神经梅毒的诊断治疗现状教学课件

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1、Current situation of Neurosyphilis:Diagnosis and Treatment神经梅毒的诊断治疗现状神经梅毒的诊断治疗现状Neurosyphilis:Diagnosis and Treatment神经梅毒：诊断及治疗神经梅毒：诊断及治疗Introduction简介简介:The manifestations of central nervous system(CNS)syphilis,readily recognized by physicians practing 3 or 4 decades ago梅毒在中枢神经系统的临床表现，真正引起梅毒在中枢神经系统

2、的临床表现，真正引起临床医生的关注大约在临床医生的关注大约在30-40年前年前;This conditions are unfamiliar to many physicians today as a result of the relative rarity由于其疾病相对并不是那麽十分常见由于其疾病相对并不是那麽十分常见，对于大多数医生来讲，对本病的认识并不熟悉;There has been an increase in recent years in the incidence of acute syphilitic meningitis and increasing recognitio

3、n of a wide variety of later forms of neurosyphilis,inclding paresis,gummas,ophthalmic disease,and otologic complications近几年来，由于梅毒以及相关的神经梅毒的症状不断增加，甚至一系列晚期神经梅毒的不断出现，如脊髓痨、神经树胶肿、视神经、听神经的相关并发症，使得人们增加了对神经梅毒的关注。Classification of the Neurosyphilis神经梅毒的分类神经梅毒的分类Early Neurosyphilis早期神经梅毒早期神经梅毒:1)Asymptomatic

4、无症状型无症状型;2)Symptomatic症状型症状型:A)Acute syphilitic meningitis急性梅毒性脑膜炎；急性梅毒性脑膜炎；B)Meningovascular syphilis膜性血管梅毒膜性血管梅毒:a)Cerebrovascular syphilis脑膜血管梅毒脑膜血管梅毒;b)Meningovascular syphilis of spinal cord脊髓膜血管梅毒脊髓膜血管梅毒Perenchymatous Neurosyphilis实质性神经梅毒实质性神经梅毒:1)General paresis系统性麻痹系统性麻痹;2)Tabes dorsalis脊髓痨脊

5、髓痨Gummas of the nervous system神经系统树胶肿神经系统树胶肿:1)Cerebral gummas脑树胶肿脑树胶肿;2)Gumma of spinal cord脊髓树胶肿脊髓树胶肿Asymptomatic无症状神经梅毒无症状神经梅毒lPresence of abnormalities in the CSF 脑脊液有异常表现;lAbsence of other findings of neurologic disease 缺乏神经系统的临床症状;lBy definition,there are no clinical manifestations of asymptom

6、atic neurosyphilis.定义：脑脊液有异常表现，缺乏神经系统的临床症状的梅毒患者，定义为无症状神经梅毒。Asymptomatic无症状神经梅毒无症状神经梅毒 Abnormalities in the CSF脑脊液异常的表现脑脊液异常的表现:10-100 WBC/mm(all of which are lymphocytes)白细胞（主要是淋巴细胞）;a protein（蛋白）of 50-100mg/dl;a recative nontreponemal antibody test (VDRL)in the CSF(90%)脑脊液非梅毒螺旋体抗体实验90%以上为阳性;blood s

7、erology(RPR)is nearly always positive.血清非梅毒螺旋体抗体实验90%以上为阳性 Asymptomatic无症状神经梅毒无症状神经梅毒lPersistence of CSF abnormalities for more than 5 years after infection(called late asymptomatic syphilis);梅毒螺旋体感染后脑脊液持续梅毒螺旋体感染后脑脊液持续5年出现异常，可定义为晚期无年出现异常，可定义为晚期无症状神经梅毒；症状神经梅毒；lThe development of neurologic disease in

