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Li HY, Wang HY, Duan YF, Gou Y, Liu XQ, Gao ZX. Neurosyphilis Presenting as Psychiatric Symptoms at Younger Age: A Case Report. Int Med Case Rep J 2024; 17:647-650. [PMID: 38974881 PMCID: PMC11227323 DOI: 10.2147/imcrj.s477459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 06/23/2024] [Indexed: 07/09/2024] Open
Abstract
Neurosyphilis is a central nervous system infection caused by Treponema pallidum that imitates various neurological and mental disorders. Therefore, patients with this disease are prone to misdiagnoses. Here, we report a case of neurosyphilis with a psychotic disorder as the main manifestation. A young girl exhibited mental and behavioural abnormalities after a heartbreak, which manifested as alternating low mood, emotional irritability, and a lack of interest in social relations, followed by memory loss. The cerebrospinal fluid protein - Treponema pallidum particle agglutination test was positive, the toluidine red unheated serum test titre was 1:4, the white blood cell count was 5 × 10^6/L, the cerebrospinal fluid protein level was 0.97 g/L, and the brain CT was abnormal. After admission, the possibility of neurosyphilis was considered and the patient received intravenous penicillin G treatment. The patient's clinical symptom ms improved. This case emphasises that doctors should maintain clinical suspicion of Treponema pallidum infection in adolescent patients with mental abnormalities.
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Affiliation(s)
- Hong-Yan Li
- West China Second University Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, People’s Republic of China
| | - Hao-Yu Wang
- Department of Radiology, The First People’s Hospital of Liangshan Yi Autonomous Prefecture, Xichang, Sichuan, People’s Republic of China
| | - Yi-Fei Duan
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, People’s Republic of China
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Yu Gou
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, People’s Republic of China
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Xiao-Qin Liu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, People’s Republic of China
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Zheng-Xiang Gao
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, People’s Republic of China
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
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2
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Tang Y, Shen L, Yang D, Zhang J, Xie Q, Sun F, Luo Q. Neutrophil CD64 index as a potential blood biomarker for the diagnosis of neurosyphilis in secondary and tertiary syphilis: A retrospective study. Heliyon 2024; 10:e29027. [PMID: 38596103 PMCID: PMC11002674 DOI: 10.1016/j.heliyon.2024.e29027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/11/2024] Open
Abstract
Objective To examine the correlation of neutrophil CD64 (nCD64) index with neurosyphilis (NS) across different stages of syphilis. Methods A total of 1243 syphilis patients at different stages (344 of primary, 385 of secondary, and 514 of tertiary) included in this study were divided into NS and non-NS (NNS). Correlations of nCD64 index with currently used syphilis biomarkers were explored using Spearman correlation test. Relationships between nCD64 index and NS at different stages were investigated by stratified analysis and restricted cubic spline model. The diagnostic performance of nCD64 index for NS was assessed by receiver operating characteristic (ROC) curve. Results Significant statistical correlations of nCD64 index with cerebrospinal fluid (CSF) NS indicators were found in secondary and tertiary syphilis. Increased nCD64 index was associated with increased risk of NS in secondary and tertiary syphilis. ROC analysis values further confirmed the diagnostic potential of nCD64 index for NS. Marked decrease of nCD64 index was observed in NS patients after effective antisyphilitic treatments. Conclusions The nCD64 index may help to the diagnosis of NS in secondary and tertiary syphilis.
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Affiliation(s)
- Yijie Tang
- Department of Clinical Laboratory Medicine, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lingyun Shen
- Department of Clinical Laboratory Medicine, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Dandan Yang
- Department of Clinical Laboratory Medicine, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jiaqin Zhang
- Department of Clinical Laboratory Medicine, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qinghui Xie
- Department of Clinical Laboratory Medicine, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Fenyong Sun
- Department of Clinical Laboratory Medicine, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qingqiong Luo
- Department of Clinical Laboratory Medicine, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
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Nunes RH, Corrêa DG, Pacheco FT, Fonseca APA, Hygino da Cruz LC, da Rocha AJ. Neuroimaging of Infectious Vasculopathy. Neuroimaging Clin N Am 2024; 34:93-111. [PMID: 37951708 DOI: 10.1016/j.nic.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Vasculitis is a complication of several infectious diseases affecting the central nervous system, which may result in ischemic and/or hemorrhagic stroke, transient ischemic attack, and aneurysm formation. Infectious agents may directly infect the endothelium causing vasculitis or indirectly affect the vessel wall through an immunological cascade. Clinical manifestations usually overlap with those of noninfectious vascular diseases, making diagnosis challenging. Neuroimaging enables the identification of inflammatory changes in intracranial vasculitis. In this article, we review the imaging features of infectious vasculitis of bacterial, viral, fungal and parasitic causes.
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Affiliation(s)
- Renato Hoffmann Nunes
- Division of Neuroradiology, DASA - Diagnósticos da América SA, Rua João Cachoeira, 743, Itaim Bibi, 04535-012, Sao Paulo, Sao Paulo, Brazil.
| | - Diogo Goulart Corrêa
- Department of Radiology, Clínica de Diagnóstico por Imagem (CDPI)/DASA, Avenida das Américas, 4666, Barra da Tijuca, 2640-102, Rio de Janeiro, Rio de Janeiro, Brazil; Department of Radiology, Federal Fluminense University, Avenida Marquês de Paraná, 303, 24033-900, Niterói, Rio de Janeiro, Brazil
| | - Felipe Torres Pacheco
- Division of Neuroradiology, DASA - Diagnósticos da América SA, Rua João Cachoeira, 743, Itaim Bibi, 04535-012, Sao Paulo, Sao Paulo, Brazil; Division of Neuroradiology, Santa Casa de Sao Paulo School of Medical Sciences, Rua Dr. Cesário Mota Júnior, 112, Vila Buarque, 01221-020, Sao Paulo, Sao Paulo, Brazil. https://twitter.com/ofelipe_pacheco
| | - Ana Paula Alves Fonseca
- Division of Neuroradiology, DASA - Diagnósticos da América SA, Rua João Cachoeira, 743, Itaim Bibi, 04535-012, Sao Paulo, Sao Paulo, Brazil
| | - Luiz Celso Hygino da Cruz
- Department of Radiology, Clínica de Diagnóstico por Imagem (CDPI)/DASA, Avenida das Américas, 4666, Barra da Tijuca, 2640-102, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Antônio José da Rocha
- Division of Neuroradiology, DASA - Diagnósticos da América SA, Rua João Cachoeira, 743, Itaim Bibi, 04535-012, Sao Paulo, Sao Paulo, Brazil; Division of Neuroradiology, Santa Casa de Sao Paulo School of Medical Sciences, Rua Dr. Cesário Mota Júnior, 112, Vila Buarque, 01221-020, Sao Paulo, Sao Paulo, Brazil
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Corrêa DG, Pacheco FT, da Cruz LCH, Nunes RH, Maia ACM, de Souza Godoy LF, Bisolo L, da Silva NA, Soldatelli MD, de Siqueira Campos CM, Vedolin LM, do Amaral LLF, da Rocha AJ. Intracranial vessel wall magnetic resonance imaging features of infectious vasculitis. Clin Imaging 2023; 98:26-35. [PMID: 36996597 DOI: 10.1016/j.clinimag.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/19/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023]
Abstract
Vasculitis is a complication of several infectious diseases affecting the central nervous system, which may result in ischemic and/or hemorrhagic stroke, transient ischemic attack, and aneurysm formation. The infectious agent may directly infect the endothelium, causing vasculitis, or indirectly affect the vessel wall through an immunological mechanism. The clinical manifestations of these complications usually overlap with those of non-infectious vascular diseases, making diagnosis challenging. Intracranial vessel wall magnetic resonance imaging (VWI) enables the evaluation of the vessel wall and the diseases that affect it, providing diagnostic data beyond luminal changes and enabling the identification of inflammatory changes in cerebral vasculitis. This technique demonstrates concentric vessel wall thickening and gadolinium enhancement, associated or not with adjacent brain parenchymal enhancement, in patients with vasculitis of any origin. It permits the detection of early alterations, even before a stenosis occurs. In this article, we review the intracranial vessel wall imaging features of infectious vasculitis of bacterial, viral, and fungal etiologies.
