Neurosyphilis presenting as progressive supranuclear palsy

PSP-Richardson syndrome mimics: An overview and pragmatic approach

Progressive supranuclear palsy-Richardson syndrome (PSP-RS) is a sporadic atypical parkinsonian syndrome with levodopa-unresponsive axial-predominant parkinsonism, early postural instability, vertical supranuclear gaze palsy, dysarthria, executive dysfunction and behavioural changes. PSP-RS can be mimicked by numbers of other disorders, generally known as PSP mimics, or PSP-like syndromes. Their aetiological spectrum includes neurodegenerative (mostly genetic), vascular, infectious and drug-induced illnesses as well as other causes. Based on the available data, we have tried to create a definition of PSP-RS mimics: a syndrome resembling PSP-RS with at least one of the following red flags: 1) positive family history; 2) onset before 45 years of age; 3) rapid or stepwise progression; 4) acute or subacute onset; 5) atypical symptoms and/or signs; 6) normal or atypical brain MRI; 7) history of HIV or untreated syphilis, aortal surgery or recent therapy with dopamine-blocking agents. We have suggested a short diagnostic algorithm leading to the identification of PSP-RS mimics and the recommended diagnostic work-up. The key point of the diagnostic process is the early identification and treatment of potentially treatable PSP-RS mimics.

Inflammation in multiple system atrophy

Misfolding protein aggregation inside or outside cells is the major pathological hallmark of several neurodegenerative diseases. Among proteinopathies are neurodegenerative diseases with atypical Parkinsonism and an accumulation of insoluble fibrillary alpha-synuclein (synucleinopathies) or hyperphosphorylated tau protein fragments (tauopathies). As there are no therapies available to slow or halt the progression of these disea ses, targeting the inflammatory process is a promising approach. The inflammatory biomarkers could also help in the differential diagnosis of Parkinsonian syndromes. Here, we review inflammation's role in multiple systems atrophy pathogenesis, diagnosis, and treatment.

Parkinsonism-Plus Syndrome Secondary to Neurosyphilis: Case Report and Literature Review

Background/Objective

Neurosyphilis can be associated with a variety of clinical manifestations. There are only a few cases of neurosyphilis associated with parkinsonism-plus syndromes (PPSs) that have been reported in the literature. We describe a case of an elderly woman who presented with abnormal gait and progressive visual disturbance, probably secondary to neurosyphilis.

Methods

Literature search was performed in Embase, Google Scholar, Medline, Scielo, and ScienceDirect using a set of terms that included parkinsonism, tremor, and syphilis.

Case Report

A 64-year-old female was admitted because of vision problems, gait disturbances, and cognitive impairment. The neurological examination revealed bradykinesia, rigidity, and rest tremor. The pupils were bilaterally small and reacted in size to a near object but did not constrict when exposed to bright light. The conjugate eye movements showed a defective downward gaze. On neuropsychological examination, the mini-mental state exam showed a moderate cognitive impairment. Reduced phonemic fluency was observed. A positive serum venereal disease research laboratory (VDRL) test was noted. A cerebrospinal fluid analysis showed positive VDRL. Brain and cervical spine magnetic resonance imaging was normal. An electro-encephalogram showed diffused slow waves. Penicillin G was started. Six months after, the patient had a full recovery of her conjugate eye movements and cognitive functions. Upon further questioning, the patient reported no response with a levodopa attempt.

Conclusions

To the authors' knowledge, two individuals developed progressive supra-nuclear palsy (PSP), and one presented corticobasal degeneration (CBD), probably associated with neurosyphilis. This is the second case to document the occurrence of a progressive supra-nuclear palsy because of syphilis.

Clinical Manifestations, Fluid Changes and Neuroimaging Alterations in Patients with General Paresis of the Insane

PURPOSE

We aim to study the clinical manifestations, fluid changes and neuroimaging alterations in patients with general paresis of the insane (GPI).

METHODS

A total of 119 patients suffering from GPI recruited in Beijing Ditan Hospital, Capital Medical University from 2010 to 2020 were retrospectively analyzed.

