20:T4fe,Within the past 18 months, we have seen four cases of neurosyphilis at our institution (two of meningovascular syphilis, one of acute syphilitic meningitis, and one of asymptomatic neurosyphilis) in young homosexual men with serologic evidence of exposure to human immunodeficiency virus (HIV). Two of the four patients had neurosyphilis despite previous adequate therapy for early syphilis with benzathine penicillin. Meningovascular syphilis developed in one patient within four months after a primary infection, in a manner consistent with an accelerated course of syphilitic infection. These findings suggest the possibility that HIV infection may alter the natural course of syphilis because of the profound defects in cell-mediated immunity it causes. The possible potentiating effects of HIV on Treponema pallidum infection suggest the need for lumbar puncture in the evaluation of HIV-seropositive patients with syphilis, as well as modifications of the currently recommended treatment regimens for primary, secondary, and latent syphilis and neurosyphilis in this patient population. Neurosyphilis should probably be added to the growing list of infectious complications of the acquired immunodeficiency syndrome (AIDS) and may be the first such complication to appear.21:T407,The diagnosis of neurosyphilis is difficult due to lack of an ideal infallible laboratory test, the obscurity of the clinical symptoms, the rising incidence of its atypical forms, and the well-known occurrence of nontreponemal seronegative neurosyphilis.¹ The incidence of neurosyphilis cannot be accurately assessed since venereal diseases remain vastly underreported. The problem has become more complicated by the fact that penicillin therapy in the first and second stages (infectious stages) of syphilis has altered the clinical picture of neurosyphilis.²The classical text book pictures of tabes dorsalis and general paresis of the insane (GPI) are becoming rare and seem to be replaced by atypical and in-between forms.²

Diagnosis

The diagnosis of neurosyphilis is based on clinical judgement. The serologic tests are useful in confirming the diagnosis of syphilis, but nontreponemal serologic tests for syphilis (STS) are not sensitive enough, and can be negative in late stages of22:T407,The diagnosis of neurosyphilis is difficult due to lack of an ideal infallible laboratory test, the obscurity of the clinical symptoms, the rising incidence of its atypical forms, and the well-known occurrence of nontreponemal seronegative neurosyphilis.¹ The incidence of neurosyphilis cannot be accurately assessed since venereal diseases remain vastly underreported. The problem has become more complicated by the fact that penicillin therapy in the first and second stages (infectious stages) of syphilis has altered the clinical picture of neurosyphilis.²The classical text book pictures of tabes dorsalis and general paresis of the insane (GPI) are becoming rare and seem to be replaced by atypical and in-between forms.²

Diagnosis

The diagnosis of neurosyphilis is based on clinical judgement. The serologic tests are useful in confirming the diagnosis of syphilis, but nontreponemal serologic tests for syphilis (STS) are not sensitive enough, and can be negative in late stages of23:T438,Approximately 5,000 new cases of neurosyphilis may occur in the United States each year. General paresis and tabes dorsalis, however, have become relatively rare since the introduction of penicillin. Seizures, neuro-ophthalmologic symptoms, stroke and acute meningoencephalitis are currently the most common manifestations of neurosyphilis. In more than a third of patients with neurosyphilis, nontreponemal tests for syphilis (such as VDRL) are negative and should not be used to exclude the diagnosis. Specific treponemal tests are more sensitive and more specific. Examination of the cerebrospinal fluid may show no abnormalities in neurosyphilis and is not an infallible guide to the activity of the infection. Penicilli

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