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Affiliation(s)
- Diogo Goulart Corrêa
- Department of Radiology, Clínica de Diagnóstico por Imagem (CDPI)/DASA, Rio de Janeiro, RJ, Brazil; Department of Radiology, Federal Fluminense University, Niterói, RJ, Brazil.
| | - Felipe Torres Pacheco
- Department of Neuroradiology, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil; Department of Radiology, DASA, São Paulo, SP, Brazil
| | | | - Renato Hoffmann Nunes
- Department of Neuroradiology, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil; Department of Radiology, DASA, São Paulo, SP, Brazil
| | - Antônio Carlos Martins Maia
- Department of Neuroradiology, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil; Department of Radiology, Fleury, São Paulo, SP, Brazil
| | | | - Louise Bisolo
- Department of Radiology, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Nivaldo Adolfo da Silva
- Department of Radiology, DASA, São Paulo, SP, Brazil; Department of Radiology, University of Campinas, Campinas, SP, Brazil
| | | | | | - Leonardo Modesti Vedolin
- Department of Radiology, DASA, São Paulo, SP, Brazil; Department of Radiology, Hospital de Clínicas de Porta Alegre, Porto Alegre, RS, Brazil
| | | | - Antônio José da Rocha
- Department of Neuroradiology, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil; Department of Radiology, DASA, São Paulo, SP, Brazil
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Corrêa DG, de Souza SR, Freddi TDAL, Fonseca APA, Dos Santos RQ, Hygino da Cruz LC. Imaging features of neurosyphilis. J Neuroradiol 2023; 50:241-252. [PMID: 36641134 DOI: 10.1016/j.neurad.2023.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 12/09/2022] [Accepted: 01/08/2023] [Indexed: 01/13/2023]
Abstract
Syphilis is an infectious disease caused by the spirochete Treponema pallidum, subspecies pallidum. Although its incidence has declined after the widespread availability of penicillin, it has recently re-emerged, especially in men who have sex with men and in people living with human immunodeficiency virus (HIV). The neurological manifestations of syphilis, generally known as neurosyphilis, may appear at any time during the infection, including the initial years after the primary infection. Neurosyphilis can be asymptomatic, only with cerebrospinal fluid abnormalities, or symptomatic, characterized by several different clinical syndromes, such as meningitis, gumma, meningovascular, brain parenchyma involvement, meningomyelitis, tabes dorsalis, and peripheral nervous system involvement. However, these syndromes may simulate several other diseases, making the diagnosis often a challenge. In addition, syphilis can also be vertically transmitted from mother to child during pregnancy, leading to neurological manifestations. Neuroimaging is essential to demonstrate abnormal brain or spinal cord findings in patients with neurosyphilis, aiding in the diagnosis, treatment, and follow-up of these patients. This article aims to review the imaging features of neurosyphilis, including the early and late stages of the infection.
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Affiliation(s)
- Diogo Goulart Corrêa
- Department of Radiology, Clínica de Diagnóstico por Imagem (CDPI)/DASA, Avenida das Américas, 4666, 302A, 303, 307, 325, 326, Barra da Tijuca, Rio de Janeiro, RJ 2640-102, Brazil; Department of Radiology, Federal Fluminense University, Rua Marquês de Paraná, 303, Centro, Niterói, RJ 24070-035, Brazil.
| | - Simone Rachid de Souza
- Department of Pathology, Federal University of Rio de Janeiro, Cidade Universitária da Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255, Rio de Janeiro, RJ 21941-617, Brazil
| | | | - Ana Paula Alves Fonseca
- Department of Radiology, UnitedHealth Group, São Paulo, SP, Brazil; Department of Radiology, DASA, São Paulo, SP, Brazil
| | - Roberto Queiroz Dos Santos
- Department of Radiology, Hospital dos Servidores do Estado, Rua Sacadura Cabral, 178, Saúde, Rio de Janeiro, RJ 20221-903, Brazil; Department of Radiology, Hospital das Américas, United Health Group, Avenida Jorge Curi, 550, Barra da Tijuca, Rio de Janeiro, RJ 22775-001, Brazil
| | - Luiz Celso Hygino da Cruz
- Department of Radiology, Clínica de Diagnóstico por Imagem (CDPI)/DASA, Avenida das Américas, 4666, 302A, 303, 307, 325, 326, Barra da Tijuca, Rio de Janeiro, RJ 2640-102, Brazil
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Clavijo Prado CA, Aroca Torres J, Abadía Rincon AL, Vargas Ramírez AM, Chauvez Gallego A. Aproximación diagnóstica de la neurosífilis. REPERTORIO DE MEDICINA Y CIRUGÍA 2022. [DOI: 10.31260/repertmedcir.01217372.1185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
La neurosífilis es la enfermedad del sistema nervioso central (SNC) causada por Treponema pallidum, perteneciente al grupo de las espiroquetas; se puede presentar en pacientes inmunocompetentes pero existe una asociación mayor con el virus de inmunodeficiencia humana (VIH). Estos casos son más severos y con manifestaciones neurológicas variables. Si bien la forma típica es la más frecuente, existen expresiones atípicas que pueden llegar a presentarse en 30% de los casos según los estudios radiológicos, por lo cual es importante reconocerlas a fin de garantizar un diagnóstico temprano y una intervención oportuna. No solo es un problema de salud pública por su prevalencia sino también por el amplio espectro clínico que le ha valido el nombre de gran simuladora, siendo desconocidas en muchas ocasiones por los médicos de atención primaria. El siguiente trabajo ha sido planteado con base en tres casos clínicos (2 de vasculitis en SNC, una panuveítis) con el objetivo de desmitificar los tiempos de presentación y aclarar las manifestaciones clínicas que comprometen el SNC, tratando de precisar el diagnóstico para la realización de un tratamiento pertinente y oportuno que reduzca las secuelas.
