Tx neurosyphilis ocular syphilis1 w IV aqueous crystalline penicillin G 18 24 MU day divided 3 4 MU IV q4h or via continuous infusion x10 14 days2

¹ No single test can be used to diagnose neurosyphilis in all instances. Dx depends on combo of CSF tests in presence of reactive serologic tests and neuro s/sx. CSF-VDRL is highly specific but insensitive. In a pt w/ neuro s/sx, a reactive CSF-VDRL (in absence of blood contamination) is considered diagnostic of neurosyphilis. When CSF-VDRL is negative despite presence of clinical signs of neurosyphilis, reactive serologic test results, and abnormal CSF cell count and/or protein, neurosyphilis should be considered. In this instance, additional eval using FTA-ABS testing on CSF may be warranted. CSF FTA-ABS test is less specific for neurosyphilis than CSF-VDRL but is highly sensitive. Neurosyphilis highly unlikely w/ a negative CSF FTA-ABS, esp among pts w/ nonspecific neuro s/sx.<br><br>
² Treat ocular syphilis as if neurosyphilis, even if CSF normal, and in collaboration w/ ophthalmologist.
<br><br>
³ Based on limited data. Cross-sensitivity between ceftriaxone and penicillin can occur, but risk for penicillin cross-reactivity between 3rd-gen cephs is negligible. If safety concern, perform skin test and desensitize in consultation w/ specialist.
<br><br>
⁴ Jarisch-Herxheimer: Acute febrile rxn (HA, myalgia, fever, other sx) can occur w/in first 24h after the initiation of syphilis tx; most frequent among pts w/ early syphilis. Antipyretics can be used to manage sx, but not proven to prevent the rxn.