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Neurosyphilis is a disorder I have tested for many times and so far have never gotten a positive.

Here in the Pacific Northwest the most common STD in the younger and pregnant patients is chlamydia. And herpes. And HPV, human papillomavirus.

Now that I am no longer doing obstetrics and 78% of my patients are 50 or older, the STDs I see are mostly herpes and HPV. I've diagnosed 5 hepatitis C cases in the last 3-4 years, but probably not sexually transmitted. Hepatitis B is more contagious sexually, then HIV, then hepatitis C.

I have seen one case of gonorrhea in 19 years here. Planned parenthood in Bremerton tells me that hepatitis C is on the rise in the people late teens and twenties, from trading sex for heroin and sharing needles. Not good news. Treating one hepatitis C patient may prevent 5 others.

So who am I testing for syphilis? Memory loss patients, the elderly who are behaving weirdly. There is currently a short list of treatable causes of memory loss, so we routinely test. Test for syphilis, because neurosyphilis is treatable. Other tests used to include CT scan, looking for hydrocephalus. I have seen one case, treated, went back to hunting pheasant at 90. Now we do a brain MRI instead. We also test thyroid, B12, a blood count, a chemistry panel (electrolytes, blood sugar, liver tests and kidney tests) and an RPR for syphilis. One person turned out to have polycythemia vera, causing a super high blood count. His count was so high that his blood was sludging in the brain capillaries. When we got the count down, his memory is normal. His wife can tell when the count goes up because he gets goofy. He needs a pint of blood drained every six weeks. Polycythemia vera is one of those not-quite-cancer bone marrow disorders. It can morph into cancer. The hematologist-oncologist keeps an eye on him.

The first thing I test with new fast onset memory loss is a urine. If grandfather lost his memory yesterday, well, it's very often a urinary tract infection. Treat it and the memory is back. Yea for antibiotics. Older folks often do not run a fever or even have symptoms like pain with urination. They can just act confused.

I have not seen a case of syphilis here and no neurosyphilis either. But it does still exist and I know people who have seen it. The current memory testing guidelines are dropping that test, but I still do it. People travel and there is some weird stuff out there. My patients are 2:1 female and I do not get a lot of under 50 year olds coming in to have STD testing. Most of the under 50 crowd don't get tested or go to the health department.

Syphilis can go through a primary stage, a secondary stage, a latent stage and then the tertiary stage is neurosyphilis. Stage one is a painless sore that goes away while the infection moves inside to the secondary stage. The secondary stage sounds like lots of viral things: "The secondary stage of syphilis develops 2 to 8 weeks after a person is infected. Symptoms during this stage can include a skin rash, appearing as rough, red, or reddish brown spots on the palms of the hands and/or the bottoms of the feet. A syphilis rash, however, can have different appearances and occur on different parts of the body. Sometimes the rash is so mild that it is not noticed. In addition to rashes, persons in the secondary stage of syphilis might experience fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue. The symptoms of secondary syphilis will go away without treatment, but the infection will continue to progress; and secondary symptoms can recur."* During the latent stage, which can last for years, there are no symptoms but the person is infectious. How nice. Tertiary stage: "The late stage of syphilis can occur anywhere from 2 to 30 years after initial infection. During this stage, damage can occur to the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints. The damage may not show up for many years. In this late stage, as a result of the damage, a person might experience uncoordinated muscle movements, paralysis, numbness, gradual blindness, and dementia. The damage syphilis can cause to internal organs can result in death. A person is not usually infectious at this stage."*

Apparently there are five named types of neurosyphilis**:

--asymptomatic neurosyphilis -- in the first few weeks to first few years of getting syphilis. No symptoms.
--meningeal neurosyphilis -- also first few weeks to first few years of infection. A meningitis with headache, stiff neck, nausea, and vomiting. Sometimes there can also be loss of vision or hearing.
--meningovascular neurosyphilis -- first few months to several years. The meningitis but with strokes too.
--general paresis -- 3 to 30 years after getting syphilis. Personality or mood changes.
--tabes dorsalis -- 5 to 50 years after initial infection. Pains in the limbs or abdomen, failure of muscle coordination, and bladder disturbances. Other signs include vision loss, loss of reflexes and loss of sense of vibration, poor gait, and impaired balance.

Neurosyphilis is treated with penicillin, high dose, sometimes with probenacid. Or with ceftriaxone. Recovery depends on the stage: if it is one of the first two, people can return to normal health. With the latter three, they can get much better than without treatment, but not fully recover.

Laboratory testing is not entirely straightforward, and the CDC site explains the testing, depending on the suspected stage. For neurosyphilis, there have to be symptoms, a positive blood test and a positive cerebrospinal fluid test. So that means a lumbar puncture. And if there is blood in the CSF that screws up the test. Reading the CDC site, I have to go look up sensitivity and specificity again.

The correct penicillin must be used as well, to get to "sequestered" sites: "e.g., the CNS and aqueous humor". CNS is central nervous system. I will wait for the reQuest for aqueous humor next year. Pregnant women should be treated right away. Patients should be warned about a possible febrile reaction in the first 24 hours, called a Jarisch-Herxheimer reaction. The treatment dosage differs for each stage of syphilis and for the stage of neurosyphilis. I would promptly get the health department and infectious disease involved, because it's a reportable disease and I want to get the treatment right.

If you are dating someone new, you are both planning to get STD testing before fooling around, right? Be careful out there!

*http://health.iupui.edu/education/sexual/syphilis.html
**https://www.ninds.nih.gov/Disorders/All-Disorders/Neurosyphilis-Information-Page
https://www.uptodate.com/contents/neurosyphilis
***https://www.cdc.gov/std/tg2015/syphilis.htm
https://newrepublic.com/article/140702/medical-theory-donald-trumps-bizarre-behavior


reQuest

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