RESULTS

In 119 GPI patients, 103 cases (86.6%) were male. Misdiagnosed rate was up to 83.2%, schizophrenia and mood disorders were the most common misdiagnosed diseases. Duration from symptom onset to the final confirmed diagnosis was 10.4±12.9 months. The main clinical manifestations included cognitive impairment (114 cases, 95.8%) and neuropsychiatric symptoms (107 cases, 90.0%). The cognitive domains including the delayed recall, visuospatial/executive function and language ability indicated by MoCA score were damaged severely. Rapid plasma regain (RPR) of all GPI patients was 100% positive in serum and 89.9% positive in cerebral spinal fluid (CSF). The white blood cell (WBC) number in CSF was between 6 and 50/μL in 73 GPI patients (61.3%). The protein level was between 45.1 and 70mg/dL in 47 cases (39.5%). In the 110 cases, 96 cases (87.3%) were abnormal indicated by cerebral atrophy mostly located in the anterior brain and abnormal signals distributed in various regions of the brain mostly in the frontal lobe and temporal lobe.

CONCLUSION

The symptoms of GPI were complex and easy to misdiagnose. The clinicians were still short of vigilance for neurosyphilis. We should expand serologic testing for syphilis especially in patients with cognitive impairment and neuropsychiatric symptoms. We suggest syphilis curricula in the training program of the clinicians especially for neurologist and psychiatrist.

Genetics Underlying Atypical Parkinsonism and Related Neurodegenerative Disorders

Atypical parkinsonism syndromes, such as dementia with Lewy bodies, multiple system atrophy, progressive supranuclear palsy and corticobasal degeneration, are neurodegenerative diseases with complex clinical and pathological features. Heterogeneity in clinical presentations, possible secondary determinants as well as mimic syndromes pose a major challenge to accurately diagnose patients suffering from these devastating conditions. Over the last two decades, significant advancements in genomic technologies have provided us with increasing insights into the molecular pathogenesis of atypical parkinsonism and their intriguing relationships to related neurodegenerative diseases, fueling new hopes to incorporate molecular knowledge into our diagnostic, prognostic and therapeutic approaches towards managing these conditions. In this review article, we summarize the current understanding of genetic mechanisms implicated in atypical parkinsonism syndromes. We further highlight mimic syndromes relevant to differential considerations and possible future directions.

Atypical parkinsonism: diagnosis and treatment

Atypical parkinsonism comprises typically progressive supranuclear palsy, corticobasal degeneration, and mutilple system atrophy, which are distinct pathologic entities; despite ongoing research, their cause and pathophysiology are still unknown, and there are no biomarkers or effective treatments available. The expanding phenotypic spectrum of these disorders as well as the expanding pathologic spectrum of their classic phenotypes makes the early differential diagnosis challenging for the clinician. Here, clinical features and investigations that may help to diagnose these conditions and the existing limited treatment options are discussed.

Acquired neurosyphilis presenting as movement disorders

After a significant decline in the second half of the 20th century, rates of infection with syphilis are again on the rise. Long known as the "great mimicker," syphilitic infection can be difficult to recognize clinically and this particularly holds true for neurologic manifestations of the disease. Gait dysfunction and sensory ataxia have been historically well described in neurosyphilis literature; however, other movement disorders have been reported to a lesser extent. Here we review reports of movement disorders in acquired neurosyphilis. Given its increasing incidence, it is important to be cognizant of its diverse presentation and retain a high index of suspicion for syphilis, particularly as it is completely curable in the early stages.

Progressive supranuclear palsy: clinicopathological concepts and diagnostic challenges

Progressive supranuclear palsy (PSP) is a clinical syndrome comprising supranuclear palsy, postural instability, and mild dementia. Neuropathologically, PSP is defined by the accumulation of neurofibrillary tangles. Since the first description of PSP in 1963, several distinct clinical syndromes have been described that are associated with PSP; this discovery challenges the traditional clinicopathological definition and complicates diagnosis in the absence of a reliable, disease-specific biomarker. We review the emerging nosology in this field and contrast the clinical and pathological characteristics of the different disease subgroups. These new insights emphasise that the pathological events and processes that lead to the accumulation of phosphorylated tau protein in the brain are best considered as dynamic processes that can develop at different rates, leading to different clinical phenomena. Moreover, for patients for whom the diagnosis is unclear, clinicians must continue to describe accurately the clinical picture of each individual, rather than label them with inaccurate diagnostic categories, such as atypical parkinsonism or PSP mimics. In this way, the development of the clinical features can be informative in assigning less common nosological categories that give clues to the underlying pathology and an understanding of the expected clinical course.

Clinicopathological features of the tauopathies

Developments in molecular neuropathology have led to protein-based classification systems for neurodegenerative disorders. Key proteins include alpha-synuclein, amyloid and tau. Alternative mRNA splicing and post-translational change, induced by a bewildering variety of protein modifying processes such as phosphorylation and ubiquitination, have generated insights into new mechanisms of selective neuronal degeneration. The task now is to bring these developments in protein chemistry to the clinic, to try to determine whether this biochemical diversity can help in explaining the phenotypic variability that is so typical of neurodegeneration in general. In this review, we will explore the clinicopathological diversity of the tau-related disorders with specific reference to three of the most common tauopathies, frontotemporal dementia (familial and sporadic), progressive supranuclear palsy and corticobasal degeneration.

