神經(jīng)梅毒的診斷治療現(xiàn)狀教學(xué)課件

1、Current situation of Neurosyphilis: Diagnosis and Treatment神經(jīng)梅毒的診斷治療現(xiàn)狀Neurosyphilis: Diagnosis and Treatment神經(jīng)梅毒：診斷及治療Introduction簡介:The manifestations of central nervous system(CNS) syphilis, readily recognized by physicians practing 3 or 4 decades ago梅毒在中樞神經(jīng)系統(tǒng)的臨床表現(xiàn)，真正引起臨床醫(yī)生的關(guān)注大約在30-40年前;This condi

2、tions are unfamiliar to many physicians today as a result of the relative rarity由于其疾病相對(duì)并不是那麼十分常見 ，對(duì)于大多數(shù)醫(yī)生來講，對(duì)本病的認(rèn)識(shí)并不熟悉;There has been an increase in recent years in the incidence of acute syphilitic meningitis and increasing recognition of a wide variety of later forms of neurosyphilis,inclding pare

3、sis, gummas, ophthalmic disease ,and otologic complications近幾年來，由于梅毒以及相關(guān)的神經(jīng)梅毒的癥狀不斷增加，甚至一系列晚期神經(jīng)梅毒的不斷出現(xiàn)，如脊髓癆、神經(jīng)樹膠腫、視神經(jīng)、聽神經(jīng)的相關(guān)并發(fā)癥，使得人們?cè)黾恿藢?duì)神經(jīng)梅毒的關(guān)注。Classification of the Neurosyphilis神經(jīng)梅毒的分類Early Neurosyphilis早期神經(jīng)梅毒: 1) Asymptomatic無癥狀型; 2) Symptomatic癥狀型: A) Acute syphilitic meningitis急性梅毒性腦膜炎； B) Menin

4、govascular syphilis膜性血管梅毒: a) Cerebrovascular syphilis腦膜血管梅毒; b) Meningovascular syphilis of spinal cord脊髓膜血管梅毒Perenchymatous Neurosyphilis實(shí)質(zhì)性神經(jīng)梅毒: 1) General paresis系統(tǒng)性麻痹; 2) Tabes dorsalis脊髓癆Gummas of the nervous system神經(jīng)系統(tǒng)樹膠腫: 1) Cerebral gummas腦樹膠腫; 2) Gumma of spinal cord脊髓樹膠腫Asymptomatic無癥狀神經(jīng)梅

5、毒Presence of abnormalities in the CSF 腦脊液有異常表現(xiàn);Absence of other findings of neurologic disease 缺乏神經(jīng)系統(tǒng)的臨床癥狀;By definition,there are no clinical manifestations of asymptomatic neurosyphilis. 定義：腦脊液有異常表現(xiàn)，缺乏神經(jīng)系統(tǒng)的臨床癥狀的梅毒患者，定義為無癥狀神經(jīng)梅毒。Asymptomatic無癥狀神經(jīng)梅毒 Abnormalities in the CSF腦脊液異常的表現(xiàn): 10-100 WBC/mm(all

6、 of which are lymphocytes)白細(xì)胞（主要是淋巴細(xì)胞）; a protein（蛋白） of 50-100mg/dl; a recative nontreponemal antibody test (VDRL) in the CSF(90%) 腦脊液非梅毒螺旋體抗體實(shí)驗(yàn)90%以上為陽性; blood serology (RPR) is nearly always positive. 血清非梅毒螺旋體抗體實(shí)驗(yàn)90%以上為陽性 Asymptomatic無癥狀神經(jīng)梅毒Persistence of CSF abnormalities for more than 5 years af

7、ter infection(called late asymptomatic syphilis); 梅毒螺旋體感染后腦脊液持續(xù)5年出現(xiàn)異常，可定義為晚期無癥狀神經(jīng)梅毒；The development of neurologic disease in up to 87%of patients. 該類晚期無癥狀神經(jīng)梅毒中大約有87%可能發(fā)展為有癥狀神經(jīng)梅毒。Symptomatic癥狀型神經(jīng)梅毒Acute syphilitic meningitis 急性梅毒性腦膜炎Meningovascular syphilis: 腦膜血管性梅毒 Cerebrovascular syphilis; 大腦膜血管性梅毒