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Currens L, Sivakumar S, Jun-O'Connell AH, Ionete C, Ghasemi M. Neurosyphilis presenting with focal middle cerebral artery stenosis and acute ischemic stroke: A case report. Radiol Case Rep 2022; 17:1620-1625. [PMID: 35321268 PMCID: PMC8935340 DOI: 10.1016/j.radcr.2022.02.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 10/28/2022] Open
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Safadi AL, Day D, Nagle B, Di Maria G, Malla P. Treatment Challenges in a Severe Case of Syphilitic Myelitis With a Longitudinally Extensive Spinal Cord Lesion. Neurohospitalist 2022; 12:400-403. [PMID: 35419144 PMCID: PMC8995592 DOI: 10.1177/19418744221075402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Syphilitic myelitis is an unusual manifestation of neurosyphilis, rarely reported in the literature. The best management approach remains unclear in severe cases with longitudinally extensive spinal cord lesions. We describe a 29-year-old man with a history of incompletely treated syphilis after a high-risk sexual encounter, who presented two years later with several weeks of progressive numbness and weakness in both legs. MRI spine showed significant cord expansion from the craniocervical junction to T6 with patchy cord enhancement. He was diagnosed with syphilitic myelitis given his history of inadequately treated syphilis, positive serum rapid plasma reagin at a high titer, and CSF pleocytosis with elevated protein along with a reactive CSF Venereal Disease Research Laboratory test. Alternative infectious or immunological etiologies were excluded. He was treated with IV penicillin and pulse steroid therapy with IV methylprednisolone 1 g daily for 3 days with improvement. However, he was soon readmitted with recurrent weakness requiring an additional course of pulse steroid therapy followed by a short prednisone taper. Afterward, his symptoms recurred with worsened cord expansion on imaging. He was re-treated with IV penicillin and pulse steroid therapy with a more prolonged prednisone taper. The patient subsequently improved and had no further recurrent symptoms on extended outpatient follow-up. This report illustrates the importance of keeping syphilitic myelitis on the differential as a treatable cause of longitudinally extensive myelopathy. The patient may have benefited from high-dose IV steroids with a prolonged taper while waiting for the full treatment effect of antibiotics.
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Affiliation(s)
- Amy Li Safadi
- Department of Neurology, MedStar Georgetown University
Hospital, Washington, DC, USA
| | - Derek Day
- Department of Rehabilitation Medicine, MedStar Georgetown University
Hospital, Washington, DC, USA
| | - Brian Nagle
- Department of Neurology, MedStar Georgetown University
Hospital, Washington, DC, USA
| | - Gianluca Di Maria
- Department of Neurology, MedStar Georgetown University
Hospital, Washington, DC, USA
| | - Prerna Malla
- Department of Neurology, MedStar Washington Hospital Center, Washington, DC, USA
- Prerna Malla, Department of Neurology, MedStar
Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA.
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9
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Qingqing C, Dongliang L, Qingqing S, Daoqian S. The effect of a large dose of intravenous immunoglobulin on general paresis of the insane. EUR J INFLAMM 2021. [DOI: 10.1177/20587392211040899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
General paresis of the insane (GPI) remains the form of neurosyphilis most closely associated with dementia, even after the advent of penicillin. Penicillin remains the top treatment choice for syphilis, but treatment failure is not rare. Although the neurological symptoms of GPI can be alleviated by antibiotic treatment, mental symptoms may continue. A 60-year-old man was admitted to hospital due to rapidly progressive dementia. He was diagnosed as GPI. With the patient’s informed consent, we treated him with a large dose of intravenous immunoglobulin (IVIG) (0.4 g/kg/day) for 5 days, as well as penicillin (24 million units daily divided into six doses) for 14 days. A near-immediate improvement in his emotions and orientation occurred on the 17th day in hospital. The patient made an excellent recovery 6 weeks after treatment, his psychotic and mood symptoms improved significantly. Therefore, we hypothesize that patients with GPI treated with IVIG and penicillin G would have better outcomes than those treated with penicillin G alone. IVIG may be introduced as a necessary treatment for GPI.
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Affiliation(s)
- Chen Qingqing
- Department of Neurology, Taihe County People’s Hospital, Fuyang, China
| | - Liu Dongliang
- Department of Neurology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Sang Qingqing
- Department of Neurology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Sang Daoqian
- Department of Neurology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
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10
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Dong H, Liu Z, Duan Y, Li D, Qiu Z, Liu Y, Huang J, Wang C. Syphilitic meningomyelitis misdiagnosed as spinal cord tumor: Case and review. J Spinal Cord Med 2021; 44:789-793. [PMID: 31603731 PMCID: PMC8477965 DOI: 10.1080/10790268.2019.1658283] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Context: Syphilitic meningomyelitis is a rare manifestation of neurosyphilis, not well described in the literature.Methods: We reported a rare case of a 29-year-old female with syphilitic meningomyelitis. Her clinical manifestations and imaging findings were discussed with the related literatures reviewed.Results: The patient presented with progressive bilateral lower extremities numbness and weakness for months. Laboratory tests revealed positive serum Treponema pallidum Hemagglutinin Test (TPHA) and rapid plasma reagin test (RPR). The cerebral spinal fluid (CSF) was positive with TPHA but negative for RPR with lymphocytic pleocytosis and elevated protein. Spinal MRI showed swelling and high-signal intensity of thoracic spinal cord except T6-7 level with associated gadolinium enhancement ("flip-flop sign") and peripheral strip-like enhancement on T1WI ("candle guttering appearance"). She was initially diagnosed as spinal cord tumor due to the chronic clinical onset and cord swelling with central enhancement found on thoracic MRI. After dramatic clinical and radiographic improvement with dexamethosone and serological tests of syphilis, she was diagnosed as probable syphilitic meningomyelitis. Till now, there are 12 cases of syphilitic myelitis reported with spinal cord MR images. Thoracic cord is the predominant involved segment (10/12), "candle guttering appearance" is the most common enhancing characteristics of the lesion (7/12), "flip-flop sign" may be seen in the stage with significant inflammation (3/12).Conclusion: Syphilitic meningomyelitis can occur at early or late stage of syphilis, the onset may be acute, subacute or chronic. The imaging findings suggested focal inflammation of the spinal cord. Prognosis is relatively good after proper treatment.
