Neurosyphilis in 2025

Syphilis continues to be a major global health problem. In recent years epidemics of syphilis have also been reported in many high-income countries. In this review, we aim to highlight varied presentations, including recent guidelines on diagnosis and treatment, including in people with HIV (PWH).

Neurosyphilis is increasingly being diagnosed and presentations are varied in both the immunocompetent and immunocompromised host. An appropriate history, examination and diagnostic work-up is central to identification of neurosyphilis and to enable appropriate treatment. Clear criteria for indication and interpretation of results from lumbar punctures, neuroimaging and treatment protocols have been outlined by the British association for sexual health and HIV (BASHH) in 2024.

The increase in overall cases of syphilis has been accompanied by increases in the number of cases with neurological involvement. The presentation of neurosyphilis is variable and may occur early or late in the disease course. It is important to be aware of the varied presentations, diagnostic and treatment criteria to limit the late sequelae of disease and address the global health challenge it poses and measures being taken to help reduce this global burden.