8、 Meningovascular syphilis of the spinal cord. 脊髓膜血管性梅毒。 Symptomatic癥狀型神經(jīng)梅毒Acute syphilitic meningitis:急性梅毒性腦膜炎The incubation period in the majority of patients with syphilis meningitis is less than 1 years;大部分梅毒性腦膜炎患者的潛伏期在一年之內(nèi)；25% of those patients meningitis is the first clinical manifestation of s

9、yphilis;大約有25%的梅毒性腦膜炎患者是以梅毒的首發(fā)癥狀出現(xiàn)的；A small percentage of patients(15%) still have a 2nd rash at the time of the meningitis.大約15%的患者在出現(xiàn)梅毒性腦膜炎的同時(shí)，仍然具有二期梅毒的皮膚損害。Acute syphilitic meningitis急性梅毒性腦膜炎Clinical manifestitations:臨床表現(xiàn)Cranial nerve palsies (sense) in 40% of cases;大約40%的患者有顱神經(jīng)麻痹（感覺障礙）The signs

10、of increased intracranial pressure; 部分患者可有顱內(nèi)壓增高的表現(xiàn)The involvement of cranial nerves(3rd, 6th,7th, 8th);多數(shù)可以累及3、6、7、8對(duì)顱神經(jīng)Sensorineural deafness may occur in about 20% of patients.大約20%的患者可以出現(xiàn)感音神經(jīng)性耳聾。Acute syphilitic meningitis急性梅毒性腦膜炎Clinical manifestitations:臨床表現(xiàn)Acute syphilitic hydrocephalus was se

11、en in 1/3 of the cases of meningitis;大約1/3的梅毒性腦膜炎患者可出現(xiàn)梅毒性腦水腫；The principal symptoms and signs are those of increased intracranial pressure (stiff neck, confusion, delirium, papilledema);主要癥狀與體征是因?yàn)轱B內(nèi)壓增高而引起的（頸部僵硬，意識(shí)喪失，譫妄等）；Syphilitic meningitis with cerebral changes accounts for of early neurosyphilis

12、;在早期神經(jīng)性梅毒患者中大約有1/4具有梅毒性腦膜炎伴發(fā)大腦的改變Fever is only low grade or may be absent可有低度發(fā)熱或無發(fā)熱Acute syphilitic meningitis急性梅毒性腦膜炎Laboratory fingings;實(shí)驗(yàn)室檢查The blood Wassermann reaction was +ve in 64%;大約64%的患者血清華氏曼反應(yīng)陽性；RPR is +ve in most of cases of ASM;大部分血清非螺旋體實(shí)驗(yàn)陽性The CSF include:腦脊液異常表現(xiàn)包括： elevated pressure;顱

13、內(nèi)壓升高； mononuclear pleocytosis(10-200/1000-2000/mm);單個(gè)核白細(xì)胞升高(10-200/1000-2000/mm); elevated globulin level;球蛋白升高； modest reduction in glucose in 45% of cases;45%的患者葡萄糖中度下降； VDRL test is recative in most,not all cases.VDRL實(shí)驗(yàn)在大多數(shù)（不是所有的患者）患者為陽性Acute syphilitic meningitis急性梅毒性腦膜炎Laboratory fingings;實(shí)驗(yàn)室檢查

14、Patient with isolated involvement of the 8th cranial nerve may has a normal CSF (VDRL -ve);僅有第八對(duì)腦神經(jīng)受累的患者腦脊液可能是正常的Correlation between abnormal findings on auditory brainstem response and CSF was noted in of cases with 2nd or early latent syphilis;All of the other cases had normal neurological examina

15、tions.Acute syphilitic meningitis急性梅毒性腦膜炎Diagnosis and differential diagnosis:診斷與鑒別診斷ASM diagnosis ia based on:急性梅毒性腦膜炎基于以下證據(jù)： Clinical picture: 臨床表現(xiàn) Aseptic meningitis;化膿性腦膜炎 Lymphocytes response in the CSF;腦脊液中的淋巴細(xì)胞數(shù)量； Reactive blood and CSF serology.血請(qǐng)和腦脊液的非螺旋體實(shí)驗(yàn)The history:病史 Recent chancre;近期是否

