Written by Mary Marschner
Spoon Feed
Syphilis cases are rising; neurologic manifestations are rare, but more likely in the elderly and HIV positive, the two highest-incidence groups.
Syphilis is all the rage
Syphilis is an STI as old as mankind. It’s a weird little bug associated with classic presentations in medical school (i.e. chancre, Argyll-Robinson pupils, tabes dorsalis), but can manifest itself in diverse ways over many years, making diagnosis challenging. Cases have significantly increased in recent years, with neurological manifestations of syphilis rising in particular, changing management.
This national surveillance data from 12 jurisdictions between 2019-2022 assessed the prevalence of neurologic manifestations among reported syphilis cases. The analysis of 171,855 cases showed an increasing prevalence of neurologic manifestations in both early (0.6% to 1.0%) and late syphilis (1.3% to 1.8%). Notably, older adults (65+) had a significantly higher prevalence (PR 7.5 for early, PR 22.6 for late vs. 15-24 year olds), and those with HIV also showed a higher prevalence (PR 1.2 for early, PR 1.5 for late). The overall annual prevalence remained low despite increases in syphilis cases.
Findings are limited and likely biased based on current screening guidelines and access to healthcare. Current guidelines recommend pregnant woman and men who have sex with men/transgender/gender-diverse people to get screened annually, and everyone else only if symptomatic. More men were identified with syphilis, but the number of women was very high, and I suspect we aren’t testing enough.
How does this change my practice?
In general, I’m going to be testing a lot more patients for syphilis and really keeping an eye out for neurologic symptoms, particularly in the elderly and in patients who also have HIV. Also, this study is only possible because of local health departments collecting infectious disease data, the National Notifiable Disease Surveillance System, and the Center for Disease Control. Given all the ongoing challenges to health departments regionally, nationally, and the cuts going on, we need to be vocal about supporting this type of work.
Another Spoonful
Need a refresher on neurosyphilis? Look no further…
Source
Reported Neurologic Manifestations Among Persons with Syphilis by Stage of Infection-12 States, 2019 -2022. Clin Infect Dis. 2025 Jan 17:ciaf015. doi: 10.1093/cid/ciaf015. Epub ahead of print. PMID: 39820304