8、 up to 87%of patients.该类晚期无症状神经梅毒中大约有晚期无症状神经梅毒中大约有87%可能发展为有症状神可能发展为有症状神经梅毒。经梅毒。Symptomatic症状型神经梅毒症状型神经梅毒lAcute syphilitic meningitis 急性梅毒性脑膜炎lMeningovascular syphilis:脑膜血管性梅毒 Cerebrovascular syphilis;大脑膜血管性梅毒 Meningovascular syphilis of the spinal cord.脊髓膜血管性梅毒。Symptomatic症状型神经梅毒症状型神经梅毒Acute syphili

9、tic meningitis:急性梅毒性脑膜炎The incubation period in the majority of patients with syphilis meningitis is less than 1 years;大部分梅毒性脑膜炎患者的潜伏期在一年之内；25%of those patients meningitis is the first clinical manifestation of syphilis;大约有大约有25%的梅毒性脑膜炎患者是以梅毒的首发症状出现的；的梅毒性脑膜炎患者是以梅毒的首发症状出现的；A small percentage of patie

10、nts(15%)still have a 2nd rash at the time of the meningitis.大约大约15%的患者在出现梅毒性脑膜炎的同时，仍然具有二期梅毒的皮肤损害。的患者在出现梅毒性脑膜炎的同时，仍然具有二期梅毒的皮肤损害。Acute syphilitic meningitis急性梅毒性脑膜炎急性梅毒性脑膜炎Clinical manifestitations:临床表现Cranial nerve palsies(sense)in 40%of cases;大约40%的患者有颅神经麻痹（感觉障碍）The signs of increased intracranial p

11、ressure;部分患者可有颅内压增高的表现The involvement of cranial nerves(3rd,6th,7th,8th);多数可以累及3、6、7、8对颅神经Sensorineural deafness may occur in about 20%of patients.大约20%的患者可以出现感音神经性耳聋。Acute syphilitic meningitis急性梅毒性脑膜炎急性梅毒性脑膜炎Clinical manifestitations:临床表现临床表现Acute syphilitic hydrocephalus was seen in 1/3 of the ca

12、ses of meningitis;大约大约1/3的梅毒性脑膜炎患者可出现梅毒性脑水肿；的梅毒性脑膜炎患者可出现梅毒性脑水肿；The principal symptoms and signs are those of increased intracranial pressure(stiff neck,confusion,delirium,papilledema);主要症状与体征是因为颅内压增高而引起的（颈部僵硬，意识丧失，谵妄等）主要症状与体征是因为颅内压增高而引起的（颈部僵硬，意识丧失，谵妄等）；Syphilitic meningitis with cerebral changes acc

13、ounts for of early neurosyphilis;在早期神经性梅毒患者中大约有在早期神经性梅毒患者中大约有1/4具有梅毒性脑膜炎伴发大脑的改变具有梅毒性脑膜炎伴发大脑的改变Fever is only low grade or may be absent可有低度发热或无发热可有低度发热或无发热Acute syphilitic meningitis急性梅毒性脑膜炎急性梅毒性脑膜炎Laboratory fingings;实验室检查实验室检查The blood Wassermann reaction was+ve in 64%;大约大约64%的患者血清华氏曼反应阳性；的患者血清华氏曼反

14、应阳性；RPR is+ve in most of cases of ASM;大部分血清非螺旋体实验阳性大部分血清非螺旋体实验阳性The CSF include:脑脊液异常表现包括：脑脊液异常表现包括：elevated pressure;颅内压升高；颅内压升高；mononuclear pleocytosis(10-200/1000-2000/mm);单个核白细胞升高单个核白细胞升高(10-200/1000-2000/mm);elevated globulin level;球蛋白升高；球蛋白升高；modest reduction in glucose in 45%of cases;45%的患者葡萄

15、糖中度下降；的患者葡萄糖中度下降；VDRL test is recative in most,not all cases.VDRL实验在大多数（不是所有的患者）患者为阳性实验在大多数（不是所有的患者）患者为阳性Acute syphilitic meningitis急性梅毒性脑膜炎急性梅毒性脑膜炎Laboratory fingings;实验室检查实验室检查Patient with isolated involvement of the 8th cranial nerve may has a normal CSF(VDRL-ve);仅有第八对脑神经受累的患者脑脊液可能是正常的Correlation

