In this issue of Clinical Infectious Diseases, 3], neurosyphilis was diagnosed clinically; CSF abnormalities or neurologic abnor-
an important article examines the sero- the diagnosis was supported by serologic malities for which other causes had been
logical response to treatment of neurosy- test results positive for syphilis and detec- excluded. Only 57% of the patients in the
philis. Marra et al. [1] show that nor- tion in CSF of antibody to cardiolipin (ini- study by Hooshmand et al. [4] had a pos-
malization of the results of the serum tially by the Wassermann reaction, then by itive CSF VDRL test result. This article [4]
antibody test for cardiolipin (rapid plasma the Hahn and other more sensitive mod- is often cited to support the notion that
reagin [RPR]) is a strong indicator of suc- ifications, and ultimately by the venereal a reactive CSF VDRL test is not a regular
cess after treatment of neurosyphilis. Most disease research laboratory [VDRL] test). feature of neurosyphilis.
of their patients had HIV infection, but If the CSF VDRL test result was negative, However, MHA-TP testing of CSF sam-
their findings are likely to apply to HIV- increased WBC count or protein concen- ples is not accepted as a diagnostic tool,
uninfected persons, as well. tration in CSF provided laboratory sup- because it is overly sensitive; passive dif-
This article [1] provides great practical port; except in forms of neurosyphilis that fusion of plasma proteins with positive se-
help to physicians who treat patients for are now rare, this was decidedly uncom- rum MHA-TP yields a positive result even
sexually transmitted diseases. Performing mon [2]. Asymptomatic neurosyphilis was when neurosyphilis is not present [5].
a lumbar puncture in a clinical setting is diagnosed on the basis of CSF VDRL test Some European authorities [6] use the
logistically difficult, and furthermore, pa- results, although in an occasional case, CSF MHA-TP assay, but they report the
tients often refuse it. Thus, it is reassuring other CSF abnormalities, in addition to a result after calculating the ratios of CSF to
to learn that normalization of the serum high serum RPR titer, might have been serum protein concentration and CSF to
RPR titer is highly predictive of a good regarded as diagnostic. Simpy stated, a di- serum MHA-TP titer to determine
response to therapy, even though this find- agnosis of neurosyphilis or the exclusion whether its detection reflects passive dif-
ing is somewhat less likely to apply to un- of this diagnosis depended largely on the fusion from plasma or local synthesis of
treated patients with AIDS. CSF VDRL test result. antibody in the CNS. Hooshmand et al.
A full understanding of the article by In 1972, Hooshmand et al. [4] reported [4] stated that 100% of their patients had
Marra et al. [1] requires further discussion a series of cases in which they diagnosed positive CSF fluorescent treponemal an-
of 2 important issuesone relating to the neurosyphilis on the basis of (1) suggestive tibody-absorption test results, as if to as-
diagnosis of neurosyphilis and the other neurologic findings, in addition to a pos- sure the reader of the correctness of their
to treatment. In the prepenicillin era [2, itive serum fluorescent treponemal anti- diagnoses. In fact, this has never been a
body-absorption test result (this highly valid basis for diagnosis of neurosyphilis,
Received 11 June 2008; accepted 19 June 2008; sensitive test, now replaced by the equiv- and it continues to astonish me that this
electronically published 20 August 2008.
Reprints or correspondence: Dr. Daniel M. Musher,
alently sensitive microhemagglutination article [4] was ever published in that form.
Infectious Disease Section, Rm. 4B-370, Michael E. DeBakey Treponema pallidum [MHA-TP] test, de- If the authors overdiagnosed neurosy-
Veterans Affairs Medical Center, 2002 Holcombe Blvd.,
tects antibody to outer cell wall proteins philis, which I believe they most certainly
Houston, TX 77030 (daniel.musher@med.va.gov).
Clinical Infectious Diseases 2008; 47:9002
of T. pallidum, and once the result is pos- did, the true percentage of patients with
This article is in the public domain, and no copyright is itive, it remains so for life) or (2) a positive negative CSF VDRL results should be
claimed.
1058-4838/2008/4707-0006
CSF fluorescent treponemal antibody-ab- much lower.
DOI: 10.1086/591535 sorption test result in addition to other There are other reasons to be suspicious