Psychosomatics 42:453-460, December 2001
© 2001 The Academy of Psychosomatic Medicine
Syphilis in Clinical Psychiatry: A Review
Burton Hutto, M.D.
Received December 22, 2000; revised June 1, 2001; accepted July 5, 2001. From the University of North Carolina School of Medicine, Chapel Hill, NC. Address correspondence and reprint requests to Dr. Hutto, University of North Carolina School of Medicine, CB #7160, UNC Chapel Hill, NC 27599–7160. E-mail: Bhutto{at}css.unc.edu
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ABSTRACT
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Syphilis is a potentially fatal infectious disease that has a long history of association with psychiatry. Recent developments in epidemiology, diagnosis, and treatment guidelines warrant a review of the current relationship of syphilis to clinical psychiatry. After a recent peak of incidence in the United States, syphilis is once again on the decline. Although the prevalence of syphilis remains endemic in certain locations, it has been targeted for elimination. Meanwhile, diagnostic testing remains complex and imperfect, especially for the detection of late stages of infection and neurosyphilis. The U.S. Public Health Service recently revised guidelines for the evaluation and management for syphilis. This paper discusses these developments and their specific implications to psychiatric practice. The likelihood of discovering previously unsuspected cases through screening and recommendations on high-risk groups to screen are discussed. A case example illustrates some of the key concepts.
Key Words: General Topics in Psychiatry • Syphilis • Diagnosis
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INTRODUCTION
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Named for the mythical swineherd Syphilis who was accursed by Apollo with the disease that rampaged across Europe in the late 1400s, syphilis was first described in a Latin poem written by an Italian physician around 1530. The true origins of the disease have been a mystery, and some believe it is the only significant infection that Native Americans gave to Europe in return for the many devastating infections brought to America by Europeans. Syphilis, also known as the French disease, soon became endemic to Europe and then to much of the world.
Kraft-Ebbing demonstrated the association of syphilis to general paresis in 1897, and prior to 1945, general paresis was reportedly involved in 5%–10% of all first psychiatric admissions.1 More than 20% of patients in U.S. mental hospitals in the 1920s had tertiary syphilis.2 However, when effective treatment of syphilis with penicillin became available, the incidence of general paresis or neurosyphilis decreased dramatically as rates of syphilis infection fell. A few years ago the incidence of syphilis appeared to be rising again in parallel with the AIDS and crack cocaine epidemics,3 but by 1997, overall rates of syphilis dipped to their lowest levels ever and the U.S. Public Health Service targeted syphilis for elimination.4
Neurosyphilis remains in the differential for a wide variety of psychiatric syndromes, including dementia, psychosis, and mood disorders, but the incidence of neurosyphilis presenting initially with psychiatric symptomatology is unclear. In addition, evidence suggests that the "Great Imitator" has changed its disguises since the introduction of antibiotics. Classic syndromes of late neurosyphilis such as general paresis or tabes dorsalis may now be much less common than asymptomatic neurosyphilis or manifestations such as seizures or ocular and auditory involvement.1 Some of this change in its manifestations may be due to the inadvertent partial treatment of earlier stages of syphilis during antibiotic treatment for other infections, including other sexually transmitted diseases. Inadequate treatment of syphilis may preferentially allow the organism to survive in the central nervous system and the eye. There it could proliferate without much challenge from the immune system since these more peripheral sites of infection might not stimulate a vigorous immune response.5
Thus not only is the incidence of syphilis rapidly changing, but its manifestations may be evolving. The relationship of syphilis to psychiatry bears some review in light of these and other developments. This paper reviews the natural course of syphilis infection, the diagnosis of the infection, the special issues of diagnosis in psychiatric populations, the psychiatric manifestations of neurosyphilis, and the treatment guidelines for the infection. A case report will be discussed to illustrate some of the issues involved.