16、有硬下疳； The secondary rash;有無繼發(fā)性皮損； Generalized lymphadenopathy.全身淋巴結(jié)有無腫大；Meningitis may be the 1st clinical manifestitation of syphilitic infection.腦膜炎可能是部分患者的首發(fā)臨床癥狀。Acute syphilitic meningitis機(jī)型梅毒性腦膜炎Differential diagnosis:鑒別診斷The various cause of a lymphocytic meningitis;排除其他淋巴性腦膜炎的可能Include包括 : en

17、terovirus 病毒, other spirochetes其他螺旋體 (Borrelia, Lyme disease); Mycobacteria分支桿菌; Fungi真菌 Mengingovascular syphilis腦膜血管性梅毒Cerebrovascular syphilis;大腦血管性梅毒Mengingovascular syphilis of spinal cord脊髓膜血管性梅毒Mengingovascular syphilis大腦膜血管性梅毒Cerebrovascular syphilis大腦膜血管梅毒: Vascular neurosyphilis may involv

18、e any part of the central nervous system; 有可能累及任何部位的中樞神經(jīng)系統(tǒng)；The common denominator is infarction secondary to syphilitic endarteritis;常見的就是繼發(fā)于梅毒性內(nèi)膜炎的腦梗死；This disease usually occurs 5-12 years after infection;該癥狀出現(xiàn)在梅毒感染之后5-12年；Earlier than the occurrence of paresis and tabes;該癥狀的出現(xiàn)早與脊髓癆和神經(jīng)麻痹；The most

19、of patients are 30-50 years old.大多數(shù)出現(xiàn)在30-50歲的患者。Cerebrovascular syphilis:大腦膜血管性梅毒The most common manifestations are:最常見的臨床表現(xiàn)是： hemiparesis (senses)or hemiplegia(disable,83%); aphasia (eating 31%);seizures(14%).The onset of symptoms may be abrupt(suddenly);About 50% of patients have premonitory sympt

20、oms: Headache; Dizziness; Insomnia; Memory loss; Mood disturbancesCerebrovascular syphilis:腦膜血管性梅毒Laboratory findings實(shí)驗(yàn)室檢查:Serum RPR is positive血清RPR陽性;The CSF VDRL test is positive in most, but not all cases.大多數(shù)患者腦脊液VDRL檢測陽性；Angiographic changes include diffuse irregularity;腦血管圖可能出現(xiàn)異常；Segmental dil

21、atation of the pericallosal artery;動(dòng)脈出現(xiàn)節(jié)段性擴(kuò)張；CT shows low-density areas with variable degrees;CT掃描可見不同程度的低密度區(qū)；MRI shows focal regions of high signal intensity. MRI掃描可見區(qū)域性高密度信號(hào)區(qū)。Cerebrovascular syphilis大腦膜血管性梅毒Diagnosis and differential diagnosis:診斷與鑒別診斷Diagnosis:診斷The possibillity of mengingovascula

22、r syphilis should be considered when:出現(xiàn)以下情況時(shí)可考慮腦膜血管梅毒的可能：Cerebrovascular accidents occur in a young adult年輕人出現(xiàn)的腦血管意外；without the usual risk factors( hypertension, embolic cardaic disease).排除其他常見的危險(xiǎn)因素（高血壓，心腦血管?。〤SF serology is importantin making the diagnosis.腦脊液的非螺旋體實(shí)驗(yàn)檢測有十分重要的意義。Cerebrovascular syph

23、ilis大腦膜血管性梅毒Differential diagnosis:鑒別診斷Includeing other causes of stroke syndromes such as:應(yīng)排除以下其他原因引起的中風(fēng)綜合征Hypertension ( stroke);高血壓（中風(fēng)）Athero-sclerotic (high blood lipid) vascular disease;動(dòng)脈硬化（高血脂）血管病；Cerebral emboli;腦血管異常；The various types of cerebral vasculitis;各種類型的腦血管炎；Angiographic changes in

