Do you routinely recommend a lumbar puncture for patients with suspected ocular or otic syphilis in the absence of additional CNS symptoms?
Do you routinely pursue a lumbar puncture for patients with suspected ocular or otic syphilis in the absence of additional CNS symptoms?
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No, this isn’t necessary, assuming no other evidence of non-ocular/otic neurosyphilis. I recommend management as advised by CDC in the 2021 treatment guidelines (https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf, p. 40). An especially careful neurological exam is advised, including cranial nerve functional assessment. Isolated ocular or otic syphilis are limited forms of NS, and some cases are accompanied by CSF findings consistent with NS — mononuclear pleocytosis, elevated protein, reactive CSF VDRL or RPR — but these do not change treatment, which is the same for ocular/otic as for NS itself (high dose benzathine penicillin G IV, or daily procaine penicillin G IM with probenecid), nor advised follow-up schedule. (Significantly, the guidelines no longer advise CSF follow-up after treatment of NS, assuming adequate clinical and serological responses).
No, generally I do not recommend an LP to patients with otic or ocular syphilis, assuming that we are relatively sure about the diagnosis and don't need additional information. An LP in these patients seems superfluous since we already have the diagnosis and, in my experience, most patients don't want the 6-month follow-up LP just to be sure they are resolving their pleiocytosis. Since such an LP does not affect the treatment or follow-up plan, I don't do it.
No, I don’t think LP adds anything to management.
Besides, unless you are in academia, it is very hard to get LP done.