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Affiliation(s)
- Huiqing Dong
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zheng Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China,Correspondence to: Zheng Liu, Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing100053, People’s Republic of China; Ph: 008613910320552; 0086-10-83198899 ext 8701.
| | - Yunyun Duan
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Dawei Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zhandong Qiu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yaou Liu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jing Huang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chaodong Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
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11
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Gombert M, Ballester P, Segura A, Peiró AM. Introducing sexual dysfunction in mental care. Expert Opin Drug Saf 2020; 20:69-79. [PMID: 33191796 DOI: 10.1080/14740338.2020.1849135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction: People with any psychiatric disorder tend to have difficulties in responding sexually. However,sexual dysfunction (SD) is usually under-recognized, even the tightly hormonal and neuronal common connexions through the brain-sex axis. Multiple sources of resistance to SD assessment and intervention persist. Areas covered: The present review aims to underline the feasibility to introduce SD evaluation in patients with any psychiatric disorders, evaluating the potential mutual benefits of their management. Expert opinion: Women and men living with mental disorders frequently display sexual difficulties; however, some of them consider sexuality as a relevant parameter of their quality of life. In fact, SD as a side effect is a frequent reason for stopping the intake of medication. What is more, a holistic approach integrating sexual function could foster a better understanding of mental pathologies due to a common origin of pathogenesis. This could improve care quality, in keeping with the global tendency toward the development of personalized medicine. Consistently, the integration of SD assessment is highly recommended in mental health, all the more so when a psychotropic drug is prescribed. An expected consequence would be a reconstruction of the healthcare professional's consideration for the sexuality of people experiencing mental disorders.
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Affiliation(s)
- Marie Gombert
- Department of Paediatrics, Obstetrics and Gynecology, University of Valencia , Valencia, Spain
| | - Pura Ballester
- Department of Pharmacology, Paediatrics and Organic Chemistry , Alicante, Spain.,Neuropharmacology on Pain (NED) Group, Alicante Institute for Health and Biomedical Research (ISABIAL) , Alicante, Spain
| | - Ana Segura
- Andrology Unit, Department of Health of Alicante - General Hospital, Alicante, Spain.,Clinical Pharmacology Unit, Department of Health of Alicante - General Hospital, Alicante, Spain
| | - Ana M Peiró
- Department of Pharmacology, Paediatrics and Organic Chemistry , Alicante, Spain.,Clinical Pharmacology Unit, Department of Health of Alicante - General Hospital, Alicante, Spain
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Weng W, Hou J, Song B, Zhang M, Zhang T, Gao Y. Identification of the factors associated with post-treatment asymptomatic neurosyphilis in HIV-negative patients with serological non-response syphilis: a retrospective study. Int J STD AIDS 2020; 32:331-335. [PMID: 33345747 DOI: 10.1177/0956462420965850] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Some syphilis patients do not exhibit an appropriate serological response after treatment despite the absence of any clinical evidence of treatment failure or reinfection. This condition is called "serofast syphilis" or "serological non-response syphilis." This study explored the incidence of asymptomatic neurosyphilis (ANS) and related factors in 324 asymptomatic patients with serological non-response syphilis. We analyzed descriptive statistics stratified by the presence of asymptomatic neurosyphilis for the basic characteristics of samples. Bivariate analysis was conducted to assess correlations between outcomes and potential predictors. Variables significant in the bivariate analysis (p<0.1) were entered into multivariable logistic regression models. All p-values were two-sided with a significance threshold of p<0.05. The results indicated that 89 of 324 patients had ANS (incidence of 27.5%), and the greatest risk factors were a < fourfold decrease in serum rapid plasma reagin (RPR) titers after treatment and current serum RPR titers >1:32. Our findings suggest that ANS is common among syphilis patients, and patients with a fourfold decrease in serum RPR titers after treatment and current serum RPR titers >1:32 are more likely to develop ANS.
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Affiliation(s)
- Wenjia Weng
- Department of Dermatology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Jiahua Hou
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory for HIV/AIDS Research, Beijing, China
| | - Bingbing Song
- Department of Dermatology, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, China
| | - Ming Zhang
- Department of Dermatology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Tong Zhang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory for HIV/AIDS Research, Beijing, China
| | - Yanqing Gao
- Department of Dermatology, Beijing Youan Hospital, Capital Medical University, Beijing, China
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13
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Cassiani-Miranda CA, Chen X. Neurocognitive disorder due to neurosyphilis: a case report. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2020; 49:202-207. [PMID: 32888665 DOI: 10.1016/j.rcp.2018.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 05/17/2018] [Accepted: 10/16/2018] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Neurosyphilis is a chronic infectious disease caused by Treponema pallidum that can cause a great variety of neuropsychiatric signs and symptoms, which complicates its diagnosis. CASE DESCRIPTION This case occurred in a 40-year-old man who consulted the Emergency Department because of a convulsion (de novo) which was related to a chronic condition of cognitive impairment and psychosis. The appropriate studies were performed for the diagnosis of neurosyphilis and the recommended treatment was initiated. The patient presented clinical improvement and was discharged. DISCUSSION Positive VDRL serology results and imaging findings of marked cortical atrophy conducted to consider a late-stage parenchymatous neurosyphilis with serious cognitive impairment and associated psychosis. Treatment with crystalline penicillin was formulated, which reduced the intensity of the patient's symptoms; however, the patient's lack of interest to attend the check-ups significantly reduces his chances of an adequate recovery. CONCLUSIONS Neurosyphilis must be suspected in patients with clinically evident neurological or psychiatric symptoms. Analysis of VDRL serology and neuroimaging studies are important as an initial evaluation of the patient and must be complemented with cognitive tests or mental examination to determine the state of cognitive impairment.
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Affiliation(s)
| | - Xueyi Chen
- Semillero de Investigación en Psiquiatría de Enlace-Grupo de Investigación en Neuropsiquiatría, Universidad Autónoma de Bucaramanga (UNAB), Bucaramanga, Colombia
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14
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Versiani I, Cabral-Castro MJ, Puccioni-Sohler M. A comparison of nontreponemal tests in cerebrospinal fluid for neurosyphilis diagnosis: equivalent detection of specific antibodies. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 77:91-95. [PMID: 30810592 DOI: 10.1590/0004-282x20180155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 10/10/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Syphilis is a re-emerging sexually-transmitted infection, caused by the spirochete Treponema pallidum, that may penetrate early into the central nervous system. The venereal disease research laboratory test (VDRL) on the cerebrospinal fluid (CSF) is the most widely used for neurosyphilis diagnosis. We evaluated the performance of two other nontreponemal tests (rapid plasma reagin [RPR] and unheated serum reagin [USR] tests) in comparison with the VDRL in CSF. METHODS We analyzed CSF samples from 120 individuals based on VDRL reactivity in the CSF and the clinical picture of neurosyphilis. RESULTS High inter-rater reliability was found among all three tests, with equivalent sensitivity and specificity. Intraclass correlation coefficient for absolute agreement was 1 for VDRL versus USR, 0.99 for VDRL versus RPR, and 0.99 for RPR versus USR. CONCLUSIONS Rapid plasma reagin and unheated serum reagin tests were identified as excellent alternatives for neurosyphilis diagnosis.
