Infect Chemother.  2011 Jun;43(3):262-265. 10.3947/ic.2011.43.3.262.

Treatment of Neurosyphilis with Ceftriaxone in a Patient Infected with Human Immunodeficiency Virus

• Si WK
• Suh KH
• Lee MH
• Choi BK
• Hwang JA
• Kim CK

• KMID: 2170348
• DOI: http://doi.org/10.3947/ic.2011.43.3.262

Abstract

The optimal and alternative antimicrobial regimens to treat neurosyphilis in human immunodeficiency virus (HIV) infected patients remain controversial. Little is known concerning the efficacy of ceftriaxone. A 75-year-old heterosexual man visited an outpatient clinic due to incidentally detected positive serum Venereal disease research laboratory (VDRL) and Fluorescent treponemal antibody absorbed tests in routine preoperative checkup. Because of benzathine penicillin was unavailable to use, 4-week regimen with doxycycline was started. After 2 weeks doxycycline treatment, a severe headache suddenly occurred. Cerebrospinal fluid (CSF) analysis showed mild lymphocyte-dominant pleocytosis, increased protein, and weakly reactive VDRL test. ELISA for HIV antibody and Western blot assay revealed he is infected with HIV. Initial CD4+ T cell count was 220/mm3 and the load of HIV RNA was 5,200 copies/mL. The most probable diagnosis was deemed to be neurosyphilis, considering the possibilities of Jarisch-Herxheimer reaction or doxycycline-induced pseudotumor cerebri. In the absence of procaine penicillin G in our hospital, intravenous ceftriaxone was administered and highly active antiretroviral therapy was started. After 14days of treatment, the patient no longer had a headache and the CSF profile was improved. Additional follow-up CSF analysis was done 3months after treatment. CSF pleocytosis and protein level were decreased and the CSF VDRL was converted to negative. Ceftriaxone may be a good alternative in the treatment of neurosyphilis in HIV infected patient.

Keyword

Neurosyphilis; Human immunodeficiency virus (HIV); Ceftriaxone

MeSH Terms

Aged
Ambulatory Care Facilities
Antiretroviral Therapy, Highly Active
Blotting, Western
Ceftriaxone
Cell Count
Doxycycline
Enzyme-Linked Immunosorbent Assay
Ethylenediamines
Follow-Up Studies
Headache
Heterosexuality
HIV
Humans
Leukocytosis
Neurosyphilis
Penicillin G Benzathine
Penicillin G Procaine
Pseudotumor Cerebri
RNA
Sexually Transmitted Diseases
Ceftriaxone
Doxycycline
Ethylenediamines
Penicillin G Benzathine
Penicillin G Procaine
RNA

Reference

1. Doherty L, Fenton KA, Jones J, Paine TC, Higgins SP, Williams D, Palfreeman A. Syphilis: old problem, new strategy. BMJ. 2002. 325:153–156.

2. Bordón J, Martínez-Vázquez C, Alvarez M, Miralles C, Ocampo A, de la Fuente-Aguado J, Sopeña-Perez Arguelles B. Neurosyphilis in HIV-infected patients. Eur J Clin Microbiol Infect Dis. 1995. 14:864–869.

3. Workowski KA, Berman S. Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010. 59:1–110.

4. Marra CM, Maxwell CL, Smith SL, Lukehart SA, Rompalo AM, Eaton M, Stoner BP, Augenbraun M, Barker DE, Corbett JJ, Zajackowski M, Raines C, Nerad J, Kee R, Barnett SH. Cerebrospinal fluid abnormalities in patients with syphilis: association with clinical and laboratory features. J Infect Dis. 2004. 189:369–376.

5. Libois A, De Wit S, Poll B, Garcia F, Florence E, Del Rio A, Sanchez P, Negredo E, Vandenbruaene M, Gatell JM, Clumeck N. HIV and syphilis: when to perform a lumbar puncture. Sex Transm Dis. 2007. 34:141–144.

6. Rolfs RT, Joesoef MR, Hendershot EF, Rompalo AM, Augenbraun MH, Chiu M, Bolan G, Johnson SC, French P, Steen E, Radolf JD, Larsen S. The Syphilis and HIV Study Group. A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. N Engl J Med. 1997. 337:307–314.

7. Jaffe HW, Kabins SA. Examination of cerebrospinal fluid in patients with syphilis. Rev Infect Dis. 1982. 4:Suppl. S842–S847.

8. Lukehart SA, Hook EW 3rd, Baker-Zander SA, Collier AC, Critchlow CW, Handsfield HH. Invasion of the central nervous system by Treponema pallidum: implications for diagnosis and treatment. Ann Intern Med. 1988. 109:855–862.

9. Gregory N, Sanchez M, Buchness MR. The spectrum of syphilis in patients with human immunodeficiency virus infection. J Am Acad Dermatol. 1990. 22:1061–1067.

10. Goh BT, Smith GW, Samarasinghe L, Singh V, Lim KS. Penicillin concentrations in serum and cerebrospinal fluid after intramuscular injection of aqueous procaine penicillin 0.6 MU with and without probenecid. Br J Vener Dis. 1984. 60:371–373.

11. Gordon SM, Eaton ME, George R, Larsen S, Lukehart SA, Kuypers J, Marra CM, Thompson S. The response of symptomatic neurosyphilis to high-dose intravenous penicillin G in patients with human immunodeficiency virus infection. N Engl J Med. 1994. 331:1469–1473.

12. De Maria A, Solaro C, Abbruzzese M, Primavera A. Minocycline for symptomatic neurosyphilis in patients allergic to penicillin. N Engl J Med. 1997. 337:1322–1323.

13. Gentile JH, Viviani C, Sparo MD, Arduino RC. Syphilitic meningomyelitis treated with ceftriaxone: case report. Clin Infect Dis. 1998. 26:528.

14. Hook EW 3rd, Baker-Zander SA, Moskovitz BL, Lukehart SA, Handsfield HH. Ceftriaxone therapy for asymptomatic neurosyphilis. Case report and Western blot analysis of serum and cerebrospinal fluid IgG response to therapy. Sex Transm Dis. 1986. 13:3 Suppl. 185–188.

15. Cnossen WM, Niekus H, Nielsen O, Vegt M, Blansjaar BA. Ceftriaxone treatment of penicillin resistant neurosyphilis in alcoholic patients. J Neurol Neurosurg Psychiatry. 1995. 59:194–195.

16. Scheld WM, Rocha H, Sande MA, Bryan JP. Rationale for clinical trials evaluating ceftriaxone in the therapy of bacterial meningitis. Am J Med. 1984. 77:42–49.

17. Patel IH, Kaplan SA. Pharmacokinetic profile of ceftriaxone in man. Am J Med. 1984. 77:17–25.

18. Dowell ME, Ross PG, Musher DM, Cate TR, Baughn RE. Response of latent syphilis or neurosyphilis to ceftriaxone therapy in persons infected with human immunodeficiency virus. Am J Med. 1992. 93:481–488.

19. Marra CM, Boutin P, McArthur JC, Hurwitz S, Simpson PA, Haslett JA, van der Horst C, Nevin T, Hook EW 3rd. A pilot study evaluating ceftriaxone and penicillin G as treatment agents for neurosyphilis in human immunodeficiency virus-infected individuals. Clin Infect Dis. 2000. 30:540–544.