Screening for neurosyphilis is recommended

EDITOR—Nicoll and Hamers report the prevalence of sexually transmitted diseases, such as syphilis, gonorrhoea, and HIV.1 Despite the frequent invasion of the central nervous system by Treponema pallidum, most infected subjects will not develop neurosyphilis. Several studies have suggested an increased incidence of neurosyphilis, particularly in patients infected with HIV.2

We measured the prevalence of neurosyphilis by screening all serum and cerebrospinal fluid received at the neuropathology laboratory between November 1989 and April 2000 using the venereal disease research laboratory assay and T pallidum haemagglutination assay with fluorescent absorbed treponema antibody. The only exclusion criterion was being positive for HIV.

A total of 9410 samples was screened, of which 195 had positive serology with the fluorescent assay. Of the 195 samples, 67 fulfilled criteria for neurosyphilis.3 Nineteen samples tested negative for fluorescent treponema antibody in cerebrospinal fluid, and neurosyphilis was considered improbable. Twenty one samples had probable neurosyphilis (negative results in research laboratory assay for cerebrospinal fluid) and 27 samples had definite neurosyphilis (positive results in research laboratory assay for cerebrospinal fluid).4

The 48 subjects with probable or definite neurosyphilis were directly evaluated or charts reviewed. Forty four were men, the mean age was 59.2 years, and three patients had been referred with primary infection. Eleven of the subjects presented with meningovascular symptoms, eight with general paresis or mental deterioration, two with tabes dorsalis, two with acute meningitis, two with ocular symptoms; six were asymptomatic, and 15 presented with atypical symptoms (four with meningoradicolytis, four with cranial nerve involvement, two with myelopathy, three with seizure, two with parkinson-like syndrome).

In cerebrospinal fluid, cell count was >5/mm³ in 27 subjects, proteins were >0.515 g/l in 28, and the immunoglobulin index was >0.8 in 27; an oligoclonal band was present in 26 out of 36.IgG index and oligoclonal bands were significantly different in patients with positive and negative results in the venereal disease research laboratory assay for cerebrospinal fluid. All patients with such positive results had reactive serum with the laboratory assay compared with 13 out of 21 patients with negative results in cerebrospinal fluid.

Over 10 years 195 (2%) samples of serum and cerebrospinal fluid gave positive results in the fluorescent treponema antibody assay, which means a primary infection of T pallidum, and 48 (0.5%) fulfilled the criteria for neurosyphilis. The clinical presentation has shifted from general paresis and tabes dorsalis to meningovascular and atypical forms.

Our data suggest that screening for syphilis in neurological populations may be appropriate in all patients because the clinical situation alone is not helpful in determining when to screen and results may quite often be positive.

Sexual health services in general practice can be improved

EDITOR—Nicoll and Hamers discussed trends in sexually transmitted diseases in Europe.1I have been involved in a pilot in a new service to deliver improved sexual health services in general practice. In practical terms general practice is the only hope to improve services as it is the only provider with the capacity needed. Also it is important to recognise that the stigma associated with services in genitourinary medicine will only be broken when this becomes “mainstream” service provision in general practice. Disappointingly, no mention of sexual health provision is made in the new contract, and there is no national primary care strategy.

Our pilot is different, and we will report by the end of 2002 when we hope to have more than 300 patient contacts. What we offer is “a relationship consultation” that patients can access at any time, but it is specifically focused at patients who are entering a new relationship. We focus equally on men and women, unlike other services in the past. We have had a good uptake by men. The consultation is entirely confidential, with no records being kept in the case notes. This practice alone makes a great deal of difference to the issues patients are willing to discuss. A nurse led model may be the ideal. 23

We offer an integrated approach and consider sexual health and contraceptive provision together. We give out free condoms, often with the “morning after pill” given for back up to take home.4We are considering providing the “morning after pill” to men who request condoms. We are experimenting with computer consultation aids for contraception in MS PowerPoint. These ensure that consistent information and sexual health promotion are given.

HIV testing and counselling is offered without referral to specialist clinics.5 Tremendous anxiety about HIV prevails, much is generated through the media, but very few places will test. These have protracted counselling and are generally hospital based. This “HIV anxiety,” therefore, can go on for many years without the possibility of resolution. When offered, some 50% of our patients want to be tested for HIV. Follow up is over the phone like any other standard investigation.

If we want patients to come forward for sexual health testing then we need to stop examining them. The new technologies virtually negate the need for examinations, and urine testing by polymerase chain reaction or ligase chain reaction is as effective as conventional testing. Currently we could test for gonorrhoea, chlamydia, and trichomonas in this way if the NHS would pay.