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Natural Course of Syphilis
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Syphilis is caused by infection with the spirochete Treponema pallidum, which is spread by sexual contact. Exposure leads within weeks to primary syphilis, which can be diagnosed by the lesion known as a chancre that develops at the site of inoculation. After this lesion resolves spontaneously, other cutaneous lesions as well as nonspecific constitutional symptoms such as weakness, fever, arthralgias, and weight loss characterize secondary syphilis. Latent syphilis follows secondary syphilis, but occasional relapses to secondary syphilis can occur within the first 2 years of the latent stage. Tertiary syphilis can occur from 5 to 20 years after initial infection, and its manifestations can include gummas (focal inflammatory nodules in liver, skin, bone, or spleen) or cardiovascular lesions such as aortitis. Neurosyphilis is another possible manifestation of tertiary syphilis and can be divided by pathology into meningeal neurosyphilis (which more typically occurs before the tertiary phase of the illness), meningovascular neurosyphilis, parenchymatous neurosyphilis, and gummatous neurosyphilis. Most patients show a combination of these forms of pathology.
General paresis, the clinical form of neurosyphilis most associated with psychiatric symptoms, occurs with parenchymatous disease and involves neuronal loss as opposed to the vascular lesions or inflammatory changes characteristic of most other forms of neurosyphilis. In the classic description, after early psychiatric manifestations such as mood changes, psychosis, or cognitive changes, dementia becomes prominent. In the untreated case, severe neurological symptoms such as paralytic manifestations lead to disability, and the illness progresses to death.
Neurologic findings are common but varied in neurosyphilis, including such ocular changes as the Argyll-Robertson pupil, which is unresponsive to light but constricts with accommodation or convergence. This pathognomonic pupillary change occurs in only 26% of cases, whereas other various pupillary changes occur in 57%.6
Tabes dorsalis is a progressive degenerative process affecting the posterior columns and posterior roots of the spinal cord. Symptoms of tabes dorsalis include progressive loss of peripheral reflexes, impairment of vibration and position sense, and progressive ataxia. Incontinence and impotence can occur. Sudden and severe pains of the larynx, abdomen, vagina, rectum, or other organs have unclear cause but can require opioid pain relief and have led to exploratory surgeries. Cold or stress occasionally triggers these "lightning pains," but they can occur without precipitant.
As seen in Table 1, the neurological symptoms associated with various forms of neurosyphilis are so numerous and nonspecific, syphilis could be on the differential diagnosis for many neurological and psychiatric presentations.
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Diagnosis of Syphilis
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The diagnosis of syphilis has remained more difficult than the diagnosis of most other infections. The organism T. pallidum has not been successfully grown in culture, so diagnosis relies on evidence of immunological response to infection or visualization of the organism. The recently completed sequencing of the genome for T. pallidum7 may one day offer improved diagnostic testing, but currently serologic testing is the standard screening test. Positive results are followed by more specific antibody tests. The Venereal Disease Research Laboratory (VDRL) test and the rapid plasma reagin (RPR) test serve as serological screens, and the fluorescent treponemal antibody-absorption (FTA-ABS) or microhemagglutination assay for T. pallidum (MHA-TP) usually serve as confirmatory tests. The VDRL is typically tested in the cerebrospinal fluid (CSF) when neurosyphilis is suspected. All these tests have difficulties, including less than optimal sensitivity and specificity. The rational usage of these available testing methods in psychiatry is controversial and will be discussed below.
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Screening Psychiatric Populations for Syphilis
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Given the historical association of neurosyphilis to psychiatric pathology and given the ease of definitive treatment for syphilis infection, screening psychiatric patients for syphilis has persisted as a standard of care in some areas. In recent years questions have arisen about the need for such broad screening of psychiatric populations and about the proper use of available diagnostic tests.
Baumgarten and Swigar8 examined the results of 2,305 VDRL tests performed on 2,037 psychiatric inpatients at Yale-New Haven Hospital from 1978 to 1985. They found that the prevalence in the psychiatric patients was actually lower than the prevalence in the local community and in the general hospital population during the same period. They concluded that routine screening of psychiatric patients was unjustified but that specific subgroups should be targeted for testing. Specifically, they suggested testing for major affective disorders and delusional dementia.