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Affiliation(s)
- Isadora Versiani
- Universidade Federal do Estado do Rio de Janeiro, Escola de Medicina e Cirurgia, Rio de Janeiro RJ, Brasil
| | - Mauro Jorge Cabral-Castro
- Universidade Federal do Rio de Janeiro, Faculdade de Medicina, Pós-Graduação em Doenças Infecciosas e Parasitárias, Rio de Janeiro RJ, Brasil
| | - Marzia Puccioni-Sohler
- Universidade Federal do Estado do Rio de Janeiro, Escola de Medicina e Cirurgia, Rio de Janeiro RJ, Brasil.,Universidade Federal do Rio de Janeiro, Faculdade de Medicina, Pós-Graduação em Doenças Infecciosas e Parasitárias, Rio de Janeiro RJ, Brasil
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15
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Pitton Rissardo J, Fornari Caprara A. Neurosyphilis-associated movement disorder: A literature review. ANNALS OF MOVEMENT DISORDERS 2020. [DOI: 10.4103/aomd.aomd_21_20] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Villar-Quiles R, Gómez-Ruiz N, Jorquera-Moya M, Porta-Etessam J. The great imitator: mesial temporal alterations in MRI in an atypical case of neurosyphilis. NEUROLOGÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.nrleng.2017.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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17
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Mupparapu M, Ko E, Omolehinwa TT, Chhabra A. Neurologic Disorders of the Maxillofacial Region. Dent Clin North Am 2019; 64:255-278. [PMID: 31735232 DOI: 10.1016/j.cden.2019.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The maxillofacial region is complex in its anatomy and in its variation in the presentation of neurologic disorders. The diagnosis and management of neurologic disorders in clinical practice remains a challenge. A good understanding of the neurologic disorder in its entirety helps dentists in the diagnosis and appropriate referral to a specialist for further investigations and management of the condition. Neurologic disorders described in this article are under broad categories of sensory and motor disturbances as well as movement disorders and infections. This article summarizes the most common maxillofacial neurologic disorders that dentists might encounter in clinical practice.
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Affiliation(s)
- Mel Mupparapu
- University of Pennsylvania School of Dental Medicine, 240 S 40th Street, Philadelphia, PA 19104, USA.
| | - Eugene Ko
- University of Pennsylvania School of Dental Medicine, 240 S 40th Street, Philadelphia, PA 19104, USA
| | - Temitope T Omolehinwa
- University of Pennsylvania School of Dental Medicine, 240 S 40th Street, Philadelphia, PA 19104, USA
| | - Avneesh Chhabra
- UT Southwestern Medical Center, Harry Hines Boulevard, Dallas, TX 75390, USA
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18
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Goutte J, Killian M, Antoine JC, Massoubre C, Fakra E, Cathébras P. [First-episode psychosis as primary manifestation of medical disease: An update]. Rev Med Interne 2019; 40:742-749. [PMID: 31421899 DOI: 10.1016/j.revmed.2019.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/09/2019] [Accepted: 07/17/2019] [Indexed: 11/15/2022]
Abstract
A huge variety of medical diseases may potentially present with isolated psychotic symptoms, and disease-specific treatment or management is available for a significant part of them. The initial medical work-up of a first-episode psychosis (FEP) is of crucial importance. This literature review aimed to identify medical conditions potentially revealed by FEP, to list the warning signs of secondary psychosis, and to discuss a screening strategy. Underlying organic conditions may be drugs and medications, neurologic diseases, infections, inflammatory and/or autoimmune pathologies, and metabolic disorders whether of hereditary origin. Each patient presenting with a first-episode psychosis should be evaluated with a precise anamnesis, a careful clinical examination, and routine laboratory tests. Brain imaging and tests (depending on the context) should be performed in the presence of atypical clinical features or "red flags", leading to suspect an organic disease.
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Affiliation(s)
- J Goutte
- Service de médecine interne, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
| | - M Killian
- Service de médecine interne, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
| | - J C Antoine
- Service de neurologie, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
| | - C Massoubre
- Service de psychiatrie, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
| | - E Fakra
- Service de psychiatrie, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
| | - P Cathébras
- Service de médecine interne, CHU de Saint-Étienne, 42055 Saint-Étienne Cedex 2, France.
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19
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Bourouache M, Mimouni R, Nejmeddine M, Chadli S, Benlmeliani F, Sardi J, Malmoussi M, Ouagari Z, Basbassi ME, Aghrouch M. The prevalence of syphilis in HIV-seropositive patients: a retrospective study at the regional hospital in Agadir, Morocco. Pan Afr Med J 2019; 33:252. [PMID: 31692814 PMCID: PMC6814908 DOI: 10.11604/pamj.2019.33.252.15781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/15/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction HIV and syphilis are major public health problems in Morocco. The region of Souss-Massa, south-west of the country, hold more than 24% of HIV seropositive cases registered in Morocco during 2009. The aim of this study is to evaluate the seroprevalence of syphilis among HIV seropositive patients in the region of Souss-Massa, south-west of Morocco. Methods To evaluate the seroprevalence of syphilis and neurosyphilis among HIV seropositive patients, we retrospectively investigated the medical records of HIV-infected patients attending the regional hospital located in the city of Agadir, during the period comprised between 2011 and 2016. Results The population studied involved 1381 males (49.18%) and 1427 females (50.82%) HIV seropositive patients. Among them, 481 patients were seropositive for syphilis and three cases were diagnosed with neurosyphilis. The sex ratio distribution was 243 male (52.71%) and 218 female (47.29%). The prevalence of syphilis among the studied population was estimated to 16.42% with a slight dominance in male (17.63%) compared to female (15.28%). By contrast, neurosyphilis was only detected in male patients, with a prevalence estimated to 0.11%. Conclusion Even if the prevalence of HIV and syphilis is stable in the region of Souss-Massa, the prevalence of syphilis among HIV seropositive patients remained high and correlated positively with that of HIV infection. We did not find a significant difference between the genders, in relation to the prevalence of HIV and syphilis. We concluded that it was essential to continue monitoring the population, in order to improve the prevention and the access to the medical care in the south-west of Morocco.
