Lukehart S A, Hook E W, Baker-Zander S A, Collier A C, Critchlow C W, Handsfield H H
University of Washington, Seattle.
Ann Intern Med. 1988 Dec 1;109(11):855-62. doi: 10.7326/0003-4819-109-11-855.
To determine the prevalence of Treponema pallidum in cerebrospinal fluid (CSF) of patients with syphilis, to determine the effect of concurrent HIV infection on central nervous system involvement by T. pallidum, and to examine the efficacy of conventional therapy for asymptomatic neurologic involvement.
Fifty-eight patients with untreated syphilis who consented to lumbar puncture, representing approximately 10% of new cases of syphilis during the study period.
Lumbar puncture was done on all patients. Rabbit inoculation was used to test cerebrospinal fluid for viable T. pallidum. Patients with normal fluid received recommended benzathine penicillin therapy according to the stage of syphilis; patients with CSF abnormalities were offered 10-day therapy for neurosyphilis.
Treponema pallidum was isolated from the CSF of 12 (30%) of 40 patients (95% CI, 17 to 46) with untreated primary and secondary syphilis; isolation of T. pallidum was significantly associated (P = 0.008) with the presence of two or more abnormal laboratory variables (among leukocyte count, protein concentration, and CSF-Venereal Disease Research Laboratory [VDRL] test). Two (67%) of 3 early latent (CI, 13 to 100) and 3 (20%) of 15 late latent syphilis patients (CI, 5 to 47) also had reactive CSF-VDRL tests and elevated cell and protein levels, although T. pallidum was not isolated. Concurrent infection with the human immunodeficiency virus (HIV) was not associated with isolation of T. pallidum, increased number of CSF abnormalities, or reactive CSF serologic tests for syphilis, although CSF pleocytosis was commoner in subjects infected with HIV. Treatment with conventional benzathine penicillin G (2.4 mIU) failed to cure 3 of 4 patients with secondary syphilis from whom T. pallidum was isolated before therapy; all 3 patients in whom treatment failed were HIV seropositive when treated or seroconverted during follow-up.
Central nervous system invasion by T. pallidum is common in early syphilis, and is apparently independent of HIV infection. Examination of the CSF may be beneficial in patients with early syphilis, and therapy should be guided by knowledge of central nervous system involvement. Conventional benzathine penicillin G therapy may have reduced efficacy in patients with early syphilis who are also infected with HIV.
确定梅毒患者脑脊液中梅毒螺旋体的患病率，确定同时感染人类免疫缺陷病毒（HIV）对梅毒螺旋体累及中枢神经系统的影响，并检验针对无症状神经受累的传统疗法的疗效。
58例未经治疗的梅毒患者同意接受腰椎穿刺，约占研究期间梅毒新发病例的10%。
所有患者均进行腰椎穿刺。采用兔接种法检测脑脊液中是否存在活的梅毒螺旋体。脑脊液正常的患者根据梅毒分期接受推荐的苄星青霉素治疗；脑脊液异常的患者接受为期10天的神经梅毒治疗。
40例未经治疗的一期和二期梅毒患者中有12例（30%）（95%可信区间，17%至46%）脑脊液中分离出梅毒螺旋体；梅毒螺旋体的分离与两个或更多实验室异常指标（白细胞计数、蛋白浓度和脑脊液性病研究实验室[VDRL]试验）的存在显著相关（P = 0.008）。3例早期潜伏梅毒患者中有2例（67%）（可信区间，13%至100%）以及15例晚期潜伏梅毒患者中有3例（20%）（可信区间，5%至47%）脑脊液VDRL试验也呈阳性，细胞和蛋白水平升高，尽管未分离出梅毒螺旋体。同时感染HIV与梅毒螺旋体的分离、脑脊液异常数量增加或梅毒脑脊液血清学试验阳性无关，尽管HIV感染患者脑脊液淋巴细胞增多更为常见。用传统苄星青霉素G（240万单位）治疗未能治愈4例二期梅毒患者中的3例，这3例患者在治疗前脑脊液中分离出梅毒螺旋体；所有3例治疗失败的患者在治疗时HIV血清学呈阳性或在随访期间血清转化。
梅毒螺旋体侵犯中枢神经系统在早期梅毒中很常见，且显然与HIV感染无关。对早期梅毒患者检查脑脊液可能有益，治疗应根据中枢神经系统受累情况进行指导。传统苄星青霉素G疗法对同时感染HIV的早期梅毒患者疗效可能降低。
