Warning:

This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:

• STD Treatment Guidelines   at http://www.cdc.gov/STD/treatment

---

1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV Prevention

Neurosyphilis

Treatment
     Central nervous system disease can occur during any stage of
syphilis. A patient with clinical evidence of neurologic
involvement (e.g., ophthalmic or auditory symptoms, cranial nerve
palsies) with syphilis warrants a CSF examination. Although four
decades of experience have confirmed the effectiveness of
penicillin, the evidence to guide the choice of the best regimen is
limited.

     Syphilitic eye disease is frequently associated with
neurosyphilis, and patients with this disease should be treated
according to neurosyphilis treatment recommendations. CSF
examination should be performed on all such patients to identify
those patients with CSF abnormalities who should have follow-up CSF
examinations to assess response to treatment.

     Patients who have neurosyphilis or syphilitic eye disease
(e.g., uveitis, neuroretinitis, or optic neuritis) and who are not
allergic to penicillin should be treated with the following
regimen.


Recommended Regimen -
     12-24 million units aqueous crystalline penicillin G daily,
     administered as 2-4 million units IV every 4 hours, for 10-14 days.

     If compliance with therapy can be assured, patients may be
treated with the following alternative regimen.

Alternative Regimen -
     2.4 million units procaine penicillin IM daily, plus
     probenecid 500 mg orally 4 times a day, both for 10-14 days.

     The durations of these regimens are shorter than that of the
regimen used for late syphilis in the absence of neurosyphilis.
Therefore, some experts administer benzathine penicillin, 2.4
million units IM after completion of these neurosyphilis treatment
regimens to provide a comparable total duration of therapy.

Other Management Considerations
     Other considerations in the management of the patient with
neurosyphilis are the following:

--   All patients with syphilis should be tested for HIV.

--   Many experts recommend treating patients with evidence of
     auditory disease caused by syphilis in the same manner as for
     neurosyphilis, regardless of the findings on CSF examination.

Follow-Up
     If CSF pleocytosis was present initially, CSF examination
should be repeated every 6 months until the cell count is normal.
Follow-up CSF examinations also may be used to evaluate changes in
the VDRL-CSF or CSF protein in response to therapy, though changes
in these two parameters are slower and persistent abnormalities are
of less certain importance. If the cell count has not decreased at
6 months, or if the CSF is not entirely normal by 2 years,
re-treatment should be considered.

Management of Sex Partners
     Refer to General Principles, Management of Sex Partners.

Special Considerations

Penicillin Allergy -
     No data have been collected systematically for evaluation of
therapeutic alternatives to penicillin for treatment of
neurosyphilis. Therefore, patients who report being allergic to
penicillin should be treated with penicillin, after desensitization
if necessary, or should be managed in consultation with an expert.
In some situations, skin testing to confirm penicillin allergy may
be useful (see Management of the Patient With a History of
Penicillin Allergy).

Pregnancy -
     Pregnant patients who are allergic to penicillin should be
treated with penicillin, after desensitization if necessary (see
Syphilis During Pregnancy).

HIV Infection -
     Refer to Syphilis Among HIV-Infected Patients.

---