Other investigators have similarly concluded that testing should be targeted, but based on studies of diverse populations in a variety of locations over time, there is not a strict consensus on the populations that require screening. Klaus et al.9retrospectively reviewed syphilis screening in 1,515 patients admitted to psychiatric, alcohol, and drug rehabilitation services at a Veterans Administration hospital in Buffalo, NY, in 1987. On the basis of finding 16 otherwise unsuspected cases of confirmed syphilis, they concluded that routine screening is justified for patients admitted for alcohol and drug treatment.
White and Barraclough10 studied syphilis screening in addition to other routine laboratory screening for psychiatric inpatients. From 1983 to 1984 in Southampton, Great Britain, 136 syphilis serology tests on a selected subgroup from approximately 1,000 patients yielded only five positive results, three of which were in patients previously treated for syphilis. They concluded that screening should be reserved for those exposed to risk of infection, but they did not identify any psychiatric subgroup to screen more carefully.
Boodhoo11 examined the results of screening 800 elderly mentally ill patients with the VDRL and found 21 cases with positive results. This study was also conducted in Great Britain in the 1980s. It was recommended that testing be confined to patients with obvious clinical manifestations of syphilis or obscure presentations.
Roberts and Emsley12 reported on 21 patients in South Africa whose neurosyphilis presented with psychiatric manifestations. They found no specific psychiatric diagnoses over-represented in this group of patients. They suggested several signs and symptoms that might serve as clues to the diagnosis: personality changes with impairment of judgment and functioning; memory impairment that is sometimes subtle; psychosis, hostility, or confusion in conjunction with cognitive impairment; and neurological signs or symptoms. They note that more routine testing may be important because none of the referring physicians had considered neurosyphilis, and the psychiatric staff only considered it in 2 of the 21 cases.
Hutto and Adimora13 retrospectively reviewed syphilis screening on 2,645 psychiatric inpatients at the University of North Carolina from 1993 through 1997. Twenty cases of confirmed syphilis were identified, and they concluded that screening is indicated in psychiatric patients with substance-related disorders, HIV infection, or clinical symptoms suggestive of neurosyphilis.
The conclusions from these studies raise other questions. Is the aim of screening psychiatric patients to identify early stages of syphilitic infection in order to prevent late stages, especially neurosyphilis? Or is it to diagnose previously undetected tertiary infections now presenting as neurosyphilis with psychiatric symptoms? These dissimilar aims may require distinctly different methods. To screen for all stages of syphilis infection in a population, the standard is to use a serologic test (VDRL or RPR) followed by a specific treponemal test (FTA-ABS or MHA-TP) for confirmation. This sequence is based on the fact that even though the specific treponemal tests are more sensitive, they are more expensive and technically demanding.5
A growing number of authors suggest, however, that with the aim of diagnosing neurosyphilis, a specific treponemal test should be performed regardless of whether the serologic test is nonreactive or is not even performed. Ross et al.14 reported two cases of neurosyphilis presenting with symptoms of a mood disorder. They state that if a patient presents with mania that could be due to neurosyphilis, a treponemal test, not a serologic test, should be obtained. However, they are not clear on whether neurosyphilis should be in the differential for all cases of mania.
Sheline and Kehr15 studied the cost and utility of routine laboratory testing for psychiatric inpatients in Santa Clara, CA, during 1987 and 1988. The VDRL was performed on 227 of 305 consecutive admissions and yielded only 1 potentially new diagnosis of infection. These authors noted that the testing was not conducted to screen for primary syphilis but to rule out tertiary syphilis as a cause for the presenting symptoms. They suggest that the FTA-ABS is the test of choice for this purpose.
Powell et al.16 reported a retrospective study of 376 patients in New Jersey who received a dementia evaluation. The FTA-ABS was used to screen 338 of these patients and 37 (10.9%) were positive. Of 9 FTA-ABS–positive patients who also received the RPR, only 2 were RPR positive. The authors suggest that screening for tertiary syphilis with the RPR or VDRL may be inadequate because these tests commonly revert to nonreactive within 2 years of the infection in untreated patients.17 The FTA-ABS is more likely to remain positive indefinitely.
