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[[Penicillin]], administered [[intravenous]]ly, 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 [[opiate]]s, [[valproate]], or [[carbamazepine]]. Patients may also require physical or rehabilitative therapy to deal with [[muscle wasting]] and [[weakness]]. | [[Penicillin]], administered [[intravenous]]ly, 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 [[opiate]]s, [[valproate]], or [[carbamazepine]]. Patients may also require physical or rehabilitative therapy to deal with [[muscle wasting]] and [[weakness]]. | ||
==Management of | ==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]]. | 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 medicine|Rehabilitation]], [[physical therapy]], and occupational therapy may help people who have [[muscle weakness]]. | 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 medicine|Rehabilitation]], [[physical therapy]], and occupational therapy may help people who have [[muscle weakness]]. | ||
* | :* The recommended regimen is intravenous [[Penicillin#Benzylpenicillin (penicillin G)|aqueous crystalline penicillin G]] every 4 hours or continuously for 10-14 days.<ref name="pmid2037785">{{cite journal| author=Musher DM| title=Syphilis, neurosyphilis, penicillin, and AIDS. | journal=J Infect Dis | year= 1991 | volume= 163 | issue= 6 | pages= 1201-6 | pmid=2037785 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2037785 }} </ref><ref name="cdc2015">http://www.cdc.gov/std/tg2015/syphilis.htm#Neurosyphilis Accessed on September 27, 2016</ref> | ||
:*If intravenous administration is not possible, then [[Penicillin G procaine|procaine penicillin]] is an alternative (administered daily with [[probenecid]] for two weeks). | :*If intravenous administration is not possible, then [[Penicillin G procaine|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. | :*Procaine injections are painful, however, and patient compliance may be difficult to ensure. | ||
:*To approximate the 21-day course of therapy for [[Syphilis pathophysiology#Latent syphilis|late latent disease]] and to address concerns about slowly dividing treponemes, most experts now recommend 3 weekly doses of [[Penicillin#Benzylpenicillin (penicillin G)|benzathine penicillin G]] after the completion of a 14-day course of aqueous crystalline or aqueous procaine penicillin G for | :*To approximate the 21-day course of therapy for [[Syphilis pathophysiology#Latent syphilis|late latent disease]] and to address concerns about slowly dividing treponemes, most experts now recommend 3 weekly doses of [[Penicillin#Benzylpenicillin (penicillin G)|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 | *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 <ref name="urlSexually Transmitted Diseases Treatment Guidelines, 2010">{{cite web |url=http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm |title=Sexually Transmitted Diseases Treatment Guidelines, 2010 |format= |work= |accessdate=2012-12-19}}</ref>=== | ===CDC Recommendations: Pharmacotherapy <ref name="urlSexually Transmitted Diseases Treatment Guidelines, 2010">{{cite web |url=http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm |title=Sexually Transmitted Diseases Treatment Guidelines, 2010 |format= |work= |accessdate=2012-12-19}}</ref>=== | ||
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*[[Penicillin#Procaine benzylpenicillin|Procaine penicillin]] 2.4 million units IM once daily, plus [[probenecid]] 500 mg orally four times a day, both for 10-14 days. | *[[Penicillin#Procaine benzylpenicillin|Procaine penicillin]] 2.4 million units IM once daily, plus [[probenecid]] 500 mg orally four times a day, both for 10-14 days. | ||
If compliance with therapy can be ensured, the following alternative regimen might be considered. | If compliance with therapy can be ensured, the following alternative regimen might be considered. | ||
*The duration of the recommended and alternative regimens for | *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, [[Penicillin#Benzylpenicillin (penicillin G)|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 Management Considerations=== | ||
*Other considerations in the management of patients who have | *Other considerations in the management of patients who have tabes dorsalis are as follows: | ||
:*All persons who have syphilis should be tested for [[HIV|HIV.]] | :*All persons who have syphilis should be tested for [[HIV|HIV.]] | ||
:*Although systemic steroids are used frequently as adjunctive therapy for otologic syphilis, such drugs have not been proven to be beneficial. | :*Although systemic steroids are used frequently as adjunctive therapy for otologic syphilis, such drugs have not been proven to be beneficial. | ||
