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Show ]. Clin. Neuro-ophth.l/nwl. 2: 75-70, \Q82. Editorial Whither Late Ocular and Neurosyphilis? The te.lChing of svphilis h.1S beCl)me so restricted in many medicoll curricul.l in recent ye.Hs tholt many young physici.lns (including those in ophthalmology, neurology, and neurosurgery) now have neither any experience with nor .lny concept of this disease at all. Indeed, I have noted on more than one occasion lately that when the disease was mentioned at all in a chart in differential diagnosis- it was spelled incorrectly i.e., "syphillis." Many are not aware of the fundamental contributions to the study of syphilis made by Prof. Pierre Collart, director of the laboratory of Researches in Experimental Syphilis, of the Alfred Fournier Institute, Paris, France. In a series of dramatic investigations, Prof. Collart demonstrated the persistence of viable Treponema pallidum in both man and experimental animal despite penicillin therapy, and has written extensively on this subject during the past 20 years. Indeed, his observations have been repeatedly confirmed in many laboratories around the world. However, this information has in general achieved little cognizance by many physicians. Having visited Prof. Collart in his laboratory in France in 1969, and enjoying a friendly and interesting correspondence with him for nearly 2 decades, I invited him to write an article reviewing the current status of the efficiency of penicillin therapy in syphilis, and his paper is presented in this issue of the Journal. It is a little difficult to get an eX.lct translation from French into English as we would express it for this article, however, I must admit that Prof. Collart's English is light years ahead of my French! The purpose of the article, however, is not to serve as an eloquent translation, but to emphasize the facts that it presents. It gives a basic insight into understanding a case only recently reported, which is summarized here, and is an .lpt example of what we are thinking about. Drs. Cohen, Gibson, and Olarte of the Neurological Institute in New York reported in the February 1982 issue of Annals of Neurology (Ann. Neurol. 11(2): 219, 1982) a very pertinent Colse, and the following is from their report. A 44-year-old right-handed man was diagnosed as having neurosyphilis following a seizure. He was treated with a 3-week course of procaine penicillin, bOO,000 units intramuscularly daily. However, he be- June ]982 came increasingly demented over the next year, lost his previously fluent command of English, and could converse only in his native Spanish. At age 45 he was hospitalized because of seizures. Examination revealed dementia, aphasia, anisocoria, light-near dissociation of the pupils, right hyperreflexia, and a right Babinski sign. A reactive serum FTA-ABS test and a reactive serum VORL (l:8 dilution) were noted. Spinal fluid protein was 41 mgm %, 15 white cells (12 mononuclears) were present, and CSF FTA-ABS test was reactive. CT scan showed mild generalized atrophy as well as focal left perisylvian atrophy involving temporal and parietal lobes. The patient was treated with penicillin G, 12 million units intravenously daily, and was given phenobarbital for seizure control. He was later lost to follow-up. The conclusion of their note was, "It should be stressed that this patient continued to deteriorate after a 'full course' of intramuscular penicillin therapy." They then stated, "Patients with proved neurosyphilis should be treated with penicillin given intravenously." Dr. Collart's data, however, must also be included in this interpretation. The prime point is that a patient was treated with 12.b million units of intramuscular penicillin over a 3-weeks courseand there was no question that he received the therapy, for it was given while in the hospital. Despite this 12 million units of penicillin, he deteriorated over the next vear and came in with classic clinical and labor.~tory findings of .lctive neurosyphilis, presenting .1S Lissauer's fl)rm l)f p.Hetic neurosyphilis. When I visited Dr. Cl)ll.lrt in 1969, I asked him the following questil)ns-"If \'l)U treat a patient with terti.lr\' syphilis with .1I1\' amount of penicillin, can you eradic.lte the treponemes from that patient?" He replied "NU." I then asked-"ff you treat .1 p.ltient with ."t'll)nJ.Ir\' syphilis with any .1n1l)Unt l)f penicillll1, c.ln \'l)'U eradicate the treponenws frlHl1 th.lt p.ltJent~"·He replied "NO." I then .Iskl'd this tin.ll qucstillIl" If you treat .1 p.ltient with prim.lf\' 5vphilis with any Jmount of penicillin. can vou er.ldic.lte the treponemes from th.lt p.ltiel~t~" He replied "DOUBTFUL." It is evident th.lt more c1inic.ll and investigative attention needs to be p.lid tl) this disease. J. Lawton Smith, M.D. 75 Editori,ll: Whithrr LJtr OClIl,H ,Hld Ncuru~yphilis? References I. Cllhrll, MS. Cibslll1, C., ,1I1d Ol.lrlc, M.l<.: Li",lUrf hlflll llf p.lrrtic I1rllrll~Yrhili" fllrglllll'11 but l10t gllill'. Ann. NCUf"!. 11(2): 2/L). Iq~2. 2. Smith, 1.L.: Acute blindness in early syphilis. Arch. Ophthalmol. 90: 256-258, 1973. 3. Smith, 1.L.: Spirochetes in Late Seronegative Syphilis, Penicillin Notwithstanding. Charles C. Thomas, Springfield, III., 1969. JournJI of Clinical Neuro-ophthalmology |
