Algorithm for the diagnosis of neurosyphilis in a patient with HIV infection

ARV: antiretroviral drug; CD4: cluster determinant 4 T lymphocyte; CIA: chemiluminescence immunoassay; CSF: cerebrospinal fluid; TP-EIA: Treponema pallidum enzyme immunoassay; FTA-ABS: fluorescent treponemal antibody-absorbed test; LP: lumbar puncture; NS: neurosyphilis; RPR: rapid plasma reagin test; TPPA: Treponema pallidum particle agglutination test; VDRL: Venereal Disease Research Laboratory test; WBC: white blood cell.
* A reactive serum TP-EIA or CIA should be confirmed with a different treponemal test.
¶ Otologic or ocular syphilis may not be accompanied by CSF abnormalities. Patients with otologic symptoms should be evaluated by an otolaryngologist and patients with ocular symptoms should be evaluated by an ophthalmologist, and if findings are consistent with otologic or ocular syphilis, these patients should be treated for neurosyphilis even if the CSF is normal. With the exception of tabes dorsals, other forms of neurosyphilis are very uncommon in the absence of CSF abnormalities.
Δ The Centers for Disease Control and Prevention (CDC) guidelines do not recommend LP in individuals with syphilis and HIV who are neurologically asymptomatic, but consideration of LP is recommended in the European guidelines in certain situations, as listed here. Refer to text for details.
◊ Monitor with neurologic examination and LP to determine success of therapy and potential need for retreatment (refer to UpToDate topic on neurosyphilis for details).