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Affiliation(s)
- Mohamed Bourouache
- Department of Biology, Faculty of Sciences, Ibn Zohr University, Agadir, Morocco
| | - Rachida Mimouni
- Department of Biology, Faculty of Sciences, Ibn Zohr University, Agadir, Morocco
| | - Mohamed Nejmeddine
- Infectious Diseases Group, Laboratory of Cell Biology and Molecular Genetics, Faculty of Sciences, Ibn Zohr University, Agadir, Morocco
| | - Smail Chadli
- Higher Institute for Nursing Professions and Health Techniques, Agadir, Morocco
| | - Fatima Benlmeliani
- Laboratory of Bio-Medical Analysis, Hassan II Regional Hospital, Agadir, Morocco
| | - Jamila Sardi
- Laboratory of Bio-Medical Analysis, Hassan II Regional Hospital, Agadir, Morocco
| | - Mourad Malmoussi
- Department of Infectious Diseases, Hassan II Regional Hospital, Agadir, Morocco
| | - Zineb Ouagari
- Department of Infectious Diseases, Hassan II Regional Hospital, Agadir, Morocco
| | - Maryam El Basbassi
- Laboratory of Bio-Medical Analysis, Hassan II Regional Hospital, Agadir, Morocco
| | - Mohamed Aghrouch
- Laboratory of Bio-Medical Analysis, Hassan II Regional Hospital, Agadir, Morocco
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20
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Yuan JL, Wang WX, Hu WL. Clinical features of syphilitic myelitis with longitudinally extensive myelopathy on spinal magnetic resonance imaging. World J Clin Cases 2019; 7:1282-1290. [PMID: 31236392 PMCID: PMC6580337 DOI: 10.12998/wjcc.v7.i11.1282] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/16/2019] [Accepted: 05/02/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Syphilitic myelitis caused by Treponema pallidum is an extremely rare disease. However, symptomatic neurosyphilis, especially syphilitic myelitis, and its clinical features have been infrequently reported. Only a few cases of syphilitic myelitis have been documented. To the best of our knowledge, there are only 19 reported cases of syphilitic myelitis. However, the clinical features of syphilitic myelitis with longitudinally extensive myelopathy have been still not clear.
AIM To explore the clinical features of syphilitic myelitis with longitudinally extensive myelopathy on spinal magnetic resonance imaging (MRI).
METHODS First, we report a patient who suffered from syphilitic myelitis with symptoms of sensory disturbance, with longitudinally extensive myelopathy with "flip-flop sign" on spinal MRI. Second, we performed a literature search to identify other reports (reviews, case reports, or case series) from January 1987 to December 2018, using the PubMed and Web of Science databases with the terms including "syphilis", "neurosyphilis", "syphilitic myelitis", "meningomyelitis", "central nervous system", and "spine". We also summarized the clinical features of syphilitic myelitis with longitudinally extensive myelopathy.
RESULTS A total of 16 articles of 20 cases were identified. Sixteen patients presented with the onset of sensory disturbance (80%), 15 with paraparesis (75%), and 9 with urinary retention (45%). Eleven patients had a high risk behavior (55%). Five patients had concomitant human immunodeficiency virus infection (25%). Serological data showed that 15 patients had positive venereal disease research laboratory test (VDRL)/treponema pallidum particle agglutination (TPHA), and 17 had positive VDRL/TPHA in cerebrospinal fluid (CSF). Seventeen patients were found to have elevated leukocytosis and protein in CSF. On MRI, 16 patients showed abnormal hyperintensities involved the thoracic spine, 6 involved the cervical spine, and 3 involved both the cervical and thoracic spine. There were 3 patients with the "flip-flop sign". All the patients were treated with penicillin, and 15 patients had a good prognosis.
CONCLUSION Our case further raises awareness of syphilitic myelitis as an important complication of neurosyphilis due to homosexuality, especially in developing countries such as China.
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Affiliation(s)
- Jun-Liang Yuan
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Wei-Xue Wang
- Department of Oncology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Wen-Li Hu
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
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21
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Clinical and Laboratory Characteristics of Symptomatic and Asymptomatic Neurosyphilis in HIV-Negative Patients: A Retrospective Study of 264 Cases. BIOMED RESEARCH INTERNATIONAL 2019; 2019:2426313. [PMID: 31198783 PMCID: PMC6526518 DOI: 10.1155/2019/2426313] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/21/2019] [Accepted: 04/16/2019] [Indexed: 12/27/2022]
Abstract
A retrospective study was performed to compare the differences in clinical and laboratory features of asymptomatic neurosyphilis (ANS) and symptomatic neurosyphilis (SNS). A total of 264 HIV-negative inpatients with neurosyphilis were enrolled from Beijing Ditan Hospital and Beijing Tiantan Hospital between January 2014 and May 2018, including 110 SNS and 154 ANS. The SNS group had more patients in males, older median age and without antisyphilis treatment than ANS group (P<0.001, P<0.001, and P<0.001, respectively). The laboratory findings showed that the SNS group had higher pretreatment serum rapid plasma regain (RPR) titer, current serum RPR titer, cerebrospinal fluid (CSF) white blood cell (WBC) counts, CSF protein concentrations, and higher positive CSF RPR rate than those in the ANS group (P=0.011, P<0.001, P<0.001, P<0.001, and P<0.001, respectively). The multivariate logistic regression analysis revealed that male (OR=2.833, P=0.009), age≥45 years (OR=3.611, P=0.001), without antisyphilis treatment (OR=0.247, P<0.001), higher current serum RPR titer (OR=1.373, P=0.022), positive CSF RPR (OR=4.616, P<0.001), and higher CSF protein concentration (OR=1.017, P=0.026) were independent risk predictors for SNS. Therefore, clinical and laboratory features between SNS and ANS are quietly different. Male gender, age≥45 years, and lack of antisyphilis treatment are risk factors for SNS. The elevated level of serum RPR titer, CSF protein concentration, and CSF RPR titer may indicate the development of neurosyphilis and the aggravation of neurological symptoms.
