Epidemiologia, apresentação clínica, diagnóstico e manejo dos pacientes com neurossífilis e alterações liquóricas no HC-HFMG entre 2011 e 2021

Abstract

Syphilis is a mostly sexually acquired, systemic, chronic and human exclusive bacterial disease caused by Treponema pallidum. Untreated disease evolution occurs into stages with paucisymptomatic initial phases and late phases with severe tissue damage that implicate high morbimortality. Neurosyphilis is the central nervous system invasion by T. pallidum and can occur at any disease’s stage, while syphilitic uveitis is characterized by T. pallidum primary uveal inflammation. Syphilis diagnose is based on treponemal and non-treponemal tests interpretation and is mandatory for neurosyphilis diagnosis, which is based on a set of cerebrospinal fluid (CSF) alterations. The literature advocates that posterior uveal involvement conditions should be considered neurosyphilis, despite the absence of CSF changes. Syphilis is a mandatory notification harm in Brazil, however, there is no neurosyphilis discrimination in its forms, which leads to clinical and epidemiological data lack. The aim of this study was to outline the clinical-epidemiological profile of neurosyphilis patients with CSF changes treated at HC-UFMG over a period of 11 years along with creation of future studies database. Based on HC-UFMG laboratory data, 575 patient’s charts with altered CSF and positivity for serum syphilis exams were selected; 397 were analyzed during the data acquirement timeline with a final 162 neurosyphilis with CSF alterations patients sample. We’ve evidenced Venereal Disease Research Laboratory (VDRL) tests positivity increase over the years, in agreement with syphilis reemergence. Total sample analysis showed more males with 127 patients (78.4%); median age of 51 [40.25 - 60] years; 102 (80.3%) syphilis first diagnostics; 132 (81.4%) syphilitic uveitis; 53 (32.7%) HIV co-infection. The estimated neurosyphilis proportion among syphilis serum positivity exams patients in HC-UFMG during the period of the study ranged from 1.12% to 1.56%; CSF-VDRL reached 67.9% sensitivity; 86.4% specificity and found moderate correlation between itself and serum VDRL titers (r=0.4716; p< 0.001; 95% confidence interval [CI] [0.331 - 0.592]). In HIV positive versus negative correlation there was statistically significant association in HIV positive group (p<0.05) with: 1) male gender; 2) younger age; 3) higher serum VDRL titer; 4) B and C hepatitis co-infection; 5) lower CSF cure rate, which are compatible HIV epidemiology and its known neurosyphilis correlation. However, there was no clinical presentation diferences. In the uveitis group ophthalmological examination statistically significant association was evidenced between anterior vitreous cellularity and: 1) CSF-VDRL positivity; 2) CSF pleocytosis. The retina is a central nervous system part and syphilitic uveitis usually associates with vitreous inflammatory infiltration, therefore, this association can be mainly due contiguity. Although owing to the lack of control group with no CSF changes we could not prove this association. The study showed: 1) syphilis reemergence; 2) neurosyphilis as a common complication; 3) syphilitic uveitis as neurosyphilis most prevalent presentation; 4) neurosyphilis and HIV association; 5) CSF-VDRL and pleocytosis associations with anterior vitreous involvement; 6) rational for posterior uveitis treatment as neurosyphilis regardless the CSF. In addition, it corroborated literature data and turns into new studies precursor.