| Line 37: | Line 36: | ||
==== Penicillin Allergy: Alternative Regimen ==== | ==== 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 | *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.<ref name="pmid3764632">Hook EW, Baker-Zander SA, Moskovitz BL, Lukehart SA, Handsfield HH (1986) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=3764632 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: [http://pubmed.gov/3764632 3764632]</ref><ref name="pmid14573840">Shann S, Wilson J (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14573840 Treatment of neurosyphilis with ceftriaxone.] Sex Transm Infect 79 (5):415-6. PMID: [http://pubmed.gov/14573840 14573840]</ref> | ||
*The possibility of cross-reactivity between [[ceftriaxone]] and [[penicillin]] exists. | *The possibility of cross-reactivity between [[ceftriaxone]] and [[penicillin]] exists. | ||
*Other regimens have not been adequately evaluated for treatment of | *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, [[Syphilis medical therapy#Pencillin allergy: Penicillin skin test|skin testing]] should be performed (if available) to confirm [[Syphilis medical therapy#Pencillin allergy|penicillin allergy]] and, if necessary, [[desensitize]] the patient. | ||
==== Pregnancy: ==== | ==== Pregnancy: ==== | ||
*Pregnant patients who are [[Syphilis medical therapy#Pencillin allergy|allergic to penicillin]] should be [[desensitize]]d and treated with [[penicillin]]. | *Pregnant patients who are [[Syphilis medical therapy#Pencillin allergy|allergic to penicillin]] should be [[desensitize]]d and treated with [[penicillin]]. | ||
==== | ==== Tabes dorsalis Among HIV-Infected Persons: ==== | ||
*[[HIV]]-infected patients with | *[[HIV]]-infected patients with tabes dorsalis should be treated according to the recommendations for HIV-negative patients with tabes dorsalis. | ||
*HIV-infected, [[Syphilis medical therapy#Pencillin allergy|penicillin-allergic]] patients who have | *[[HIV]]-infected, [[Syphilis medical therapy#Pencillin allergy|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 | *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.<ref name="pmid1442850">Dowell ME, Ross PG, Musher DM, Cate TR, Baughn RE (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1442850 Response of latent syphilis or neurosyphilis to ceftriaxone therapy in persons infected with human immunodeficiency virus.] Am J Med 93 (5):481-8. PMID: [http://pubmed.gov/1442850 1442850]</ref><ref name="pmid15117503">Smith NH, Musher DM, Huang DB, Rodriguez PS, Dowell ME, Ace W et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15117503 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. [http://dx.doi.org/10.1258/095646204323012823 DOI:10.1258/095646204323012823] PMID: [http://pubmed.gov/15117503 15117503]</ref><ref name="pmid18532887">Ghanem KG, Moore RD, Rompalo AM, Erbelding EJ, Zenilman JM, Gebo KA (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18532887 Antiretroviral therapy is associated with reduced serologic failure rates for syphilis among HIV-infected patients.] Clin Infect Dis 47 (2):258-65. [http://dx.doi.org/10.1086/589295 DOI:10.1086/589295] PMID: [http://pubmed.gov/18532887 18532887]</ref> | ||
===Follow-Up=== | ===Follow-Up=== | ||
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*Follow-up CSF examinations also can be used to evaluate changes in the [[Syphilis laboratory findings#CSF analysis|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.<ref name="pmid15034833">Marra CM, Maxwell CL, Tantalo L, Eaton M, Rompalo AM, Raines C et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15034833 Normalization of cerebrospinal fluid abnormalities after neurosyphilis therapy: does HIV status matter?] Clin Infect Dis 38 (7):1001-6. [http://dx.doi.org/10.1086/382532 DOI:10.1086/382532] PMID: [http://pubmed.gov/15034833 15034833]</ref><ref name="pmid18715154">Marra CM, Maxwell CL, Tantalo LC, Sahi SK, Lukehart SA (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18715154 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. [http://dx.doi.org/10.1086/591534 DOI:10.1086/591534] PMID: [http://pubmed.gov/18715154 18715154]</ref> | *Follow-up CSF examinations also can be used to evaluate changes in the [[Syphilis laboratory findings#CSF analysis|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.<ref name="pmid15034833">Marra CM, Maxwell CL, Tantalo L, Eaton M, Rompalo AM, Raines C et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15034833 Normalization of cerebrospinal fluid abnormalities after neurosyphilis therapy: does HIV status matter?] Clin Infect Dis 38 (7):1001-6. [http://dx.doi.org/10.1086/382532 DOI:10.1086/382532] PMID: [http://pubmed.gov/15034833 15034833]</ref><ref name="pmid18715154">Marra CM, Maxwell CL, Tantalo LC, Sahi SK, Lukehart SA (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18715154 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. [http://dx.doi.org/10.1086/591534 DOI:10.1086/591534] PMID: [http://pubmed.gov/18715154 18715154]</ref> | ||