Similarly, Reeves et al.18 studied 200 chronically mentally ill patients presenting to Louisiana State University Medical Center between 1992 and 1995. By obtaining both RPR and MHA-TP tests in all subjects, they found that 10 patients (5%) in this population had positive MHA-TP results but were RPR nonreactive. Four of these 10 patients, although they all refused lumbar puncture, were assessed by specialists to have active syphilis and to be possible cases of neurosyphilis. The authors concluded that serological tests are unacceptable for detecting late stages of syphilis in the chronically mentally ill.
Thus, there is a clear risk of missing the diagnosis of this highly treatable, progressively debilitating, and potentially fatal infection if screening or even targeted testing is performed using serologic tests in psychiatric populations. If the aim is to screen for early stages of syphilis in populations at risk, such as patients with substance-related disorders, HIV infection, other sexually transmitted diseases, or unprotected sexual activity, serologic screening remains the test of choice. The more sensitive treponemal tests may be the tests of choice if clinical symptoms suggest the possibility of neurosyphilis.
An additional issue bears on the detection of syphilis in psychiatric populations. Recent changes in the epidemiology of syphilis infections may now put some psychiatric populations at an increased risk of infection. After years of declining rates, in 1989 the incidence of syphilis had climbed to its highest level since 1949.19 Although syphilis remained a rare disease in most of the United States, 50-fold differences in incidence between various states and between whites and blacks made syphilis endemic in some localities.19 Cocaine use, especially in the form of crack, appeared partly responsible for the overall increase in incidence.20
Sitzman et al.21 retrospectively reviewed screening for all non-HIV sexually transmitted diseases in patients admitted to the Tulane University Medical Center emergency psychiatry service for 1 month in 1990. Only 208 of the 426 consecutive patients had been screened for syphilis using the RPR or VDRL at admission or in the previous 12 months, but 19 new cases were confirmed by FTA-ABS. No psychiatric diagnosis or symptom was found to put the infected patients at higher risk. The authors also compared the rate of syphilis in this psychiatric population, conservatively calculated as 19 cases in the total 426 patients, with rates in the city of New Orleans, the state of Louisiana, and the United States during the same period. This period also coincided with a peak in incidence across the country. The conservatively calculated rate was 23 times the New Orleans rate, 63 times the Louisiana rate, and 99 times the overall national rate. Thus, an emergency psychiatry population appears to be highly at risk for syphilis infection, and the authors suggested that screening of all psychiatric patients should be considered.
More recent developments in the epidemiology of syphilis4 may modify these authors' conclusion that all psychiatric populations be considered for screening. By 1997, syphilis incidence had fallen again to its lowest recorded incidence on record, and the U.S. Public Health Service has recommended an effort to eliminate syphilis. Still an approximately 40-to-1 ratio between blacks and whites in reported primary and secondary syphilis persisted in 1997. In addition, more than 50% of the reported primary and secondary syphilis cases reported in 1997 occurred in just 31 of the 3,115 counties in the United States. The 33 cities and states targeted by the U.S. Health Department are Alabama, Arizona, Arkansas, Baltimore, California, Chicago, Connecticut, Florida, Georgia, Illinois, Indiana, Kentucky, Los Angeles, Louisiana, Maryland, Massachusetts, Michigan, Mississippi, Missouri, New Jersey, New York City, North Carolina, Ohio, Oklahoma, Philadelphia, Puerto Rico, San Francisco, South Carolina, Tennessee, Texas, Virginia, Washington, D.C., and Wisconsin.
Thus, screening psychiatric populations with the aim of diagnosing early stages of infection to prevent future morbidity is consistent with the effort to prevent spread of the infection and accomplish the elimination of syphilis in the United States. However, screening might best be targeted not only at subgroups whose behavior places them at higher risk, but at populations in areas with endemic levels of infection. Broad screening may be advisable in the New Orleans area where Sitzman et al.21 conducted their study because that area has some of the highest rates in the country. However, many localities in the United States have incidences of syphilis that may be too low to warrant screening most psychiatric patients. Awareness of local rates of infection would be crucial for psychiatrists to participate in this public health effort to eliminate the disease. Syphilis is a reportable disease in every state in the country.
