Examination of Cerebrospinal Fluid in Patients with Syphilis

Physicians' questions about the care of patients with syphilis often touch on the need for cerebrospinal fluid (CSF) examination. The question often goes as follows: "I am taking care of an elderly patient who has reactive blood tests (e.g., the Venereal Disease Research Laboratory [VDRL] and the fluorescent treponemal antibody [FTAABS] tests) for syphilis and has never received adequate antibiotic treatment. As part of my evaluation of this patient, should I perform a lumbar puncture?" This seemingly straightforward question is, in fact, complex and includes the issues of the diagnostic and therapeutic importance of CSF examination at each stage of syphilis and also the need for posttreatment CSF examination. Implicit in the question is the issue of which tests to perform on the CSF sample. Although some general guidelines for CSF examination are included in the recommendations for syphilis therapy published in 1976 by the Centers for Disease Control (CDC) [1], the data upon which these guidelines are based are not included. Furthermore, recent studies raise questions concerning the efficacy of some of the recommended treatment schedules for neurosyphilis [2-8] and, implicitly, question the indications for CSF examination. We will review, therefore, the available data on both the need for CSF examination in adult patients with syphilis and the tests that should be done. Because these data are somewhat incomplete and sometimes contradictory, some of our conclusions can only be tentative.