Skip directly to site content Skip directly to page options Skip directly to A-Z link


Centers for Disease Control and Prevention. CDC twenty four seven. Saving Lives, Protecting People
															Search

		Submit


Sexually Transmitted Diseases (STDs)


Facebook
        Twitter
        LinkedIn
        Syndicate





Neurosyphilis, Ocular Syphilis, and Otosyphilis										Related Pages
					On This Page
			NeurosyphilisOcular SyphilisOtosyphilisEvaluation and TreatmentReportingLaboratoryFor More Information
		
Be aware of neurosyphilis, ocular syphilis, and otosyphilis.
Screen for neurologic, visual, and auditory signs and symptoms in patients at risk for syphilis (e.g., men who have sex with men, people with HIV, and people with multiple or anonymous partners).
Screen patients for syphilis if they present with neurologic, visual, or auditory complaints.
Conduct a careful neurological exam, including an evaluation of all cranial nerves, for patients with reactive nontreponemal and treponemal serology and clinical signs of early syphilis.
Conduct an immediate ophthalmologic evaluation for patients with syphilis and ocular complaints.
Evaluate and manage patients with syphilis and otologic symptoms in collaboration with an otolaryngologist.Neurosyphilis
Neurosyphilis is a result of invasion of the central nervous system by *Treponema pallidum,* which can occur at any stage of syphilis. It is unknown whether certain *T. pallidum* strains are neurotropic.
Early neurologic clinical manifestations (e.g., cranial nerve dysfunction, meningitis, meningovascular syphilis, stroke, and altered mental status) are usually present within the first few months or years of infection. Late neurologic manifestations (e.g., tabes dorsalis and general paresis) occur 10–30 years after infection but can occur earlier in people who are immunocompromised.
Invasion of cerebrospinal fluid (CSF) by *T. pallidum* can occur during any stage of syphilis and CSF laboratory abnormalities are common among people with early syphilis regardless of neurologic signs or symptoms. No evidence supports variation from the CDC-recommended treatment regimen for syphilis at any stage for people without clinical neurologic findings. If clinical signs or symptoms of neurologic involvement are present (e.g., cranial nerve dysfunction, meningitis, stroke, acute or chronic altered mental status, or motor or sensory deficits), CSF examination should be performed.
Infection of the visual system (ocular syphilis) or auditory system (otosyphilis) can also occur at any stage of syphilis.
Ocular Syphilis
Ocular syphilis can occur at any stage of syphilis, with variable clinical presentations, including isolated ocular abnormalities or with neurologic manifestations. Ocular syphilis can involve almost any eye structure, but posterior uveitis and panuveitis are the most common clinical manifestations. Additional ocular manifestations may include anterior uveitis, optic neuropathy, retinal vasculitis, and interstitial keratitis. Ocular syphilis may lead to decreased visual acuity with subsequent permanent blindness.
Ocular syphilis may be the initial presentation of syphilis in a patient. Screening for syphilis should be considered in new onset vision changes.
Otosyphilis
Otosyphilis is caused by an infection of the cochleovestibular system with *T. pallidum* and typically presents with sensorineural hearing loss, tinnitus, or vertigo. Hearing loss can be unilateral or bilateral, have a sudden onset, and progress rapidly. Otosyphilis can result in permanent hearing loss.
Otosyphilis may be the initial presentation of syphilis in a patient. Screening for syphilis should be considered in new onset sensorineural hearing loss, tinnitus, and vertigo.
Patients who present with otosyphilis may also have manifestations of ocular and neurosyphilis (especially involving cranial nerve VIII) and should be evaluated accordingly.
Evaluation and Treatment
Patients who receive a diagnosis of syphilis and have neurologic, ocular, and/or otologic symptoms should be evaluated for neurosyphilis, ocular syphilis, or otosyphilis according to their clinical presentation.
Patients who have syphilis and symptoms or signs suggestive of neurologic disease (e.g., cranial nerve dysfunction, meningitis, stroke, acute or chronic altered mental status, or motor or sensory deficits) should have an evaluation that includes CSF analysis before treatment. Patients with syphilis who have symptoms or signs of ocular syphilis (e.g., uveitis, iritis, neuroretinitis, or optic neuritis) should have a full ocular slit-lamp and ophthalmologic examination, including a thorough cranial nerve evaluation; if cranial nerve dysfunction is present, CSF examination is indicated.
Patients with syphilis, isolated ocular symptoms (no cranial nerve dysfunction or other neurologic abnormalities), and confirmed ocular abnormalities on examination, CSF analysis is not necessary before treatment. CSF examination may be helpful in evaluating patients with syphilis who have ocular symptoms and do not have abnormalities on ocular examination.
Patients with syphilis, isolated auditory symptoms, and normal neurologic examination, CSF examination is not recommended before treatment since it is usually normal. If there are signs and symptoms of otosyphilis, then otologic examination is needed.
All patients with syphilis should receive an HIV test if status is unknown or previously HIV-negative.
Treatment
Treatment for neurosyphilis should be managed according to the STI Treatment Guidelines, 2021 – Neurosyphilis, Ocular Syphilis, and Otosyphilis.
Ocular syphilis should be managed in collaboration with an ophthalmologist; immediate referral to an ophthalmologist is critical if ocular syphilis is suspected. Patients diagnosed with ocular syphilis should be managed according to the STI Treatment Guidelines, 2021 – Neurosyphilis, Ocular Syphilis, and Otosyphilis.
Otosyphilis should be managed in collaboration with an otolaryngologist. Treatment for otosyphilis should follow the STI Treatment Guidelines, 2021 – Neurosyphilis, Ocular Syphilis, and Otosyphilis.
Follow-up
Repeat CSF examinations are not necessary for patients without HIV infection or among patients with HIV infection who are on antiretroviral therapy and who exhibit serologic and clinical responses after treatment.
Reporting
In 2018, the Council of State and Territorial Epidemiologists revised the syphilis case definition to include neurosyphilis related variables: neurologic, ocular, and otic manifestations.  Cases should be reported according to stage of infection and the clinical manifestations should be reported with the case report data. Healthcare providers should follow state or local health department’s guidance for reporting clinical manifestations of cases of syphilis.
Laboratory
CDC is conducting a study on ocular syphilis to determine whether specific molecular strain types of *T. pallidum* are associated with this type of syphilis. Healthcare providers with patients suspected of ocular syphilis can collect clinical specimens for molecular typing. Pre-antibiotic residual clinical samples (whole blood in EDTA tubes, exudate or tissue from primary and secondary lesions, CSF or ocular fluid) collected as part of routine clinical testing should be saved and stored at -80°C immediately upon collection for molecular typing.
For assistance with the collection procedure or shipment of samples, please contact Dr. Allan Pillay at 404-639-2140 or stdlaboratoryspecim@cdc.gov. Submitters should notify CDC and their respective state and local public laboratory prior to sending specimens.
For additional laboratory considerations, see the Sexually Transmitted Infections Treatment Guidelines, 2021.
For More Information
Healthcare providers needing CDC advice on the clinical management of neurosyphilis, ocular syphilis, or otosyphilis can contact:
CDC-INFO
1-800-CDC-INFO (800-232-4636)
TTY: 1-888-232-6348In English, en EspañolRelated ContentStatement from CSTE on 2018 update to syphilis case definitionpdf iconexternal icon
2021 STI Treatment Guidelines
Ocular Syphilis — Eight Jurisdictions, United States, 2014–2015 MMWR November 4, 2016
Keep an Eye Out For Ocular Syphilisexternal icon – Tom Peterman, MD, MSc; Kimberly Workowski, MD Medscape CDC Expert Commentary (Requires free membership to access commentary) (February 8, 2016)
Notes from the Field: A Cluster of Ocular Syphilis Cases — Seattle, Washington, and San Francisco, California, 2014–2015 MMWR October 16, 2015
STD Clinical Consultation Network Clinical Consultation Serviceexternal icon intended for licensed healthcare professionals and STD program staff
STD Data and Statistics (CDC.gov)
Association of Public Health Laboratories Laboratory Testing for Syphilisexternal icon
							