24、 SLE;SLE患者的腦血管改變；Polyarteritis nodosa. 多發(fā)性動(dòng)脈結(jié)節(jié)。 Meningovascular syphilis of the spinal cord脊髓膜血管性梅毒Meningovascular syphilis of the spinal cord consists of :脊髓膜血管梅毒包括以下不同疾病：Syphilitic meningomyelitis;梅毒性脊髓內(nèi)膜炎；Spinal vascular syphilis.脊髓血管梅毒；Spinal syphilis has always been rare(3%);脊髓梅毒罕見（低于3%）It alwa

25、ys associated with cerebral involvement; butthe disease of the spinal cord may be preeminent.脊髓梅毒通常伴隨大腦受累，但脊髓癥狀可能更為突出。Meningovascular syphilis of the spinal cord脊髓膜血管性梅毒Symptoms and signs:癥狀與體征The weakness of paraplegia of the legs;雙下肢無力；Progressive to paraparesis(mild) or paraplegia(severe)雙下肢進(jìn)行性麻痹

26、或疼痛 wihch is asymmetrmic;多數(shù)表現(xiàn)為不對(duì)稱；Urinary and fecal incontinence ;大小便失禁；Variable sensory disorders (pain and paraplegia) in the legs are prominent.雙下肢的各種感覺異常（疼痛和麻痹）更明顯。Meningovascular syphilis of the spinal cord脊髓膜血管性梅毒Symptoms and signs:癥狀與體征On the examinations:體檢The legs are weak and spastic(stiff

27、);雙下肢虛弱和僵硬；The deep tendon reflexes are hyperreactive;The ankle clonus is present;深肌腱反射過度，踝反射陽性Abdominal reflexes are abscent;腹壁反射消失；The most of senseory abnormalities are loss of position and vibratory sense in the lower extremities.雙下肢最常見的感覺異常是位置和震動(dòng)感覺消失；The classic manifestations are a transection

28、 of the spinal cord.大多數(shù)感覺異常呈節(jié)段性。Meningovascular syphilis of the spinal cord脊髓膜血管性梅毒Laboratory findings:實(shí)驗(yàn)室檢查Blood serology tests are regularly positive;血清學(xué)檢測通常為陽性；CSF tests discloses(showing) the same abormalities seenIn other forms of neurosyphilis;腦脊液檢測與其他型的神經(jīng)梅毒表現(xiàn)相同；CSF serology tests are positive

29、 in most of , not all cases腦脊液血清學(xué)檢測大多數(shù)表現(xiàn)陽性。Meningovascular syphilis of the spinal cord脊髓膜血管性梅毒Diagnosis and differential diagnosis診斷與鑒別診斷Diagnosis:診斷The diagnosis is made on the clinical pictures of an abrupt flaccid (soft, slow) paraplegia developing in a patients with consistent CSF abnormalities

30、and reactive blood and CSF serologies在腦脊液持續(xù)性異常并伴有腦脊液血清學(xué)反應(yīng)陽性，出現(xiàn)下肢緩慢的進(jìn)行性麻痹的患者；Multiple sclerosis and subacute combined degeneration.脊髓出現(xiàn)多發(fā)性硬化和變性；Meningovascular syphilis of the spinal cord脊髓膜血管性梅毒Diagnosis and differential diagnosis診斷與鑒別診斷Differental diagnosis:鑒別診斷Multiple sclerosis and subacute combi

31、ned degeneration.脊髓多發(fā)性硬化和變性；Parenchymatous neurosyphilis實(shí)質(zhì)性神經(jīng)梅毒General paresis;麻痹Tabes dorsalis脊髓癆Parenchymatous neurosyphilis實(shí)質(zhì)性神經(jīng)梅毒General paresis;Early symptom: 早期癥狀 Irritablity (temper loss), memory loss, personal changes, impaired capacity to concentrate, carelessness in appearance, hadeache,in

32、somnia;易怒、記憶喪失、人格變化、注意力不易集中、表現(xiàn)淡漠、頭痛、嗅覺減退；Late symptom: 晚期癥狀 Defective judgment, emotional lability (changeable) (depression,agitation,euphoria-joyful), lack of insight, confusion and disorientation, delusions of grandeur, paranoia (psychological problems),seizures. Parenchymatous neurosyphilis實(shí)質(zhì)性神經(jīng)梅