*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. | *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. | ||
*Limited data suggest that in immunocompetent persons and [[HIV|HIV-infected persons]] on highly active [[AIDS medical therapy#Anti Retroviral Therapy (ART)|antiretroviral therapy]], normalization of the [[Rapid plasma reagent|serum RPR titer]] predicts normalization of CSF parameters.<ref name="pmid18715154">Marra CM, Maxwell CL, Tantalo LC, Sahi SK, Lukehart SA (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18715154 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. [http://dx.doi.org/10.1086/591534 DOI:10.1086/591534] PMID: [http://pubmed.gov/18715154 18715154]</ref> | *Limited data suggest that in [[Immunocompetence|immunocompetent]] persons and [[HIV|HIV-infected persons]] on highly active [[AIDS medical therapy#Anti Retroviral Therapy (ART)|antiretroviral therapy]], normalization of the [[Rapid plasma reagent|serum RPR titer]] predicts normalization of [[CSF]] parameters.<ref name="pmid18715154">Marra CM, Maxwell CL, Tantalo LC, Sahi SK, Lukehart SA (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18715154 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. [http://dx.doi.org/10.1086/591534 DOI:10.1086/591534] PMID: [http://pubmed.gov/18715154 18715154]</ref> | ||
*Follow-up for | *Follow-up for tabes dorsalis Among HIV-Infected Persons | ||
:*Follow-up CSF examinations also can be used to gauge response after therapy | |||
:*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. | :*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. | ||
Revision as of 20:52, 1 March 2018
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Tabes Dorsalis Microchapters |
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Tabes Dorsalis medical therapy On the Web |
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Risk calculators and risk factors for Tabes Dorsalis medical therapy |
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.
- The recommended regimen is intravenous aqueous crystalline penicillin G every 4 hours or continuously for 10-14 days.[1][2]
- 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:
- Aqueous crystalline penicillin G 18-24 million units per day, administered as 3-4 million units IV every 4 hours or continuous infusion, for 10-14 days.
Alternative regimen:
- Procaine penicillin 2.4 million units IM once daily, plus probenecid 500 mg orally four times a day, both for 10-14 days.
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:
- All persons who have syphilis should be tested for HIV.
- Although systemic steroids are used frequently as adjunctive therapy for otologic syphilis, such drugs have not been proven to be beneficial.
- One may need analgesics to control pain. These may include over-the-counter medications such as aspirin or acetaminophen for mild pain, or narcotics for more severe pain. Anti-epilepsy drugs such as carbamazepine may help treat lightning pains.
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]
- The possibility of cross-reactivity between ceftriaxone and penicillin exists.
- 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:
- Pregnant patients who are allergic to penicillin should be desensitized and treated with penicillin.
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
- If CSF pleocytosis was present initially, a CSF examination should be repeated every 6 months until the cell count is normal.
- 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.
- Limited data suggest that in immunocompetent persons and HIV-infected persons on highly active antiretroviral therapy, normalization of the serum RPR titer predicts normalization of CSF parameters.[10]
- 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
- ↑ Musher DM (1991). "Syphilis, neurosyphilis, penicillin, and AIDS". J Infect Dis. 163 (6): 1201–6. PMID 2037785.
- ↑ http://www.cdc.gov/std/tg2015/syphilis.htm#Neurosyphilis Accessed on September 27, 2016
- ↑ "Sexually Transmitted Diseases Treatment Guidelines, 2010". Retrieved 2012-12-19.
- ↑ 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
- ↑ Shann S, Wilson J (2003) Treatment of neurosyphilis with ceftriaxone. Sex Transm Infect 79 (5):415-6. PMID: 14573840
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ 10.0 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