Tabes Dorsalis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2] Aysha Anwar, M.B.B.S[3] Nate Michalak, B.A.

Overview

Penicillin, administered intravenously, is the treatment of choice of tabes dorsalis. Preventive treatment for those who come into sexual contact with an individual with tabes dorsalis is important. CNS involvement can occur during any stage of syphilis. Associated pain can be treated with opiates, valproate, or carbamazepine. Patients may also require physical or rehabilitative therapy to deal with muscle wasting and weakness.

Management of tabes dorsalis

The goals of treatment are to cure the infection and slow the progression of the disorder. Treating the infection helps prevent new nerve damage and may reduce symptoms, but it does not reverse existing nerve damage.

Symptoms of existing neurologic damage need to be treated. People who are unable to eat, dress themselves, or take care of themselves may need help. Rehabilitation, physical therapy, and occupational therapy may help people who have muscle weakness.

  • If intravenous administration is not possible, then procaine penicillin is an alternative (administered daily with probenecid for two weeks).
  • Procaine injections are painful, however, and patient compliance may be difficult to ensure.
  • To approximate the 21-day course of therapy for late latent disease and to address concerns about slowly dividing treponemes, most experts now recommend 3 weekly doses of benzathine penicillin G after the completion of a 14-day course of aqueous crystalline or aqueous procaine penicillin G for tabes dorsalis.
  • No oral antibiotic alternatives are recommended for the treatment of tabes dorsalis. The only alternative that has been studied and shown to be effective is intramuscular ceftriaxone daily for 14 days.

CDC Recommendations: Pharmacotherapy [3]

Recommended Regimen:

Alternative regimen:

If compliance with therapy can be ensured, the following alternative regimen might be considered.

  • The duration of the recommended and alternative regimens for tabes dorsalis are shorter than the duration of the regimen used for late syphilis in the absence of tabes dorsalis. Therefore, benzathine penicillin, 2.4 million units IM once per week for up to 3 weeks, can be considered after completion of these tabes dorsalis treatment regimens to provide a comparable total duration of therapy.

Other Management Considerations

  • Other considerations in the management of patients who have tabes dorsalis are as follows:

Special Considerations

Penicillin Allergy: Alternative Regimen

  • Limited data suggest that ceftriaxone 2 g daily either IM or IV for 10-14 days can be used as an alternative treatment for patients with tabes dorsalis.[4][5]
  • Other regimens have not been adequately evaluated for treatment of tabes dorsalis. Therefore, if concern exists regarding the safety of ceftriaxone for a patient with tabes dorsalis, skin testing should be performed (if available) to confirm penicillin allergy and, if necessary, desensitize the patient.

Pregnancy:

Tabes dorsalis Among HIV-Infected Persons:

  • HIV-infected patients with tabes dorsalis should be treated according to the recommendations for HIV-negative patients with tabes dorsalis.
  • HIV-infected, penicillin-allergic patients who have tabes dorsalis should be managed according to the recommendations for penicillin-allergic, HIV-negative patients with tabes dorsalis.
  • Several small observational studies conducted in HIV-infected patients with tabes dorsalis suggest that ceftriaxone 1-2 g IV daily for 10-14 days might be effective as an alternate agent.[6][7][8]

Follow-Up

  • Follow-up CSF examinations also can be used to evaluate changes in the CSF-VDRL or CSF protein after therapy; however, changes in these two parameters occur more slowly than cell counts, and persistent abnormalities might be less important.[9][10]
  • The leukocyte count is a sensitive measure of the effectiveness of therapy. If the cell count has not decreased after 6 months or if the CSF cell count or protein is not normal after 2 years, re-treatment should be considered.
  • Follow-up for tabes dorsalis Among HIV-Infected Persons
  • Follow-up CSF examinations also can be used to gauge response after therapy
  • If the cell count has not decreased after 6 months or if the CSF is not normal after 2 years, re-treatment should be considered.

References

  1. Musher DM (1991). "Syphilis, neurosyphilis, penicillin, and AIDS". J Infect Dis. 163 (6): 1201–6. PMID 2037785.
  2. http://www.cdc.gov/std/tg2015/syphilis.htm#Neurosyphilis Accessed on September 27, 2016
  3. "Sexually Transmitted Diseases Treatment Guidelines, 2010". Retrieved 2012-12-19.
  4. Hook EW, Baker-Zander SA, Moskovitz BL, Lukehart SA, Handsfield HH (1986) Ceftriaxone therapy for asymptomatic neurosyphilis. Case report and Western blot analysis of serum and cerebrospinal fluid IgG response to therapy. Sex Transm Dis 13 (3 Suppl):185-8. PMID: 3764632
  5. Shann S, Wilson J (2003) Treatment of neurosyphilis with ceftriaxone. Sex Transm Infect 79 (5):415-6. PMID: 14573840
  6. Dowell ME, Ross PG, Musher DM, Cate TR, Baughn RE (1992) Response of latent syphilis or neurosyphilis to ceftriaxone therapy in persons infected with human immunodeficiency virus. Am J Med 93 (5):481-8. PMID: 1442850
  7. Smith NH, Musher DM, Huang DB, Rodriguez PS, Dowell ME, Ace W et al. (2004) Response of HIV-infected patients with asymptomatic syphilis to intensive intramuscular therapy with ceftriaxone or procaine penicillin. Int J STD AIDS 15 (5):328-32. DOI:10.1258/095646204323012823 PMID: 15117503
  8. Ghanem KG, Moore RD, Rompalo AM, Erbelding EJ, Zenilman JM, Gebo KA (2008) Antiretroviral therapy is associated with reduced serologic failure rates for syphilis among HIV-infected patients. Clin Infect Dis 47 (2):258-65. DOI:10.1086/589295 PMID: 18532887
  9. Marra CM, Maxwell CL, Tantalo L, Eaton M, Rompalo AM, Raines C et al. (2004) Normalization of cerebrospinal fluid abnormalities after neurosyphilis therapy: does HIV status matter? Clin Infect Dis 38 (7):1001-6. DOI:10.1086/382532 PMID: 15034833
  10. 10.0 10.1 Marra CM, Maxwell CL, Tantalo LC, Sahi SK, Lukehart SA (2008) Normalization of serum rapid plasma reagin titer predicts normalization of cerebrospinal fluid and clinical abnormalities after treatment of neurosyphilis. Clin Infect Dis 47 (7):893-9. DOI:10.1086/591534 PMID: 18715154

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