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22
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Ozturk-Engin D, Erdem H, Hasbun R, Wang SH, Tireli H, Tattevin P, Argemi X, Ouamara-Digue E, Gombos A, Lakatos B, Sırmatel F, Cag Y, Pekok AU, Senbayrak S, Balkan II, Gheno M, Uzun N, Kaya S, Cicek-Senturk G, Şengöz G, Tekin R, Çelen MK, Nayman-Alpat S, Ergen P, Şener A, Agalar C, Köse S, Inkaya AÇ, Kaptan F, Al-Majid F, Savasci U, Vahaboglu H. Predictors of unfavorable outcome in neurosyphilis: Multicenter ID-IRI Study. Eur J Clin Microbiol Infect Dis 2018; 38:125-134. [PMID: 30368740 DOI: 10.1007/s10096-018-3403-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 10/12/2018] [Indexed: 11/28/2022]
Abstract
Neurosyphilis (NS) has different clinical manifestations and can appear during any stage of syphilis. We aimed to identify the factors affecting poor outcome in NS patients. Patients with positive cerebrospinal fluid Venereal Disease Research Laboratory test, and positive serological serum treponemal or nontreponemal tests were classified as definite NS. The data of 141 patients with definite NS were submitted from 22 referral centers. Asymptomatic NS, syphilitic meningitis, meningovascular syphilis, tabes dorsalis, general paresis, and taboparesis were detected in 22 (15.6%), 67 (47.5%), 13 (9.2%), 10 (7%), 13 (9.2%), and 16 patients (11.3%), respectively. The number of HIV-positive patients was 43 (30.4%). The most common symptoms were headache (n = 55, 39%), fatigue (n = 52, 36.8%), and altered consciousness (50, 35.4%). Tabetic symptoms were detected in 28 (19.8%), paretic symptoms in 32 (22.6%), and vascular symptoms in 39 patients (27.6%). Eye involvement was detected in 19 of 80 patients (23.7%) who underwent eye examination and ear involvement was detected in eight of 25 patients (32%) who underwent ear examination. Crystallized penicillin was used in 109 (77.3%), procaine penicillin in seven (4.9%), ceftriaxone in 31 (21.9%), and doxycycline in five patients (3.5%). According to multivariate regression analysis, while headache was a protective factor in NS patients, double vision was significantly associated to poor outcome. We concluded that double vision indicated unfavorable outcome among NS patients. A high clinical suspicion is needed for the diagnosis NS. As determined in our study, the presence of headache in syphilitic patients can help in early diagnosis of central nervous system disease.
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Affiliation(s)
- Derya Ozturk-Engin
- Department of Infectious Diseases and Clinical Microbiology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey.
| | - Hakan Erdem
- Principal Coordinator of ID-IRI, Ankara, Turkey
| | - Rodrigo Hasbun
- Department of Infectious Diseases, UT Health McGovern Medical School, Houston, TX, USA
| | - Shu-Hua Wang
- Division of Infectious Diseases, Deparment of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Hulya Tireli
- Department of Neurology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Xavier Argemi
- Department of Infectious Diseases and Clinical Microbiology, Nouvel Hôpital Civil, Strasbourg, France
| | - Enora Ouamara-Digue
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Andrea Gombos
- Department of Infectious Disease and Clinical Microbiology, Saint Laszlo Hospital Budapest, Budapest, Hungary
| | - Botond Lakatos
- Department of Infectious Disease and Clinical Microbiology, Saint Laszlo Hospital Budapest, Budapest, Hungary
| | - Fatma Sırmatel
- Department of Infectious Disease and Clinical Microbiology, Izzet Baysal University School of Medicine, Bolu, Turkey
| | - Yasemin Cag
- Department of Infectious Diseases and Clinical Microbiology, Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Abdullah Umut Pekok
- Department of Infectious Diseases and Clinical Microbiology, Private Erzurum Sifa Hospital, Erzurum, Turkey
| | - Seniha Senbayrak
- Department of Infectious Diseases and Clinical Microbiology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Ilker Inanç Balkan
- Department of Infectious Diseases and Clinical Microbiology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Marie Gheno
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Nuray Uzun
- Department of Infectious Diseases and Clinical Microbiology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Selçuk Kaya
- Department of Infectious Diseases and Clinical Microbiology, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Gönül Cicek-Senturk
- Department of Infectious Disease and Clinical Microbiology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Gönül Şengöz
- Department of Infectious Diseases and Clinical Microbiology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Recep Tekin
- Department of Infectious Diseases and Clinical Microbiology, Dicle University Faculty of Medicine, Diyarbakır, Turkey
| | - Mustafa Kemal Çelen
- Department of Infectious Diseases and Clinical Microbiology, Dicle University Faculty of Medicine, Diyarbakır, Turkey
| | - Saygın Nayman-Alpat
- Department of Infectious Disease and Clinical Microbiology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Pınar Ergen
- Department of Infectious Diseases and Clinical Microbiology, Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Alper Şener
- Department of Infectious Diseases and Clinical Microbiology, Onsekiz Mart University School of Medicine, Canakkale, Turkey
| | - Canan Agalar
- Department of Infectious Diseases and Clinical Microbiology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Sükran Köse
- Department of Infectious Diseases and Clinical Microbiology, Tepecik Training and Education Hospital, İzmir, Turkey
| | - Ahmet Çagkan Inkaya
- Department of Infectious Disease and Clinical Microbiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Figen Kaptan
- Department of Infectious Diseases and Clinical Microbiology, Atatürk Training and Research Hospital, İzmir Kâtip Çelebi University, İzmir, Turkey
| | - Fahad Al-Majid
- Department of Medicine, Infectious Diseases Division, King Saud University Hospital, Riyadh, Saudi Arabia
| | - Umit Savasci
- Department of Infectious Diseases and Clinical Microbiology, Gulhane Medical Academy, Ankara, Turkey
| | - Haluk Vahaboglu
- Department of Infectious Diseases and Clinical Microbiology, Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey
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23
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Borges CR, Almeida SMD, Sue K, Koslyk JLA, Sato MT, Shiokawa N, Teive HAG. Neurosyphilis and ocular syphilis clinical and cerebrospinal fluid characteristics: a case series. ARQUIVOS DE NEURO-PSIQUIATRIA 2018; 76:373-380. [PMID: 29972419 DOI: 10.1590/0004-282x20180054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 03/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND During the first decade of this century, a significant increase in the incidence of syphilis was documented. OBJECTIVE To study clinical and laboratory characteristics of central nervous system and ocular syphilis. METHODS A retrospective case series of 13 patients with a clinical and laboratory diagnosis of neurosyphilis and/or ocular syphilis who had been admitted to the Neurology and Neuro-ophthalmology Service of the Hospital de Clínicas, Federal University of Paraná. RESULTS Nine patients had a diagnosis of neurosyphilis and two of them also had ocular syphilis. Four patients had a diagnosis of ocular syphilis alone. Among the patients with a diagnosis of neurosyphilis, six had symptomatic syphilitic meningitis, of whom one manifested as cranial nerve palsy alone, one as cranial nerve palsy plus ocular syphilis, two as transverse myelitis (syphilitic meningomyelitis), one as meningitis worsening the patient's myasthenia gravis symptoms and one as meningitis plus ocular syphilis. Additionally, we diagnosed three patients with meningovascular neurosyphilis. In the univariate analysis, patients without ocular syphilis showed greater levels of total protein and white blood cells in the cerebrospinal fluid than patients with ocular syphilis. CONCLUSION This Brazilian case series of patients with neurosyphilis and ocular syphilis highlights the wide variability of this disease. A high degree of diagnostic suspicion is necessary when facing neurological and ocular symptoms for rapid diagnosis and appropriate management of patients.