33、毒General paresis;Laboratory findings:實(shí)驗(yàn)室檢查Nontreponemal serology tests of blood and CSF are nearly uniformly +ve in cases of paresis;腦脊液、血清非梅毒螺旋體實(shí)驗(yàn)陽性O(shè)ther CSF findings are typical of those in neurosyphilis;腦脊液的其他改變與其他的神經(jīng)梅毒表現(xiàn)一致；The CSF may be normal in a patients whose neurosyphilis has been arrested

34、 by treatment.經(jīng)過治療的神經(jīng)梅毒患者腦脊液可能是正常的。Parenchymatous neurosyphilis實(shí)質(zhì)性神經(jīng)梅毒Diagnosis:診斷The diagnosis is based on the clinical pictures, which is readily recognizable in it full-blown (developement) form, together with characteristic spinal fluid abnormalities.診斷主要基于臨床表現(xiàn)，脊柱神經(jīng)系統(tǒng)不斷加重的神經(jīng)系統(tǒng)的癥狀，腦脊液的各種異常表現(xiàn)。Pare

35、nchymatous neurosyphilis實(shí)質(zhì)性神經(jīng)梅毒Differential diagnosis:鑒別診斷Cerebnral tumor;腦腫瘤；Subdural hematoma;血管瘤Cerebral arteriosclerosis;腦動(dòng)脈硬化Alzheimers disease (Senil dementia);阿茨海默?。ɡ夏晷园V呆）Multiple sclerosis;多發(fā)性硬化癥；Chronic alcholism.慢性酒精中毒。Parenchymatous neurosyphilis實(shí)質(zhì)性神經(jīng)梅毒Tabes dorsalis脊髓癆Symptoms :癥狀Lightin

36、g;畏光Ataxia;Bladder disturbance;膀胱功能紊亂Parethesia;Visual loss (optic atrophy);視力減退（視神經(jīng)萎縮）Rectal incontinence.大便失禁。Parenchymatous neurosyphilis實(shí)質(zhì)性神經(jīng)梅毒Signs:體征Pupillary abnomarlities; Argyll Roberstson pupil;瞳孔異常 阿羅月瞳孔Absent ankles jerks; Absent knee jerks;踝反射缺失 膝反射缺失Rombergs sign (close eye down); Impa

37、ired vibratory sense;羅伯戈征陽性 震動(dòng)覺減退Impaired touch and pain sense; Impaired position;痛覺、觸覺減退 位置覺減退Ocular palsies (sense); Charcots joint. 夏克氏關(guān)節(jié)Parenchymatous neurosyphilis實(shí)質(zhì)性神經(jīng)梅毒Laboratory fidingns:實(shí)驗(yàn)室檢測The laboratory findings are variable;實(shí)驗(yàn)室檢測結(jié)果是可變的Depand on: 基于以下因素1). The stage of tabes; 不同的疾病階段 2).

38、 Whether partial or full treatment has been administered in the past; 以前有無不規(guī)則或規(guī)則的治療。Parenchymatous neurosyphilis實(shí)質(zhì)性神經(jīng)梅毒Laboratory fidingns:實(shí)驗(yàn)室檢測The CSF findings among patients with tabes are:脊髓癆患者腦脊液異常包括：1). Lymphocytic pleocytosis in 50%;50%以上患者淋巴細(xì)胞升高；2). Elevated protein concentration (45-100mg/dl

39、) in 50%;50%以上患者蛋白濃度升高(45-100mg/dl) ；3). Reactive nontreponemal serology of CSF (Wassermanns test) in 72%.72%的患者腦脊液非梅毒螺旋體抗體實(shí)驗(yàn)陽性。Parenchymatous neurosyphilis實(shí)質(zhì)性神經(jīng)梅毒Diagnosis and differential diagnosis:診斷和鑒別診斷A clinical diagnosis of tabes is most likely in a case with lighting pain, ataxia who exhibit