16、 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 examinations.Acute syphilitic meningitis急性梅毒性脑膜炎急性梅毒性脑膜炎Diagnosis and differential diagnosis:诊断与鉴别诊断诊断与鉴别诊断ASM diagnosis ia based o

17、n:急性梅毒性脑膜炎基于以下证据：Clinical picture:临床表现 Aseptic meningitis;化脓性脑膜炎 Lymphocytes response in the CSF;脑脊液中的淋巴细胞数量；Reactive blood and CSF serology.血请和脑脊液的非螺旋体实验The history:病史 Recent chancre;近期是否有硬下疳；The secondary rash;有无继发性皮损；Generalized lymphadenopathy.全身淋巴结有无肿大；Meningitis may be the 1st clinical manifes

18、titation of syphilitic infection.脑膜炎可能是部分患者的首发临床症状。Acute syphilitic meningitis机型梅毒性脑膜炎机型梅毒性脑膜炎Differential diagnosis:鉴别诊断The various cause of a lymphocytic meningitis;排除其他淋巴性脑膜炎的可能Include包括:enterovirus 病毒,other spirochetes其他螺旋体(Borrelia,Lyme disease);Mycobacteria分支杆菌;Fungi真菌 Mengingovascular syphili

19、s脑膜血管性梅毒脑膜血管性梅毒lCerebrovascular syphilis;大脑血管性梅毒lMengingovascular syphilis of spinal cord脊髓膜血管性梅毒Mengingovascular syphilis大大脑膜血管性梅毒脑膜血管性梅毒Cerebrovascular syphilis大脑膜血管梅毒大脑膜血管梅毒:Vascular neurosyphilis may involve any part of the central nervous system;有可能累及任何部位的中枢神经系统；The common denominator is infarc

20、tion secondary to syphilitic endarteritis;常见的就是继发于梅毒性内膜炎的脑梗死；This disease usually occurs 5-12 years after infection;该症状出现在梅毒感染之后5-12年；Earlier than the occurrence of paresis and tabes;该症状的出现早与脊髓痨和神经麻痹；该症状的出现早与脊髓痨和神经麻痹；The most of patients are 30-50 years old.大多数出现在30-50岁的患者。Cerebrovascular syphilis:大

21、大脑膜血管性梅毒脑膜血管性梅毒The most common manifestations are:最常见的临床表现是：最常见的临床表现是：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 symptoms:Headache;Dizziness;Insomnia;Memory loss;Mood disturbances

22、Cerebrovascular syphilis:脑膜血管性梅毒脑膜血管性梅毒Laboratory findings实验室检查实验室检查:Serum RPR is positive血清RPR阳性;The CSF VDRL test is positive in most,but not all cases.大多数患者脑脊液VDRL检测阳性；Angiographic changes include diffuse irregularity;脑血管图可能出现异常；Segmental dilatation of the pericallosal artery;动脉出现节段性扩张；CT shows l

23、ow-density areas with variable degrees;CT扫描可见不同程度的低密度区；MRI shows focal regions of high signal intensity.MRI扫描可见区域性高密度信号区。Cerebrovascular syphilis大大脑膜血管性梅毒脑膜血管性梅毒lDiagnosis and differential diagnosis:诊断与鉴别诊断Diagnosis:诊断The possibillity of mengingovascular syphilis should be considered when:出现以下情况时可考虑

24、脑膜血管梅毒的可能：Cerebrovascular accidents occur in a young adult年轻人出现的脑血管意外；without the usual risk factors(hypertension,embolic cardaic disease).排除其他常见的危险因素（高血压，心脑血管病）CSF serology is importantin making the diagnosis.脑脊液的非螺旋体实验检测有十分重要的意义。Cerebrovascular syphilis大大脑膜血管性梅毒脑膜血管性梅毒lDifferential diagnosis:鉴别诊断鉴

