Neurosyphilis natural history, complications and prognosis

The symptoms of neurosyphilis usually develop secondary to long-term untreated syphilis, and include diplopia, impaired vision, hearing loss, hoarseness, persistent headache, dizziness, vertigo, lightning pains, impaired sensation and proprioception, hypesthesias, hemiparesis, homonymous hemianopsia, slurred speech and dysarthria. If left untreated, most patients with neurosyphilis may progress to develop paralysis, dementia, Charcot arthropathy, stroke and blindness. Common complications of neurosyphilis include meningitis, meningiovascular syphilis, Argyll-Robertson pupil, stroke, cranial nerve neuropathies, dementia, paralysis, Charcot arthropathy (Charcot joint) of the foot and sensory ataxic gait.

Neurosyphilis is one of the late manifestations of untreated syphilis disease.

• Painless chancre appears 3-4 weeks after exposure.
• Chancre typically resolves, after which the patient may develop constitutional symptoms and generalized symmetric rash in 4 to 8 weeks.
  • In less than 10% of individuals, complications such as hepatitis, iritis, nephritis, and neurological problems may develop at this stage.
• This stage is typically self limited to 4 to 8 weeks without treatment and patient enters into asymptomatic latent phase.
• Approximately 25% of patients develop recurrent symptoms in one year.^[1]
• Approximately 35% of patients develop tertiary syphilis, which includes the following complications:^[2][3][4]
  • Cardiovascular involvement after 15-30 years (80-85% of patients) including aortic aneurysm, aortic regurgitation, angina, and heart failure
  • Gummatous lesions involving skin, bone and joints, associated with significant morbidity and mortality^{[5][6][7][8][9]}
• Neurologic infection in 10-15 years (5-10% of patients) including cranial nerve dysfunction, meningitis, stroke, acute or chronic altered mental status, loss of vibration sense, and auditory or ophthalmic abnormalities.
• The symptoms of tabes dorsalis typically occurs 10 to 30 years after primary infection by treponema pallidum.^[10]
• If left untreated, most patients with neurosyphilis may progress to develop paralysis, dementia, charcot arthropathy, stroke and blindness.

Common complications of neurosyphilis include:

• Meningitis^[11]
• Meningiovascular syphilis^[12][13][14]
• Stroke^[15]
• Cranial nerve neuropathies ^[16]

• Dementia^[17]
• Paralysis^[18]

Prognosis varies by site of involvement and duration of disease:^[5][6][7]

• Among patients with neurosyphilis, 90% respond to treatment.
• Gummatous lesions reverse with treatment.
• Mortality rate of patients with neurosyphilis is around 20% which is mainly due to related complications.

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