Several principles of testing for syphilis in psychiatric patients are presented in Table 2.
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Neurosyphilis Presenting with Psychiatric Symptoms
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The study by Roberts and Emsley12 describes the 21 neurosyphilis patients they treated in South Africa. Presenting symptoms (in decreasing order of frequency) included personality change, memory impairment, neurological signs or symptoms, hostility, confusion, hallucinations, expansiveness, delusions, and dysphoria. These patients exhibited many of the classic signs and symptoms of neurosyphilis, and it is worth emphasizing that despite these classic presentations, the diagnosis of neurosyphilis was considered before screening by the physicians in only 2 of these 21 cases.
Klaus et al.9 also noted that none of the patients studied had clinical signs of early or late syphilis infection on physical examination. Few studies cited in this paper discuss how often physical signs prompted targeted testing for syphilis, but findings of neurological or ophthalmic changes are particularly suggestive of the diagnosis of neurosyphilis.
The role of testing for syphilis in evaluation of dementia remains unclear. Certainly if the patient has other neurological signs or symptoms suggestive of neurosyphilis, syphilis testing should be part of the evaluation, and a treponemal test is the preferred method. With little data on the prevalence of active neurosyphilis uncovered by screening all cases of newly diagnosed dementia, the clinician can consider the lifelong risk of infection in deciding the value of syphilis testing. Dementia as a symptom of neurosyphilis is unlikely to improve with treatment, but the course of the illness can be stopped.
The diagnosis of neurosyphilis may now be more elusive, not because the manifestations have changed, but because the prevalence is low enough that most psychiatrists very rarely, if ever see a confirmed case and therefore do not recognize neurosyphilis or carefully consider it in a differential diagnosis.
Once a case is identified by a positive treponemal test, diagnosis of neurosyphilis requires a lumbar puncture and examination of CSF for elevated leukocyte count, elevated protein, or reactive VDRL-CSF. Reactive VDRL-CSF in the absence of blood contamination of CSF during the lumbar puncture is considered diagnostic of neurosyphilis. However, it is not a perfectly sensitive test, and some experts recommend the FTA-ABS test on the CSF. This test is less specific, but is sensitive enough that some experts argue a negative result excludes the diagnosis of neurosyphilis.5,22
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Guidelines for Treatment of Syphilis
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The U.S. Public Health Service updated guidelines for the treatment of syphilis in 1998.22 This section will summarize highlights of the guidelines that might be of interest to psychiatrists (see also Table 3). The guidelines stress that all newly diagnosed patients should be tested for HIV and retested in 3 months in areas of high HIV prevalence. Parenteral penicillin G is the preferred drug for treatment of all stages of syphilis. The guidelines discuss special considerations for treatment of children, pregnant women, HIV-infected patients, and patients with penicillin allergies.
Primary and secondary syphilis should be treated with benzathine penicillin G (2.4 million units im in a single dose). Lumbar puncture is not recommended for routine evaluation in primary or secondary syphilis unless there are signs or symptoms of neurological or ophthalmic disease. Patients should be reexamined clinically at 6 and 12 months with serologic testing done. Results of serologic testing can identify treatment failures and possible reinfections. The guidelines discuss further management of such cases.
Latent infections are classified as early or late. Almost all patients diagnosed with latent syphilis should be considered to have late latent syphilis. A latent infection can safely be considered an early latent infection only if in the year prior to diagnosis the patient had 1) documented seroconversion, 2) unequivocal symptoms of primary or secondary syphilis, or 3) a sex partner with primary, secondary, or early latent syphilis. Early latent infections are treated with the same penicillin regimen recommended for primary or secondary syphilis. Late latent infections should be treated with a series of three weekly injections of 2.4 million units of benzathine penicillin G im. In patients with presumed latent syphilis, lumbar puncture is indicated by neurological or ophthalmic signs or symptoms, evidence of active tertiary syphilis, treatment failure, or HIV infection. Follow-up for latent syphilis should include serologic testing at 6, 12, and 24 months.
