treponematosis : Sixth report, Tech Rep Ser No. 736, WHO, Geneva, 1986; p 126-130.  Back to cited text no. 13    
14.Mohr JA, Griffiths W, Jackson R et al : Neurosyphilis and penicillin levels in CSF, J Amer Med Assoc, 1976; 236: 2208-2209.  Back to cited text no. 14    


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