Syphilitic myelopathy

Answer 1

Definition

Syphilitic myelopathy is a complication of untreated syphilis that involves muscle weakness and abnormal sensations.

Alternative Names

Tabes dorsalis

Causes, incidence, and risk factors

Syphilitic myelopathy is a form of neurosyphilis, which is a complication of late or tertiary syphilisinfection. Syphilis is a sexually transmitted, infectious disease. For information on the disease, see: Syphilis.

The condition called tabes dorsalis includes syphilitic myelopathy and additional symptoms of nerve damage.

The infection damages the tissue of the spinal cord and peripheral nervous tissue. This causes decreased muscle function (myelopathy), including progressive weakness of the legs, arms, and other areas. Loss of function may eventually result in paralysis.

Coordination difficulties contribute to problems walking. There are often changes in sensation, including painful paresthesia (abnormal sensations), which are also referred to as "lightning pains."

In syphilitic myelopathy, the muscle problems are accompanied by other symptoms characteristic of nervous system damage caused by syphilis. These include vision changes, stroke, and psychiatric illness.

Syphilitic myelopathy is now very rare because syphilis is usually treated early in the disease or as a result of screening blood tests that identify the disease in its latent (silent) form. Such blood tests are performed, for example, on individuals who donate blood and during pregnancy.

Symptoms

• Abnormal sensations, often called "lightning pains"
• Difficulty walking
• Loss of coordination
• Loss of reflexes
• Muscle weakness
• Wide-based gait (the person walks with the legs far apart)

Signs and tests

Physical examination may suggest myelopathy. Decreased or absent reflexes may be present due to nerve damage.

Tests may include the following:

• Head CT, spine CT, or MRI scans of the brain and spinal cord to rule out other diseases
• Serum VDRL or serum RPR (used as a screening test for syphilis infection -- if positive, one of the following will be required to confirm the diagnosis):
  • FTA-ABS
  • MHA-TP
• CSF (cerebrospinal fluid) examination
  • abnormal results indicating chronic meningitis
  • a positive neurosyphilis test (CSF VDRL test)

Treatment

The goals of treatment are to cure the infection and to reduce progression of the disorder. Treatment of the infection reduces new nerve damage and may reduce symptoms but does not cure existing nerve damage.

For neurosyphilis, aqueous penicillin G (by injection) is the drug of choice. Some patients with penicillin Allergies may undergo desensitization to penicillin so that they can be safely treated with it.

Treatment of symptoms is required for existing neurologic damage. Assistance or supervision may be needed if the person is unable to perform self-care activities (eating, dressing, etc.). Rehabilitation, physical therapy, occupational therapy, or other interventions may be appropriate for people with muscle weakness.

Analgesics may be required to control pain. These may include over-the-counter medications such as aspirin (oral salicylates) or acetaminophen for mild pain but narcotics may be required. Anti-epilepsy drugs such as carbamazepine may have a role in the treatment of lightning pains.

Expectations (prognosis)

Progressive disability is possible if the disorder is left untreated.

Complications

• Complications of late-stage syphilis infection, which may include:
  • Inflammation of the aorta (aortitis) with aortic aneurysm
  • Disease of the heart valves
  • Destructive changes in bones, skin, and other organs
• Complications of neurosyphilis, including dementia, strokes, eye disease
• Difficulty with walking and balance

Calling your health care provider

Call your health care provider if loss of coordination, loss of muscle strength, or loss of sensationoccurs.

Prevention

Adequate treatment and follow-up of primary syphilis infections reduces the risk of developing syphilitic myelopathy.

If you are sexually active, practice safe sex and always use a condom.

All pregnant women should be screen for syphilis.

References

Centers for Disease Control and Prevention (CDC). Recommendations and Reports: Sexually Transmitted Diseases. MMWR Morb Mortal Wkly Rep. 2006;55(RR-11).

