Alteration in the Natural History of Neurosyphilis by Concurrent Infection with the Human Immunodeficiency Virus

Abstract

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. (N Engl J Med 1987; 316:1569–72.) THE incidence of neurosyphilis has decreased markedly since the introduction of penicillin, but cases are still encountered.1 In the era before antibiotics, only 6.5 percent of patients with untreated syphilis went on to have symptomatic neurologic involvement in the secondary and tertiary stages.2 In the past year and a half at the Massachusetts General Hospital, we have seen four cases of neurosyphilis, three of them symptomatic, in young homosexual men, all of whom had serologic evidence of exposure to the human immunodeficiency virus (HIV). The course of many infections is altered by concurrent infection with HIV, and these cases suggest. © 1987, Massachusetts Medical Society. All rights reserved.