					
						Page last reviewed:  August 24, 2021					Content source: 	Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention homeSyphilis
Facts & Brochuresplus icon
Basic Fact Sheet
Detailed Fact Sheet
Congenital Syphilis Fact Sheet
Syphilis Prenatal Screening Brochure
Syphilis & MSM Fact Sheet
Syphilis Images
Statistics
Laboratory Information
Treatment and Careplus icon
Neurosyphilis, Ocular Syphilis, and Otosyphilis
What You Can Doplus icon
What Healthcare Providers Can Do
What Gay and Bisexual Men Can Do
What Pregnant Women Can Do
Other Resources
Archive Other STD Topics
 STDs Home Page
Bacterial Vaginosis (BV)
Chlamydia
Gonorrhea
Genital Herpes
Hepatitis
HIV/AIDS & STDs
Human Papillomavirus (HPV)
*Mycoplasma genitalium (Mgen)*
Pelvic Inflammatory Disease (PID)
STDs & Infertility
STDs during Pregnancy
Syphilis
Trichomoniasis
Other STDs
 See Also Pregnancy
HIV / AIDS
 **Enter your ZIP code to find an STI testing site near you.** Find Sites
 Follow STD STD on Twitter
STD on Facebook


About CDC
					Contact Us
					800-232-4636
 Facebook Twitter Instagram LinkedIn Youtube Pinterest Snapchat
 CONTACT CDC
				Contact Us
							Call 800-232-4636
							Email Us
			ABOUT CDC
				About CDC
							Jobs
							Funding
			POLICIES
				Accessibility
							External Links
							Privacy
							Policies
							No Fear Act
							FOIA
							OIG
							Nondiscrimination
							Vulnerability Disclosure Policy
			CONNECT WITH US
				Facebook
								Twitter
								Instagram
								LinkedIn
							Youtube
								Pinterest
								Snapchat
								Email
			LANGUAGES
				Español
							繁體中文
							Tiếng Việt
							한국어
							Tagalog
							Русский
							العربية
							Kreyòl Ayisyen
							Français
							Polski
							Português
							Italiano
							Deutsch
							日本語
							فارسی
							English


U.S. Department of Health & Human Services
			Accessibility
			External Links
			Privacy
			Policies
			No Fear Act
			FOIA
			Nondiscrimination
			OIG
			Vulnerability Disclosure Policy
			USA.gov


Exit Notification / Disclaimer Policy Close
 Links with this icon  indicate that you are leaving the CDC website. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website.
				Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website.
				You will be subject to the destination website's privacy policy when you follow the link.
				CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. Website Disclaimers
 Cancel Continue