Tertiary syphilis other than neurosyphilis such as gummatous disease or cardiovascular syphilis is treated with the same regimen used for late latent syphilis. Such patients should receive a lumbar puncture. The guidelines suggest that these patients always be managed in consultation with an expert.
Neurosyphilis can occur at any stage of syphilis, and neurological and ophthalmic signs or symptoms raise suspicion. Patients diagnosed with neurosyphilis or syphilitic eye disease should be treated with aqueous crystalline penicillin G (18–24 million units/day, administered as 3–4 million units iv every 4 hours for 10–14 days). If compliance is ensured, an alternative is procaine penicillin (2.4 million units im/day, plus probenecid 500 mg orally four times/day, both for 10–14 days). Examination of CSF in 6 months should show a decrease in cell count. The VDRL-CSF and CSF protein should return to normal within 2 years. If either condition is not met, re-treatment should be considered.
Sexual partners of patients may require evaluation and treatment. Partners exposed within the 90 days preceding the patient's diagnosis of primary, secondary, or early latent syphilis should be treated presumptively. Partners exposed more than 90 days before the patient's diagnosis of primary, secondary, or early latent syphilis should be treated presumptively if follow-up is uncertain and serologic test results for the partner are not immediately available. Long-term partners of patients with late syphilis should be evaluated clinically and serologically and treated based on the evaluation.
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Case Illustration
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Mr. B., a 33-year-old married black male with a 10-year history of cocaine use presented to a university hospital with suicidal ideation. Unemployed and spending $200/week on cocaine for months, Mr. B. tried to jump out of a moving vehicle three times on the way to the emergency room. He had noted decreased sleep, energy, and appetite with a depressed mood over recent weeks. His wife reported his irritability and angry outbursts. In addition, Mr. B. described recently seeing "green men."
Mr. B. reported 2 weeks of outpatient rehabilitation recently with no success, but he had never sought help prior to that. He had no known medical history and took no medications. He denied any other drug or alcohol use. Review of systems revealed blurry vision in the left eye following an untreated eye trauma 1 year previously. Physical examination on admission revealed no notable findings.
On mental status examination, Mr. B. was slightly disheveled and unkempt with mild psychomotor retardation. He cooperated, but his mood was depressed and irritable. His speech was slow and rambling but understandable with no slurring. Mr. B. reported tersely that he sometimes saw green men who were not there, but there were no auditory hallucinations. There was no evidence of delusion or psychotic thought content, but he reported suicidal ideation and intent to do it any way he could. He was oriented to person, place, month, and year but not exact date. On cognitive screening, this literate man who had received a GED could remember only two of three items at 5 minutes and had trouble calculating and abstracting. His fund of knowledge appeared limited. His judgment and insight were judged impaired.
Mr. B. thus appeared to have cocaine dependence, probable cocaine-induced depression, and probable cocaine-induced psychosis with hallucinations during intoxication. He was admitted to stabilize his suicidal ideation and intensify his rehabilitation efforts. His initial presentation seemed typical, and it was expected that the intensity of his depression and his cloudy cognition would abate with each sober day.
Mr. B.'s laboratory data all returned normal except a reactive RPR with a titer of 1:128. Meanwhile by the second day in the hospital, he appeared increasingly confused with complaints of disorientation and poor memory. A head CT showed no structural problems, and neurological consultation on the third hospital day found him oriented to person, city, and hospital but not to exact location or date, including month or year. Slight horizontal nystagmus and slow pupillary reaction were noted. Mr. B. gave a history of a recent minor head injury, but the CT did not show any bleeding or structural injury. A lumbar puncture was recommended, and meanwhile the MHA-TP returned positive.