25、别诊断Includeing other causes of stroke syndromes such as:应排除以下其他原因引起的中风综合征Hypertension(stroke);高血压（中风）Athero-sclerotic(high blood lipid)vascular disease;动脉硬化（高血脂）血管病；动脉硬化（高血脂）血管病；Cerebral emboli;脑血管异常；The various types of cerebral vasculitis;各种类型的脑血管炎；Angiographic changes in SLE;SLE患者的脑血管改变；Polyarteri

26、tis nodosa.多发性动脉结节。Meningovascular syphilis of the spinal cord脊髓膜血管性梅毒脊髓膜血管性梅毒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;梅毒性脊髓内膜炎；Spinal vascular syphilis.脊髓血管梅毒；Spinal syphilis has always been rare(3%);脊髓梅毒罕见（低于3%）It always associated with cer

27、ebral involvement;butthe disease of the spinal cord may be preeminent.脊髓梅毒通常伴随大脑受累，但脊髓症状可能更为突出。脊髓梅毒通常伴随大脑受累，但脊髓症状可能更为突出。Meningovascular syphilis of the spinal cord脊髓膜血管性梅毒脊髓膜血管性梅毒Symptoms and signs:症状与体征症状与体征The weakness of paraplegia of the legs;双下肢无力；Progressive to paraparesis(mild)or paraplegia(s

28、evere)双下肢进行性麻痹或疼痛双下肢进行性麻痹或疼痛 wihch is asymmetrmic;多数表现为不对称；Urinary and fecal incontinence;大小便失禁；Variable sensory disorders(pain and paraplegia)in the legs are prominent.双下肢的各种感觉异常（疼痛和麻痹）更明显。双下肢的各种感觉异常（疼痛和麻痹）更明显。Meningovascular syphilis of the spinal cord脊髓膜血管性梅毒脊髓膜血管性梅毒Symptoms and signs:症状与体征症状与体征O

29、n the examinations:体检The legs are weak and spastic(stiff);双下肢虚弱和僵硬；The deep tendon reflexes are hyperreactive;The ankle clonus is present;深肌腱反射过度，踝反射阳性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.双下肢最常见的感觉异

30、常是位置和震动感觉消失；The classic manifestations are a transection of the spinal cord.大多数感觉异常呈节段性。Meningovascular syphilis of the spinal cord脊髓膜血管性梅毒脊髓膜血管性梅毒Laboratory findings:实验室检查实验室检查Blood serology tests are regularly positive;血清学检测通常为阳性；CSF tests discloses(showing)the same abormalities seenIn other forms

31、 of neurosyphilis;脑脊液检测与其他型的神经梅毒表现相同；CSF serology tests are positive in most of,not all cases脑脊液血清学检测大多数表现阳性。Meningovascular syphilis of the spinal cord脊髓膜血管性梅毒脊髓膜血管性梅毒Diagnosis and differential diagnosis诊断与鉴别诊断Diagnosis:诊断The diagnosis is made on the clinical pictures of an abrupt flaccid(soft,slow

32、)paraplegia developing in a patients with consistent CSF abnormalities and reactive blood and CSF serologies在脑脊液持续性异常并伴有脑脊液血清学反应阳性，出现下肢缓慢的进行性麻痹的患者；Multiple sclerosis and subacute combined degeneration.脊髓出现多发性硬化和变性；脊髓出现多发性硬化和变性；Meningovascular syphilis of the spinal cord脊髓膜血管性梅毒脊髓膜血管性梅毒Diagnosis and

33、differential diagnosis诊断与鉴别诊断Differental diagnosis:鉴别诊断Multiple sclerosis and subacute combined degeneration.脊髓多发性硬化和变性；脊髓多发性硬化和变性；Parenchymatous neurosyphilis实质性神经梅毒实质性神经梅毒lGeneral paresis;麻痹lTabes dorsalis脊髓痨Parenchymatous neurosyphilis实质性神经梅毒实质性神经梅毒General paresis;Early symptom:早期症状 Irritablity(t

