Syphilitic meningitis is an inflammation of the meninges that occurs as a result of infection of the body with pale treponema. The disease can develop at any stage of syphilis. Inflammation occurs in an asymptomatic, acute or chronic form, manifested by headaches, symptoms of irritation of the meninges, signs of damage to the cranial nerves. Neuroimaging, cerebrospinal fluid examination, serological reactions are performed for diagnosis. The basis of treatment is antibiotic therapy, diuretics, glucocorticoids, neuroprotectors are used as pathogenetic agents.
ICD 10
A51.4 A52.1
General information
Neurosyphilis accounts for 0.5% of all neurological diseases. The prevalence of syphilitic meningitis depends on its form. Up to 9.5% of patients face this CNS lesion in the primary period of the syphilitic process. In the secondary and tertiary phases, against the background of the absence or inferiority of treatment, signs of pathology develop in 40% of patients. Neurosyphilis is an urgent problem in practical neurology, due to the prevalence of venereal infection, late circulation, and the risk of life-threatening consequences.
Causes
The causative agent of syphilitic meningitis is pale treponema (Treponema pallidum). In 95-98% of cases, it is transmitted sexually from a patient in any period of syphilis, less often there is a hemocontact, indirect household way of infection. Pale treponema spreads through the body by hematogenic and lymphogenic pathways, in addition, they can penetrate the blood-brain barrier, which is associated with a high frequency of meningitis in patients with syphilis.
Pathogenesis
Macroscopically, with syphilitic inflammation of the cerebral membranes, signs of their thickening and turbidity are determined, which indicates the serous form of the disease. In the later stages, gum meningitis is formed, in which proliferative processes prevail — gray-red tubercles 1-2 mm in size are formed, located in the soft meninges. Pathological changes are most often localized on the basal surface of the brain.
Microscopic signs of the inflammatory process include cellular infiltrates from lymphocytes, plasma cells with predominant localization on the lower cerebral surface. Then there is exudate, which spreads along the cerebral cisterns from the area of the visual intersection to the entire basal part of the brain and the lateral furrow. Gummas in histological examination are clusters of giant, plasma and lymphoid cells.
Symptoms
Asymptomatic syphilitic meningitis
Latent syphilitic meningitis mainly develops during the first months after infection with syphilis. With a long-existing infection, its frequency decreases sharply. It is manifested by changes in the cerebrospinal fluid, clinical signs are usually absent. Occasionally, patients present nonspecific complaints of the type of periodic headaches, increased fatigue, visual impairment.
Acute syphilitic meningitis
The disease occurs more often at 1-2 years of illness. The predisposing factor is too early termination of the course of treatment or incomplete therapy. The acute form of syphilitic lesion is called neurorecidivism, its clinical picture combines the classic signs of meningeal inflammation with lesions of the cranial nerves.
The disease begins acutely with an increase in temperature to 38-39 ° C (subfebrility is also possible), severe headache, repeated vomiting, which does not bring relief. Pathological signs are amplified by loud sounds, bright light, and touching. The defeat of the cerebral membranes is manifested by painful tension of the occipital muscles, positive symptoms of Kernig and Brudzinsky.
In acute syphilitic meningitis, convulsive seizures often occur, signs of mental disorders in the form of agitation or depression. The damage to the oculomotor nerves is indicated by involuntary drooping of the upper eyelid, strabismus, double vision. Involvement of the facial nerve in the process is characterized by impoverishment of facial expressions of half of the face, lowering of the corner of the mouth on the side of the lesion.
Chronic syphilitic meningitis
Pathology is mainly formed in the tertiary period of infection, 3-5 years or more after infection with pale treponema. The main symptom of the disease is severe headache of a diffuse or focal nature, increasing at night. Occasionally they are combined with dizziness, vomiting, hyperesthesia. Meningeal signs are weakly expressed, may be absent altogether.
Body temperature remains normal or rises to subfebrile. With late neurosyphilis, the Argyle-Robertson pathognomonic symptom is revealed, which consists in the absence of a pupillary reflex to light while maintaining the ability to accommodate and converge. Most patients have signs of damage to the oculomotor, block and diverting nerves that innervate the movements of the eyeballs.