On the fourth hospital day, a Folstein Mini-Mental State Exam yielded a score of 14/30. The lumbar puncture that day showed normal protein, elevated white cell count, and VDRL reactive 1:4. Penicillin G (4 million units iv every 4 hours for 14 days) was initiated for neurosyphilis, as recommended by infectious disease specialists. Over the first several days of the antibiotic course, Mr. B.'s mental status cleared, and by the third day of treatment his Mini-Mental State Exam score was 29/30. He denied any further hallucinations, his mood improved, and his suicidal ideation resolved. He tested HIV negative, and his wife agreed to clinical evaluation and testing for syphilis.
Mr. B. successfully completed the intravenous antibiotics at home with help from a home health agency and his wife. At follow-up at an infectious disease clinic, Mr. B. remained well with a RPR positive at a titer of 1:32. He was sober at the time with no mental status complaints.
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Discussion
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This patient might not have been diagnosed with neurosyphilis if the RPR had not been performed. His known risk factors included black race, a substance-related disorder, and living in an area with high prevalence of syphilis. On initial presentation, no sign or symptom strongly suggested the need for screening—only minimal ophthalmic changes were noted on careful neurological examination. However, by the second hospital day it was clear that his mental status was further from his baseline than initially thought and that it was not entirely because of his recent cocaine use. His mental status appeared to deteriorate, and if he had presented with the mental status of the fourth hospital day, he could have been assessed as psychotic and simply been treated with antipsychotics. The risk of such a misdiagnosis would have been increased had no collateral history been available from his wife.
Even if neurosyphilis had been considered in the differential diagnosis under those conditions, the RPR might have been nonreactive in the presence of neurosyphilis. Few clinicians would have pursued that possibility with an MHA-TP. Thus, although he presented with many of the classic psychiatric symptoms of neurosyphilis, including impairment of judgment and functioning, memory impairment, psychosis, hostility, and confusion in conjunction with cognitive impairment, it could be argued that an element of luck uncovered this case and allowed adequate treatment to occur.
The robust clinical improvement was an atypical feature of this case.1 More commonly, when neurosyphilis of the general paresis variety is treated, clinical progression is halted, but little improvement in mental status is expected because of neuronal loss. This case was more likely a case of neurosyphilis of the meningovascular variety, in which the symptoms can fluctuate and often resolve with treatment.
The guidelines were followed in this case except in the area of follow-up for neurosyphilis. Repeat CSF examinations were not done, and the assessment of adequate treatment was made more on the basis of the clinical exam and the falling serologic titer.
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Conclusions
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Syphilis remains an infection of significance to clinical psychiatry. Psychiatric populations may be at increased risk of infection because of a variety of factors, including disinhibition or substance use leading to unprotected sexual activity, decreased capacity to understand instructions for safe sex, inadequate general medical services for the mentally ill, or reluctance to seek medical help. Psychiatrists can thus play an important role in the effort to eliminate this infection in the United States. Screening for patients at risk for infection, especially in areas with endemic levels of infection, should be done with serologic tests.
Neurosyphilis can present with protean psychiatric symptoms. Not only is a high index of suspicion in the psychiatrist crucial to the diagnosis of neurosyphilis, knowledge of the complexities of testing for syphilis reduces the chances of missing the diagnosis. Because serologic tests can revert to normal 2 years after infection, and treponemal tests are more likely to remain positive, employing a treponemal test can reduce the potential for missing neurosyphilis.
With proper treatment the prognosis can be optimistic for some patients, so the diagnosis of neurosyphilis should be aggressively pursued when the clinical picture suggests it. Some forms of neurosyphilis can occur at any stage of infection, and neurosyphilis that occurs early in the course of infection is especially responsive to treatment. Syphilis at all stages is susceptible to penicillin.
Although patients with syphilis no longer represent a large percentage of the psychiatric population, psychiatrists can still play a pivotal role in the control and elimination of this sexually transmitted disease and are often the last line of defense against the progression of neurosyphilis in infected patients. Vigilance must be combined with knowledge about the natural course, diagnosis, and treatment of syphilis.
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This article has been cited by other articles:
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H. L. Berkowitz
Argyll-Robertson Pupil and Neurosyphilis
Psychosomatics,
August 1, 2002;
43(4):
340 - 341.
[Full Text]
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ABSTRACT
INTRODUCTION