NS Infection - Spirochaetes

Question 1

What are the main spirochaete infections of the CNS?

Answer 1

Lymes Disease (Borrelia Burgdorferi)
Syphilis (Trepomena Pallidum)
Leptospirosis (Leptospira Interrogans)

Question 2

What are 2 other rashes in Lyme disease

Answer 2

1. Acrodermatitis chronic atrophicans

2. Lymphocytoma: bluish solitary nodule on earlobe or areola

Question 3

Describe presentation of early stage of Lyme Disease? [2]

Answer 3

• erythema chroncium migrans (small papule at site of tick bite which develops into larger annular lesion with central clearing; Bull’s eye rash AT LEAST 3-4d after bite)
• fever, arthralgia

Question 4

What is stage 2?
Later features include cardiovascular problems [2]
What are MSK problems

Answer 4

Early Disseminated Infection over weeks to months where one or more organs become involved.
CVS: heart block, myocarditis
MSK: polyarthritis

Question 5

Stage 2 Lyme disease
What are the neurological manifestations of lymes disease? [5]
NB PNS more than CNS- in stage 3 can get subacute encephalopathy and encephalomyelitis

Answer 5

• Mononeuropathy
• Myelitis
• Painful Radiculoneuropathy
• Cranial Neuropathy
• Meningo-encephalitis

Question 6

How do we investigate Lyme DIsease? [4]

Treatment [3]

Answer 6

• Clinical dx on erythema migrant
• Serology
• CSF: lymphocytosis and PCR
• Brain/Spine MRI if CNS manifestations
• Nerve Conduction study/EMG If PNS manifestations

Suspected or confirmed Lyme disease: DOXYCYCLINE (or AMOXILCILLIN in pregnancy)
Disseminated infection: CEFTRIAXONE

Question 7

How do we investigate/treat Neurosyphilis? [3]

How to monitor disease activity?

Answer 7

1. Serology of treponema pallidum:
   - IgG/IgM
   - enzyme immunoassay (EIA)
   - tremponaemea hemagglutination test (TPHA)
   - particle agglutination test (TPPA).
   Serology ALWAYS remains positive.
2. PCR: ulcer swab
3. Dark ground microscopy of ulcer base: motile spring shaped bacteria

Disease activity: cardiolipin serology tests (rapid plasma regain (RPR))

Question 8

Timeline of syphilis

Answer 8

Primary stage: incubation period is 9-90 days until chancre appears
Secondary: 6w-6m
Early latent: within 2y of infection
Late latent: after 2y of infection
Tertiary: if untreated over many years

Question 9

Neuroborrelosis

Answer 9

Classic triad:

• Radicular pain; migratory & worse at night
• Cranial neuropathy
• Lymphocytic meningitis 2-6w after bite

Question 10

Secondary stage [5]

Answer 10

Non-pruritic maculopapular rash, palms & soles, alopecia
Condylomata lata
Generalized lymphadenopathy
Oral snail track lesions
Systemic symptoms: pyrexia, fatigue, malaise

Question 11

Primary stage [3]

Answer 11

Painless indurated ulcer called Chancres
Localised lymphadenopathy
Prodromal symptoms

Question 12

Tertiary stage [3]

Answer 12

o Neurosyphilis: tabes dorsalis, general paresis, stroke
o Cardiovascular syphilis: aortitis, aortic aneurysms
o Gummatous syphilis: granulomas of skin, bone and mucosa

Question 13

Management of syphilis with no neuro involvement

Answer 13

Early <2y with no neuroinvolvement

• BENZATHINE BENZYLPENICILLIN 2.4MU IM once
• or DOXYCYCLINE 100mg oral twice daily for 2 weeks

Late >2y with no neuroinvolvement:

• BENZATHINE BENZYLPENICILLIN 2.4MU IM
• weekly for three weeks OR
• DOXYCYCLINE 100mg oral twice daily for 28 days

Question 14

Congenital syphilis [6]

Answer 14

• thrombocytopenia
• condylata mata
• haemorrhagic rhinitis
• Hutchison’s incisors
• frontal bossing
• saddle nose deformity

Question 15

Neurosyphilis mx [2]

Answer 15

IM PROCAINE PENICILLIN 2.4U IM for 14d with PROBENECID