34、emper loss),memory loss,personal changes,impaired capacity to concentrate,carelessness in appearance,hadeache,insomnia;易怒、记忆丧失、人格变化、注意力不易集中、表现淡漠、头痛、嗅觉减退；Late symptom:晚期症状 Defective judgment,emotional lability(changeable)(depression,agitation,euphoria-joyful),lack of insight,confusion and disorientat

35、ion,delusions of grandeur,paranoia(psychological problems),seizures.Parenchymatous neurosyphilis实质性神经梅毒实质性神经梅毒General paresis;Laboratory findings:实验室检查Nontreponemal serology tests of blood and CSF are nearly uniformly+ve in cases of paresis;脑脊液、血清非梅毒螺旋体实验阳性Other CSF findings are typical of those in

36、neurosyphilis;脑脊液的其他改变与其他的神经梅毒表现一致；The CSF may be normal in a patients whose neurosyphilis has been arrested by treatment.经过治疗的神经梅毒患者脑脊液可能是正常的。Parenchymatous neurosyphilis实质性神经梅毒实质性神经梅毒Diagnosis:诊断诊断The diagnosis is based on the clinical pictures,which is readily recognizable in it full-blown(develo

37、pement)form,together with characteristic spinal fluid abnormalities.诊断主要基于临床表现，脊柱神经系统不断加重的神经系统的症状，脑脊液的各种异常表现。Parenchymatous neurosyphilis实质性神经梅毒实质性神经梅毒Differential diagnosis:鉴别诊断鉴别诊断Cerebnral tumor;脑肿瘤；Subdural hematoma;血管瘤血管瘤Cerebral arteriosclerosis;脑动脉硬化Alzheimers disease(Senil dementia);阿茨海默病（老年

38、性痴呆）Multiple sclerosis;多发性硬化症；Chronic alcholism.慢性酒精中毒。慢性酒精中毒。Parenchymatous neurosyphilis实质性神经梅毒实质性神经梅毒Tabes dorsalis脊髓痨脊髓痨Symptoms:症状Lighting;畏光Ataxia;Bladder disturbance;膀胱功能紊乱Parethesia;Visual loss(optic atrophy);视力减退（视神经萎缩）Rectal incontinence.大便失禁。Parenchymatous neurosyphilis实质性神经梅毒实质性神经梅毒Signs

39、:体征体征Pupillary abnomarlities;Argyll Roberstson pupil;瞳孔异常 阿罗月瞳孔Absent ankles jerks;Absent knee jerks;踝反射缺失 膝反射缺失Rombergs sign(close eye down);Impaired vibratory sense;罗伯戈征阳性 震动觉减退Impaired touch and pain sense;Impaired position;痛觉、触觉减退 位置觉减退Ocular palsies(sense);Charcots joint.夏克氏关节夏克氏关节Parenchymatou

40、s neurosyphilis实质性神经梅毒实质性神经梅毒Laboratory fidingns:实验室检测实验室检测The laboratory findings are variable;实验室检测结果是可变的Depand on:基于以下因素1).The stage of tabes;不同的疾病阶段 2).Whether partial or full treatment has been administered in the past;以前有无不规则或规则的治疗。Parenchymatous neurosyphilis实质性神经梅毒实质性神经梅毒Laboratory fidingns:

41、实验室检测实验室检测The CSF findings among patients with tabes are:脊髓痨患者脑脊液异常包括：1).Lymphocytic pleocytosis in 50%;50%以上患者淋巴细胞升高；以上患者淋巴细胞升高；2).Elevated protein concentration(45-100mg/dl)in 50%;50%以上患者蛋白浓度升高以上患者蛋白浓度升高(45-100mg/dl)；3).Reactive nontreponemal serology of CSF(Wassermanns test)in 72%.72%的患者脑脊液非梅毒螺旋体

