Neurosyphilis in HIV infection: persistence after high-dose penicillin therapy

Ten years after treatment of secondary syphilis a 44-year-old otherwise asymptomatic HIV-infected patient developed acute meningovascular syphilis with multifocal manifestations and neurological deficit. Whether it was a reactivation or new infection could not be established. High-dosage intravenous penicillin treatment failed to eliminate completely the CNS disease process. Inflammatory CSF findings with pleocytosis and demonstration of intrathecally formed specific antibodies, still present a year later, made it likely that the syphilitic infection was persisting. The concurrent HIV infection probably aggravated the course of the neurosyphilis. Serological tests for syphilis should be done in every HIV-infected patient, followed by CSF examination if the results are suspicious. Analogous to the known opportunistic CNS infections, a more extensive period of treatment should also be considered in the case of neurosyphilis in HIV-infected patients.