Tackling the ‘Great imitator’!

Dear Editor,

We read with interest the intriguing case of neurosyphilis mimicking giant cell arteritis by Chung et al. ¹ in the recent issue of the Journal and noted that after establishing the diagnosis of neurosyphilis the patient was treated with intravenous ceftriaxone. We are curious about choosing ceftriaxone as first-line treatment for neurosyphilis in that patient. In a non-penicillin allergic patient, international guidelines recommend aqueous crystalline penicillin G as first-line therapy with an alternative regime being procaine penicillin G plus probenecid. ² The 2020 European International Union Against Sexually Transmitted Infections (IUSTI) guidelines recommended IV ceftriaxone only if aqueous crystalline penicillin G is unavailable. ³ These recommendations are supported by another recent review as well. ⁴

While there are some studies that do suggest the use of ceftriaxone, particularly in patients living with HIV^5,6 most of the current literature recommends penicillin as the first-line treatment for neurosyphilis and in our opinion that should be preferred treatment considering the risks and long-term sequelae associated with various forms of tertiary syphilis, including neurosyphilis.