42、抗体实验阳性。Parenchymatous neurosyphilis实质性神经梅毒实质性神经梅毒Diagnosis and differential diagnosis:诊断和鉴别诊断诊断和鉴别诊断A clinical diagnosis of tabes is most likely in a case with lighting pain,ataxia who exhibits findings of absent deep tendon reflexs,Argyll Robertson pupil and a+ve Rombergs sign.临床表现包括临床表现包括LIGHTING疼

43、痛、抑郁、深部腱反射消失；阿罗月瞳孔，罗伯戈征疼痛、抑郁、深部腱反射消失；阿罗月瞳孔，罗伯戈征阳性等症状对脊髓痨的诊断有重要的提示作用；阳性等症状对脊髓痨的诊断有重要的提示作用；Early and atypical case present greater problem in diagnosis;早期或不典型患者经常会被误诊；早期或不典型患者经常会被误诊；The results of serology tests and spinal fluid tests may lead to the correct diagnosis.血清学、脑脊液检测结果对于确诊有重要价值。血清学、脑脊液检测结果对

44、于确诊有重要价值。Optic atrophy 视神经萎缩视神经萎缩 It with the same ocular manisfestations as occurs in tabes;与脊髓痨的眼部表现相同；与脊髓痨的眼部表现相同；The disease may appear as an isolated manifestations of neuresyphilis;也有可能是也有可能是神经梅毒唯一的临床表现；神经梅毒唯一的临床表现；The usual symptoms are those of progressive visual loss Involving frist one eye

45、 and then the other;通常的症状是进行性视力减退，一般是单眼通常的症状是进行性视力减退，一般是单眼开始，再波及另一只眼；开始，再波及另一只眼；CSF abnormalities are most present in the untreated case;大多数未经治疗的患者脑脊液通常具有异常表现；大多数未经治疗的患者脑脊液通常具有异常表现；Optic atrophy may also result from prior syphilitic optic neuritis;PG treatment can usually prevent further progression

46、 of visual loss.青霉素治疗通青霉素治疗通常可以阻止视力的进行性减退。常可以阻止视力的进行性减退。Gummas of nervous system神经系统树胶肿神经系统树胶肿lCerabral gummas;脑树胶肿lGumma of spinal cord.脊髓树胶肿Gummas of nervous system神经系统树胶肿神经系统树胶肿 Cerebral gummas:脑树胶肿脑树胶肿This form of neurosyphilis is esceedingly rare;该型神经梅毒极为罕见；The presentation is that of a space o

47、ccupying lesion;临床表现是大脑占位性病变的表现；The diagnosis may only be made when the patient is operated on for a suspected intracranial mass lision;大部分确诊是可疑颅内肿块手术切除中发现的；大部分确诊是可疑颅内肿块手术切除中发现的；Multiple ring-enhancing lesions may be found on CT or MRI examinations.CT、MRI检测可发现环状信号增强区。Gummas of nervous system神经系统树胶肿神

48、经系统树胶肿Gumma of the spinal cord:脊髓树胶肿脊髓树胶肿It is fundamentally a granuloma of the meninges compressing the cord;主要表现为脊髓膜肉芽肿压迫脊索的表现The clinical picture is that of a cord tumor,root pain,spastic paraplegia,urinary and fecal incintinence and loss of sensation below the lesion.临床症状表现为脊索肿瘤、神经根疼痛、僵直麻痹、大小便失禁

49、和损害以下感觉丧失；The progressive is subacute;呈亚急性病程；The CSF findings consist of dynamic block,markedly elevated protein(over 350mg/dl)and a+ve nontreponemal serologic test.脑脊液检测表现为梗阻性的表现特征，蛋白明显升高（高于脑脊液检测表现为梗阻性的表现特征，蛋白明显升高（高于350mg/dl)，非梅毒螺旋体抗体实验阳性。Current manifestations of neurosyphilisAtypical presentation

50、s不典型表现考虑神经梅毒的提示不典型表现考虑神经梅毒的提示The following clinical manifestations should be considered the diagnosis of neurosyphilis:出现以下临床症状时应该考虑神经梅毒；出现以下临床症状时应该考虑神经梅毒；1).Positive blood FTA-ABS serology along with neurologic or ophthalmologic findings suggestive of neurosyphilis;血清血清FTA-ABS实验阳性，同时出现神经系统或视神经的异常表现

