Asymptomatic neurosyphilis in HIV infected patients is probably grossly underestimated. he most recent CDC guidelines recommend spinal fluid analysis for HIV-infected patients who have late latent syphilis, syphilis of unknown duration, or serologic failure after a course of syphilis treatment. Other authorities suggest that spinal fluid should be obtained in individuals with CD4 counts 350 cells/mm³ or rapid plasma reagin (RPR) titers 1:32. To determine which nomogram might yield an ANS diagnosis most efficiently, investigators reviewed data from a large cohort of HIV-infected patients at the Johns Hopkins Moore Clinic. In a recent study, the authors discovered that 202 of 231 patients (87%) did not have neurological symptoms. Immediate lumbar puncture was performed on 46 patients and 22% had neurosyphilis without any symptoms! (Journal of Clinical Infectious Diseases, 2009 Mar 15;48(6):816-21) – Comments: Neurosyphilis remains under diagnosed and under treated. Just because there are no symptoms, does not mean there is no disease. Lumbar puncture is a lot easier that neurosyphilis. BA