U.S. Preventive Services Task Force. Screening for Syphilis Infection: Recommendation Statement. Ann Fam Med. 2004;2:362-365.

Hook EW III. Syphilis. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 340.

Tremont EC. Treponema pallidum (Syphilis). In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 6th ed. Philadelphia, Pa: Churchill Livingstone Elsevier; 2005: chap 235.

Answer 2

Definition

Syphilitic myelopathy is a complication of untreated syphilis that involves muscle weakness and abnormal sensations.

Alternative Names

Locomotor ataxia

Causes, incidence, and risk factors

Syphilitic myelopathy is a form of neurosyphilis, which is a complication of late or tertiary syphilis infection. Syphilis is a sexually transmitted, infectious disease. For information on the disease, see: Syphilis.

The condition called tabes dorsalis includes syphilitic myelopathy and other symptoms of nerve damage.

The infection damages the spinal cord and peripheral nervous tissue.

Syphilitic myelopathy is now very rare because syphilis is usually treated early in the disease. Blood tests can identify the disease in its silent (latent) form. People who donate blood and pregnant women are given these tests.

Symptoms

• Abnormal sensations (paresthesia), often called "lightning pains"
• Difficulty walking
• Loss of coordination
• Loss of reflexes
• Muscle weakness
• Wide-based gait (the person walks with the legs far apart)

In syphilitic myelopathy, there are also symptoms of nervous system damage, including:

• Mental illness
• Stroke
• Vision changes

Signs and tests

Physical examination may show:

• Damage to the spinal cord (myelopathy)
• Pupils that react abnormally to light
• Reduced or absent reflexes due to nerve damage

Tests may include the following:

• CSF (cerebrospinal fluid) examination
• Head CT, spine CT, or MRI scans of the brain and spinal cord to rule out other diseases
• Serum VDRL or serum RPR (used as a screening test for syphilis infection -- if it is positive, one of the following tests will be needed to confirm the diagnosis):
  • FTA-ABS
  • MHA-TP

Treatment

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.

For neurosyphilis, aqueous penicillin G (by injection) is the drug of choice. Some patients with penicillin allergies may have to be desensitized to penicillin so that they can be safely treated with it.

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.

You may needanalgesics 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.

Expectations (prognosis)

Progressive disability is possible if the disorder is left untreated.

Complications

• Complications of late-stage syphilis infection, which may include:
  • Inflammation of the aorta (aortitis) with aortic aneurysm
  • Disease of the heart valves
  • Damage to bones, skin, and other organs
• Complications of neurosyphilis, including dementia, stroke, eye disease
• Difficulty with walking and balance
• Paralysis

Calling your health care provider

Call your health care provider if you have:

• Loss of coordination
• Loss of muscle strength
• Loss of sensation

Prevention

Proper treatment and follow-up of primary syphilis infections reduces the risk of developing syphilitic myelopathy.

If you are sexually active, practice safe sex and always use a condom.

All pregnant women should be screened for syphilis.

References

Centers for Disease Control and Prevention (CDC). Recommendations and Reports: Sexually Transmitted Diseases. MMWR Morb Mortal Wkly Rep. 2006;55(RR-11).

U.S. Preventive Services Task Force. Screening for syphilis infection in pregnancy: reaffirmation recommendation statement. Ann Fam Med. 2009;150:705-709.

Screening for Syphilis Infection. Topic Page. July 2004. U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality, Rockland, MD. Accessed 6/28/2010.

Hook EW III. Syphilis. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 340.

Tremont EC. Treponema pallidum (syphilis). In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Churchill Livingstone Elsevier; 2009: chap 238.

Reviewed By

Review Date: 08/30/2010

Linda Vorvick, MD, Medical Director, MEDEX Northwest Division of Physician Assistant Studies, University of Washington School of Medicine; and Jatin Vyas, MD, PhD, Assistant Professor in Medicine, Harvard Medical School, Assistant in Medicine, Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.