51、；实验阳性，同时出现神经系统或视神经的异常表现；2).Unexplained neurological illness with positive blood&CSF FTA-ABS test&CSF showing more than 5 WBC/mm;无法解释的神经系统疾病，同时出现血清及脑脊液无法解释的神经系统疾病，同时出现血清及脑脊液FTA-ABS阳性反应，脑脊液白细胞数阳性反应，脑脊液白细胞数5 个个/mm以上以上;3).Positive FTA-ABS in blood&in cases with progressive neurologic disease in whom oth

52、er etiologic considerations had been excluded.已经排除其他的相关疾病原因，具有进行性神经系统疾病的患者同时出现血清已经排除其他的相关疾病原因，具有进行性神经系统疾病的患者同时出现血清FTA-ABS实实验阳性。验阳性。Antobiotic therapy for neurosyphilis神经梅毒的抗生素治疗神经梅毒的抗生素治疗The introduction of PG in the 1940s strikingly simplified the therapy&improved the outcome of neurosyphilis;上世纪40

53、年代由于青霉素的使用，大大简化了对神经梅毒的治疗，也明显改善了预后；Recently reports were showed that a few cases in which benzathine or procaine PG in recommended dose failed to cure neurosyphilis;近几年来，有部分报告用推荐剂量的苄星青霉素和普鲁卡因青霉素治疗神经梅毒近几年来，有部分报告用推荐剂量的苄星青霉素和普鲁卡因青霉素治疗神经梅毒失败的个案；失败的个案；Those cases reports suggests that the failures represe

54、nted early cases of neurosyphilis in HIV infected persons.大多数治疗失败的个案与感染HIV相关。Antobiotic therapy for neurosyphilis神经梅毒的抗生素治疗神经梅毒的抗生素治疗As a result of those considerations,WHO&CDC of USA no longer recommend benzathine PG to treat neurosyphilis;基于多种因素，基于多种因素，WHO和美国和美国CDC不再考虑推荐苄星青霉素治疗神经梅毒不再考虑推荐苄星青霉素治疗神经梅

55、毒The most recent recommendations of CDC are:美国CDC最近治疗方案如下；1).IV aqueous PG 18-24 million daily for 10-14 days;静脉使用水剂青霉素1800-2400万治疗10-14天；2).IM procaine PG 2.4 million plus probenecid 500mg by mouth Qid for 10-14 days.肌注普鲁卡因青霉素240万，加口服丙磺舒500mg，10-14天。Antobiotic therapy for neurosyphilis神经梅毒的抗生素治疗神经梅

56、毒的抗生素治疗Drug regimens for treatment of neurosyphilis:神经梅毒的药物治疗方案神经梅毒的药物治疗方案1).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;静脉使用水剂青霉素静脉使用水剂青霉素1800-2400万，万，10-14天（每天（每4小时小时300-400万），然后苄星青霉素万），然后苄星青霉素240万

57、肌注每周一次，再用三次。万肌注每周一次，再用三次。2).IM aqueous procaine PG 2.4million+probenecid 500mg by mouth Qid for 10-14 days,followed by benzathine PG 2.4 million IM weekly for 3 doses.肌注水剂普鲁卡因青霉素肌注水剂普鲁卡因青霉素240万加丙磺舒万加丙磺舒0。5每日四次口服每日四次口服10-14天；然后苄星青霉素天；然后苄星青霉素240万肌注每周一次，再用三次。万肌注每周一次，再用三次。Note:For patients who are aller

58、gic to PG,the official recommendation isthat desensitization be undertaken;Althrough some experts recommend a 3 wks courses of ceftriaxone,1 gm daily.注意事项：对青霉素过敏的患者，官方推荐使用脱敏治疗；也有专家推荐注意事项：对青霉素过敏的患者，官方推荐使用脱敏治疗；也有专家推荐ceftriaxone每每天一克，三周一个疗程的治疗方案。天一克，三周一个疗程的治疗方案。Follow-up随访随访Clinical(including CSF)exami