Neurodegenerative disorders mimicking progressive supranuclear palsy: a report of three cases

Progressive supranuclear palsy (PSP) is rarely confused with other parkinsonian disorders once the vertical gaze palsy appears. Corticobasal degeneration is the most common differential diagnostic entity. We describe three cases diagnosed during life as PSP but found to have another neurologic disorder at autopsy. No explanation for the gaze palsies was found in any case.

Neurosyphilis masquerading as corticobasal degeneration

We report on a patient with a syndrome resembling corticobasal ganglionic degeneration (CBD), including slight cognitive impairment, asymmetric akinesia, rigidity with myoclonus, and arm levitation, which can be one of the features of alien limb phenomenon; however, further diagnostic testing was consistent with neurosyphilis. Syphilis, "the great imitator," may also masquerade as CBD. Because neurosyphilis is treatable, it should be considered in the workup of patients with cognitive impairment and motor signs of CBD.

Creutzfeldt-Jakob disease presenting as progressive supranuclear palsy

Progressive supranuclear palsy (PSP) is a neurodegenerative disorder characterized by an akinetic rigid syndrome with vertical supranuclear ophthalmoplegia, early falls, and levodopa resistance. The pathological substrate of PSP consists of filamentous tau degenerative lesions affecting neurons and glia. Other disorders can present with a similar clinical picture, most commonly corticobasal degeneration and multiple system atrophy. Non-neurodegenerative disorders are rare causes of the PSP syndrome. In this report we describe clinical and pathological features of two cases of Creutzfeldt-Jakob disease (CJD) presenting with the PSP syndrome and discuss which features may help prevent misdiagnosis. To our knowledge, this is the first report of cases of CJD with autopsy confirmation that presented with a PSP syndrome.

Diagnostic accuracy of progressive supranuclear palsy in the Society for Progressive Supranuclear Palsy Brain Bank

Diagnostic accuracy has been addressed previously for Parkinson's disease in a brain bank collection, but accuracy of progressive supranuclear palsy (PSP) has not been addressed in a similar setting. Clinical and genetic features of pathologically confirmed cases of PSP were compared with misdiagnosed cases to determine ways to improve diagnostic accuracy. Medical records were reviewed for 180 cases sent to the Society of Progressive Supranuclear Palsy Brain Bank that had standardized neuropathologic evaluations as well as determination of apolipoprotein E and tau genotypes. Of the 180 cases studied, 137 had PSP and 43 had other pathologic diagnoses. Corticobasal degeneration (CBD), multiple system atrophy (MSA), and diffuse Lewy body disease (DLBD) accounted for 70% of the misdiagnosed cases. History of tremor, psychosis, dementia, and asymmetric findings were more frequent in misdiagnosed cases. The frequency of H1 tau haplotype (93 vs. 80%) and H1H1 genotype (86 vs. 66%) were significantly greater and APOE epsilon4 carrier state was significantly less (17 vs. 41 %) in PSP compared with misdiagnosed cases. Pathologic evaluation of clinically diagnosed PSP remains important for definitive diagnosis, and CBD, MSA, and DLBD are the disorders most likely to be misdiagnosed as PSP. Tremor, psychosis, early dementia, asymmetric findings, absence of H1 haplotype, and presence of APOE epsilon4 should raise questions about a diagnosis of PSP.

Progressive supranuclear palsy: where are we now?

This review provides an update on progressive supranuclear palsy (PSP, or Steele-Richardson-Olszewski disease), an adult-onset neurodegenerative disorder characterised by early postural instability, which leads to falls, and a vertical supranuclear-gaze palsy. Recent epidemiological studies have shown that the disorder is more common than previously recognised, that it is commonly misdiagnosed, and that it may present to a wide range of hospital specialists. The diagnosis of PSP hinges on clinical acumen. Attempts to identify a suitable biomarker in the CSF or a specific and sensitive imaging or neurophysiological technique have so far failed to have a significant effect on the diagnostic process. Better understanding of the molecular pathology of PSP has highlighted the importance of tau-protein accumulation and tau-genotype susceptibility in its pathogenesis. No drug treatment significantly and consistently benefits patients, and novel therapies are urgently required.