Complications
In the acute form, there is often a rapid development of the clinical picture with the addition of signs of hydrocephalus, cerebral edema, Meniere’s symptom complex — unilateral hearing loss, ear congestion, attacks of systemic dizziness. With the rapid progression of the process, there is a risk of multiple organ failure and death, especially in patients who do not receive correct anti-syphilitic treatment.
Chronic meningitis in syphilis is often complicated by compression of the cranial roots due to the formation of multiple gummae. At the same time, persistent paresis of the oculomotor nerves, progressive deterioration of visual acuity as a result of atrophy of the optic nerves, trigeminal neuralgia are observed. With long-term gum meningitis, signs of compression of the medulla appear.
Treatment of neurosyphilis with antibiotics may be complicated by the Yarish-Herksheimer reaction — a sudden deterioration in the condition on the first day due to the death of pathogens and massive intoxication of the body. The condition is manifested by febrile fever, a sharp drop in blood pressure, myalgia and cephalgia. The appearance of signs of pathology is not a reason to cancel antibiotic therapy.
Diagnostics
The examination of the patient is carried out by a neurologist together with a dermatovenerologist. In the acute course of the disease, typical meningeal signs are determined, and making a clinical diagnosis with a latent or chronic course is difficult. To identify meningitis and confirm its syphilitic etiology , the following are performed:
- CT scan of the brain. Neuroimaging is necessary to detect thickening of the meninges, detect syphilitic gum and clarify their localization. With complications of the process, the CT results show signs of hydrocephalus, atrophy of the brain substance.
- CSF research. Sufferers of syphilitic meningitis have lymphocytic pleiocytosis with a small admixture of neutrophils, an increase in the amount of protein. Macroscopically, the cerebrospinal fluid is transparent, sometimes a fibrin film forms in it, as in tuberculosis inflammation. A specific sign of infection — the Wasserman reaction (WR) — in CSF is always positive.
- Serological reactions. To confirm syphilis, non-specific tests are performed for antibodies to pale treponema (rapid plasma reagin test, WR), reactions to species-specific antibodies (immunofluorescence analysis, pale treponema immobilization reaction).
Treatment
Syphilitic meningitis requires etiotropic treatment — parenteral antibiotic therapy with high doses of penicillins, to which pale treponema is sensitive. Alternative regimens may include tetracyclines, cephalosporins. To improve the penetration of antibiotics through the BBB, uric acid reabsorption inhibitors are used. Pathogenetic therapy includes drugs of the following groups:
- Diuretics. With signs of intracranial hypertension, osmotic diuretics, saluretics, oncodehydrants are prescribed to prevent cerebral edema-swelling. Taking medications is carried out under strict control of the volume of infusion therapy and diuresis.
- Glucocorticoids. Recommended for the elimination of brain edema, relief of the Yarish-Herksheimer reaction.
- Neuroprotectors. To protect the cerebral tissue from damage and hypoxia, neurometabolic drugs, antioxidants, and B vitamins are administered.
- Means that improve microcirculation. Antiplatelet agents and anticoagulants are used to correct the coagulogram and prevent thrombosis.
- Immunostimulants. In order to increase the effectiveness of antibiotic therapy, biogenic stimulants and synthetic immunomodulators are indicated.
In severe cases, patients require oxygen support to eliminate hypoxia. With the development of brain edema, an emergency transfer to a ventilator is necessary. During the convalescence of syphilitic meningitis, courses of physiotherapy, physical therapy, respiratory gymnastics are recommended, which accelerate recovery after the disease, prevent long-term complications.
Recovery in neurosyphilis is determined by the results of studies of the cerebrospinal fluid. The first control diagnosis is carried out six months after the end of the course of antibiotic therapy. The following signs indicate a positive trend — a sharp decrease in cytosis, a gradual decrease in protein levels. The results of serological reactions to syphilis may remain positive for about 1-2 years after the end of treatment, provided that there is a continuing tendency to decrease them.
Prognosis and prevention
Syphilitic meningitis responds well to treatment with timely detection of its signs. Therefore, the forecast is relatively favorable. The prognosis is less optimistic in patients with tertiary syphilis, multiple manifestations of neurosyphilis. Prevention consists in preventive treatment of partners of a patient with syphilis, educational work among the population, examinations of representatives of risk groups and blood donors.