59、nation should done 3 months after treatment and then at 6 months intervals,until the CSF findings return to normal;治疗后治疗后3个月随访一次（包括临床和脑脊液）然后半年个月随访一次（包括临床和脑脊液）然后半年1次，直到脑脊液恢复正常；次，直到脑脊液恢复正常；Reevaluation should be performed annually for several years;以后每年随访一次；以后每年随访一次；In a minority of patients CSF abnor

60、malities persist,patients whose WBC count and protein do not decline after 6 months are often retrated;对少数脑脊液持续异常，在治疗后半年白细胞和蛋白保持不下降着应重新治疗对少数脑脊液持续异常，在治疗后半年白细胞和蛋白保持不下降着应重新治疗A true failure of therapy may rarely occur,in which an initial normalization of CSF findings is followed by replase,in such cases

61、,repeate therapy needs to be given;完全的治疗失败并不常见，经过治疗脑脊液恢复正常后，如果出现异常表明完全的治疗失败并不常见，经过治疗脑脊液恢复正常后，如果出现异常表明为复发，这类患者应该再次治疗；为复发，这类患者应该再次治疗；If relapse has not occurred during 2 years after therapy,the case can generally be regarded as cured.l在治疗后在治疗后2年未见副发，可以判定为临床痊愈。年未见副发，可以判定为临床痊愈。Prognosis预后预后PG therapy of

62、 acute syphilitic meningitis have been very good,with clearing of the CSF changes and lack of progression to parenchymatous neurosyphilis;急性梅毒性脑膜炎对青霉素治疗效果很好，可使脑脊液恢复正常，并阻断向实质性神经梅毒发展的机会。Treatment was effective,and most cases had no further cerebrovascular accidents;对大多数治疗有效的患者，不会继续发展为脑血管意外；对大多数治疗有效的患者

63、，不会继续发展为脑血管意外；PG therapy has usually been effective in clearing the CSF changes and in preventing progressive clinical disease;青霉素治疗对脑脊液异常的恢复，阻止其他临床症状的发展是有效的The therapy can not reverse structural damage that has already occured.治疗不可能使已经受损的结构发生逆转，个别患者可能还会加重症状治疗不可能使已经受损的结构发生逆转，个别患者可能还会加重症状 Prognosis预后

64、预后Among a group of 58 cases with paresis treated with one or more courses of PG,26(45%)improved and discharged from hospital;对一组58例神经麻痹的住院患者，用水性青霉素治疗1个或几个疗程后，26/48（45%）明显改善出院；PG therapy for this form of neurosyphilis is not hopeless;青霉素对于这些神经梅毒患者并不是毫无希望的青霉素对于这些神经梅毒患者并不是毫无希望的Particularly when treatme

65、nt is instituted as soon as clinical symptoms become evident,but response to therapy is by no means(should be)assured.尤其是在刚出现神经症状时，立即治疗，大部分效果良好；Prognosis预后预后1)The prognosis of tabes is variable,and the disease can be compatible with life long;脊髓劳的预后因人而不同，有时候会是终生的；1)About 4-10%of untreated cases beco

66、me spontaneously arrested at an early stage;在早期患者有4-10%可能未经过治疗，自行缓解1)In the prepenicillin era,treatment improved or arrested the clinical course in over 80%of cases;一般来讲，青霉素治疗可以使80%以上的患者明显改善或缓解Prognosis预后预后1)The course of untreated general paresis is progressive,and the outcome is eventually fatal;系统性麻痹不经过治疗，病情可能进行性发展，结局可能是致死性的系统性麻痹不经过治疗，病情可能进行性发展，结局可能是致死性的1)Many of the residual signs and symptoms of tabes may presist after PG therapy;即使经过治疗，有些症状也可能持续存在即使经过治疗，有些症状也可能持续存在1)The most satisfactory t