40、s findings of absent deep tendon reflexs, Argyll Robertson pupil and a +ve Rombergs sign.臨床表現(xiàn)包括LIGHTING疼痛、抑郁、深部腱反射消失；阿羅月瞳孔，羅伯戈征陽性等癥狀對(duì)脊髓癆的診斷有重要的提示作用；Early and atypical case present greater problem in diagnosis;早期或不典型患者經(jīng)常會(huì)被誤診；The results of serology tests and spinal fluid tests may lead to the correct

41、 diagnosis. 血清學(xué)、腦脊液檢測結(jié)果對(duì)于確診有重要價(jià)值。 Optic atrophy 視神經(jīng)萎縮 It with the same ocular manisfestations as occurs in tabes;與脊髓癆的眼部表現(xiàn)相同；The disease may appear as an isolated manifestations of neuresyphilis;也有可能是神經(jīng)梅毒唯一的臨床表現(xiàn)；The usual symptoms are those of progressive visual loss Involving frist one eye and then

42、 the other;通常的癥狀是進(jìn)行性視力減退，一般是單眼開始，再波及另一只眼；CSF abnormalities are most present in the untreated case;大多數(shù)未經(jīng)治療的患者腦脊液通常具有異常表現(xiàn)；Optic atrophy may also result from prior syphilitic optic neuritis;PG treatment can usually prevent further progression of visual loss.青霉素治療通?？梢宰柚挂暳Φ倪M(jìn)行性減退。Gummas of nervous system神

43、經(jīng)系統(tǒng)樹膠腫Cerabral gummas;腦樹膠腫Gumma of spinal cord.脊髓樹膠腫Gummas of nervous system神經(jīng)系統(tǒng)樹膠腫 Cerebral gummas:腦樹膠腫This form of neurosyphilis is esceedingly rare;該型神經(jīng)梅毒極為罕見；The presentation is that of a space occupying lesion;臨床表現(xiàn)是大腦占位性病變的表現(xiàn)；The diagnosis may only be made when the patient is operated on for a

44、suspected intracranial mass lision;大部分確診是可疑顱內(nèi)腫塊手術(shù)切除中發(fā)現(xiàn)的；Multiple ring-enhancing lesions may be found on CT or MRI examinations.CT、MRI檢測可發(fā)現(xiàn)環(huán)狀信號(hào)增強(qiáng)區(qū)。Gummas of nervous system神經(jīng)系統(tǒng)樹膠腫Gumma of the spinal cord:脊髓樹膠腫It is fundamentally a granuloma of the meninges compressing the cord;主要表現(xiàn)為脊髓膜肉芽腫壓迫脊索的表現(xiàn)The cl

45、inical picture is that of a cord tumor, root pain, spastic paraplegia, urinary and fecal incintinence and loss of sensation below the lesion.臨床癥狀表現(xiàn)為脊索腫瘤、神經(jīng)根疼痛、僵直麻痹、大小便失禁和損害以下感覺喪失；The progressive is subacute;呈亞急性病程；The CSF findings consist of dynamic block, markedly elevated protein (over 350mg/dl) a

46、nd a +ve nontreponemal serologic test.腦脊液檢測表現(xiàn)為梗阻性的表現(xiàn)特征，蛋白明顯升高（高于350mg/dl) ，非梅毒螺旋體抗體實(shí)驗(yàn)陽性。Current manifestations of neurosyphilisAtypical presentations不典型表現(xiàn)考慮神經(jīng)梅毒的提示The following clinical manifestations should be considered the diagnosis of neurosyphilis:出現(xiàn)以下臨床癥狀時(shí)應(yīng)該考慮神經(jīng)梅毒；1).Positive blood FTA-ABS ser

47、ology along with neurologic or ophthalmologic findings suggestive of neurosyphilis;血清FTA-ABS實(shí)驗(yàn)陽性，同時(shí)出現(xiàn)神經(jīng)系統(tǒng)或視神經(jīng)的異常表現(xiàn)；2). Unexplained neurological illness with positive blood & CSF FTA-ABS test & CSF showing more than 5 WBC/mm;無法解釋的神經(jīng)系統(tǒng)疾病，同時(shí)出現(xiàn)血清及腦脊液FTA-ABS陽性反應(yīng)，腦脊液白細(xì)胞數(shù)5 個(gè)/mm以上;3). Positive FTA-ABS in bl

