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Treatment

The main goal in treatment of symptomatic late neurosyphilis is to halt progression of the disease, since much of the damage to the CNS is irreversible. Patients who have neurosyphilis or ocular syphilis should be treated with aqueous crystalline penicillin G, 18 to 24 million units per day, given as 3 to 4 million units intravenously every 4 hours or continuous infusion, for 10 to 14 days. An alternative regimen that requires strict assurance of compliance is procaine penicillin G, 2.4 million units IM once daily plus probenecid 500 mg orally four times daily, both for 10 to 14 days. Since the duration of therapy for neurosyphilis is shorter than the 3-week course recommended for latent syphilis, which theoretically may coexist, many specialists recommend an additional intramuscular dose of benzathine penicillin, 2.4 million units, after completion of the 2-week therapy for neurosyphilis to achieve at least 3 weeks of serum penicillin levels.

Syphilitic otitis should be treated the same way as neurosyphilis, regardless of CSF results. Adjunctive systemic steroids are often used in this setting, but the benefit of such therapy has not been proven.

Penicillin Allergy

Ceftriaxone, 2 g IM or IV daily for 10 to 14 days, is an alternative regimen for patients with a penicillin allergy, although there is potential for cross-reactivity. No other regimen has been adequately evaluated for treatment of neurosyphilis. Therefore, if ceftriaxone is not considered a safe alternative, the patient should undergo skin testing to confirm the penicillin allergy and be desensitized if necessary.

Assessing Response to Therapy

Patients with elevated cell counts in the CSF prior to treatment should have repeated lumbar punctures every 6 months until the pleocytosis resolves. Changes in the VDRL-CSF and protein counts may take longer to occur, and persistent elevations may not be significant. As a general guideline, the cell count should decrease after 6 months and the CSF should normalize after 2 years; otherwise, retreatment should be considered.

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