High Titers, Hidden Disease: Asymptomatic Neurosyphilis in Secondary Syphilis - A Case Series from Western Maharashtra.

Syphilis can involve the central nervous system at any stage; however, routine cerebrospinal fluid (CSF) examination is rarely performed in neurologically asymptomatic patients with secondary syphilis. We describe a case series of eight male patients with secondary syphilis and high serum venereal disease research laboratory (VDRL) titers (≥1:16) evaluated at a tertiary teaching hospital in western Maharashtra, India (2024-2025). Five patients were human immunodeficiency virus (HIV)-positive and on antiretroviral therapy. None had neurological symptoms or signs; however, all had CSF abnormalities, consistent with asymptomatic neurosyphilis, including reactive CSF-VDRL in all patients, with mild pleocytosis and/or elevated protein in some. All patients received intravenous aqueous crystalline penicillin G for 14 days, with a serological response observed in most follow-up cases. These findings suggest that high titers in secondary syphilis, particularly in the presence of HIV co-infection and behavioral risk factors, may warrant consideration of CSF evaluation even in the absence of neurological manifestations.