48、ood & in cases with progressive neurologic disease in whom other etiologic considerations had been excluded. 已經(jīng)排除其他的相關(guān)疾病原因，具有進(jìn)行性神經(jīng)系統(tǒng)疾病的患者同時(shí)出現(xiàn)血清FTA-ABS實(shí)驗(yàn)陽性。 Antobiotic therapy for neurosyphilis神經(jīng)梅毒的抗生素治療The introduction of PG in the 1940s strikingly simplified the therapy & improved the outcome of ne

49、urosyphilis;上世紀(jì)40年代由于青霉素的使用，大大簡化了對(duì)神經(jīng)梅毒的治療，也明顯改善了預(yù)后；Recently reports were showed that a few cases in which benzathine or procaine PG in recommended dose failed to cure neurosyphilis;近幾年來，有部分報(bào)告用推薦劑量的芐星青霉素和普魯卡因青霉素治療神經(jīng)梅毒失敗的個(gè)案；Those cases reports suggests that the failures represented early cases of neur

50、osyphilis in HIV infected persons.大多數(shù)治療失敗的個(gè)案與感染HIV相關(guān)。Antobiotic therapy for neurosyphilis神經(jīng)梅毒的抗生素治療As a result of those considerations, WHO & CDC of USA no longer recommend benzathine PG to treat neurosyphilis;基于多種因素，WHO和美國CDC不再考慮推薦芐星青霉素治療神經(jīng)梅毒The most recent recommendations of CDC are:美國CDC最近治療方案如下；

51、1). IV aqueous PG 18-24 million daily for 10-14 days;靜脈使用水劑青霉素1800-2400萬治療10-14天；2). IM procaine PG 2.4 million plus probenecid 500mg by mouth Qid for 10-14 days.肌注普魯卡因青霉素240萬，加口服丙磺舒500mg，10-14天。Antobiotic therapy for neurosyphilis神經(jīng)梅毒的抗生素治療Drug regimens for treatment of neurosyphilis:神經(jīng)梅毒的藥物治療方案1).

52、 IV aqueous crystalline PG 18-24 million daily for 10-14 days(3-4 million every 4 hs),followed by benzathine PG 2.4 million IM weekly for 3 doses;靜脈使用水劑青霉素1800-2400萬，10-14天（每4小時(shí)300-400萬），然后芐星青霉素240萬肌注每周一次，再用三次。2). IM aqueous procaine PG 2.4million + probenecid 500mg by mouth Qid for 10-14 days, foll

53、owed by benzathine PG 2.4 million IM weekly for 3 doses.肌注水劑普魯卡因青霉素240萬加丙磺舒0。5每日四次口服10-14天；然后芐星青霉素240萬肌注每周一次，再用三次。Note: For patients who are allergic to PG, the official recommendation isthat desensitization be undertaken;Althrough some experts recommend a 3 wks courses of ceftriaxone, 1 gm daily. 注

54、意事項(xiàng)：對(duì)青霉素過敏的患者，官方推薦使用脫敏治療；也有專家推薦ceftriaxone每天一克，三周一個(gè)療程的治療方案。Follow-up隨訪Clinical (including CSF) examination should done 3 months after treatment and then at 6 months intervals, until the CSF findings return to normal;治療后3個(gè)月隨訪一次（包括臨床和腦脊液）然后半年1次，直到腦脊液恢復(fù)正常；Reevaluation should be performed annually for s

55、everal years;以后每年隨訪一次；In a minority of patients CSF abnormalities persist, patients whose WBC count and protein do not decline after 6 months are often retrated;對(duì)少數(shù)腦脊液持續(xù)異常，在治療后半年白細(xì)胞和蛋白保持不下降著應(yīng)重新治療A true failure of therapy may rarely occur, in which an initial normalization of CSF findings is followed by replase, in such cases, repeate therapy needs to be given;完全的治療失敗并不常見，經(jīng)過治療腦脊液恢復(fù)正常后，如果出現(xiàn)異常表明為復(fù)發(fā)，這類患者應(yīng)該再次治療；If rela