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Affiliation(s)
- Conrado Regis Borges
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Serviço de Neurologia, Curitiba PR, Brasil
| | - Sérgio Monteiro de Almeida
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Serviço de Neurologia, Curitiba PR, Brasil.,Faculdades Pequeno Príncipe Curitiba, Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba PR, Brasil
| | - Karen Sue
- Universidade Federal do Paraná, Hospital de Clínicas, Serviço de Neuro-Oftalmologia, Curitiba PR, Brasil
| | - Jéssyca Luana Alves Koslyk
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Serviço de Neurologia, Curitiba PR, Brasil
| | - Mario Teruo Sato
- Universidade Federal do Paraná, Hospital de Clínicas, Serviço de Neuro-Oftalmologia, Curitiba PR, Brasil
| | - Naoye Shiokawa
- Universidade Federal do Paraná, Hospital de Clínicas, Serviço de Neuro-Oftalmologia, Curitiba PR, Brasil
| | - Hélio Afonso Ghizoni Teive
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Serviço de Neurologia, Curitiba PR, Brasil
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Abstract
The epidemiology of spinal cord disease in human immunodeficiency virus (HIV) infection is largely unknown due to a paucity of data since combination antiretroviral therapy (cART). HIV mediates spinal cord injury indirectly, by immune modulation, degeneration, or associated infections and neoplasms. The pathologies vary and range from cytotoxic necrosis to demyelination and vasculitis. Control of HIV determines the differential for all neurologic presentations in infected individuals. Primary HIV-associated acute transverse myelitis, an acute inflammatory condition with pathologic similarities to HIV encephalitis, arises in early infection and at seroconversion. In contrast, HIV vacuolar myelopathy and opportunistic infections predominate in uncontrolled disease. There is systemic immune dysregulation as early as primary infection due to initial depletion of gut-associated lymphoid tissue CD4 cells and allowance of microbial translocation across the gut that never fully recovers throughout the course of HIV infection, regardless of how well controlled. The subsequent proinflammatory state may contribute to spinal cord diseases observed even after cART initiation. This chapter will highlight an array of spinal cord pathologies classified by stage of HIV infection and immune status.
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Affiliation(s)
- Seth N Levin
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Jennifer L Lyons
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
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Ikeda S, Yakushiji Y, Eriguchi M, Fujii Y, Ishitsuka K, Hara H. [Neurosyphilis with cerebellar ataxia, personality change and cognitive decline one year after onset of cerebral infarction]. Rinsho Shinkeigaku 2018; 58:499-504. [PMID: 30068812 DOI: 10.5692/clinicalneurol.cn-001170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 51-year-old man with a cerebral lacunar infarction of the midbrain that had occurred two years before, was transferred from a regional psychiatric hospital with chronic progressive psychiatric symptoms including cognitive decline, irritability and hallucinations. Neurological examinations upon admission revealed cerebellar ataxia including dysarthria, ataxic gait and bilateral intention tremor. Brain FLAIR MRI on day 2 revealed abnormal hyperintense lesions in the bilateral insular cortex and temporal pole. Treponemal and non-treponemal specific antibodies were positive in both serum and cerebrospinal fluid (CSF), indicating a diagnosis of neurosyphilis. Treatment with intravenous penicillin (24 × 106 units/day × 28 days) improved his psychiatric symptoms, ataxia, imaging abnormalities and inflammatory CSF findings. Cerebellar ataxia is a rare symptom of neurosyphilis. Nonetheless, the possibility of neurosyphilis should be considered if a young adult ataxia accompanied by psychiatric symptoms.
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Affiliation(s)
- Shuhei Ikeda
- Division of Neurology, Department of Internal Medicine
| | | | | | - Yuka Fujii
- Department of Psychiatry, Saga University Faculty of Medicine
| | - Koji Ishitsuka
- Department of Cerebrovascular Medicine, Saga Medical Centre Koseikan
| | - Hideo Hara
- Division of Neurology, Department of Internal Medicine
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Rapalino O, Mullins ME. Intracranial Infectious and Inflammatory Diseases Presenting as Neurosurgical Pathologies. Neurosurgery 2018; 81:10-28. [PMID: 28575459 DOI: 10.1093/neuros/nyx201] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 05/22/2017] [Indexed: 12/28/2022] Open
Abstract
There are many infectious and inflammatory processes affecting the central nervous system that can simulate other neurosurgical pathologies (e.g. tumor) and may precipitate a brain biopsy for definitive diagnosis if not suspected a priori. The challenge for the healthcare team is to recognize imaging features that support a nonsurgical pathology to avoid unnecessary interventions. This review aims to give a general overview of some common inflammatory and infectious entities that affect the central nervous system, with illustrative examples and highlighting important pearls and pitfalls.
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Affiliation(s)
- Otto Rapalino
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Mark E Mullins
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
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[Chronic course of neurosyphilis]. DER NERVENARZT 2017; 89:586-588. [PMID: 29188351 DOI: 10.1007/s00115-017-0465-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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The great imitator: Mesial temporal alterations in MRI in an atypical case of neurosyphilis. Neurologia 2017; 35:59-61. [PMID: 28863830 DOI: 10.1016/j.nrl.2017.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 07/03/2017] [Indexed: 11/23/2022] Open
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29
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Gordon LK. Optic Nerve. Handb Exp Pharmacol 2017; 242:369-386. [PMID: 27787712 DOI: 10.1007/164_2016_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Optic nerve diseases arise from many different etiologies including inflammatory, neoplastic, genetic, infectious, ischemic, and idiopathic. Understanding some of the characteristics of the most common optic neuropathies along with therapeutic approaches to these diseases is helpful in designing recommendations for individual patients. Although many optic neuropathies have no specific treatment, some do, and it is those potentially treatable or preventable conditions which need to be recognized in order to help patients regain their sight or develop a better understanding of their own prognosis. In this chapter several diseases are discussed including idiopathic intracranial hypertension, optic neuritis, ischemic optic neuropathies, hereditary optic neuropathies, trauma, and primary tumors of the optic nerve. For each condition there is a presentation of the signs and symptoms of the disease, in some conditions the evaluation and diagnostic criteria are highlighted, and where possible, current therapy or past trials are discussed.
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Affiliation(s)
- Lynn K Gordon
- Stein Eye Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA.
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Tohge R, Shinoto Y, Takahashi M. Longitudinally Extensive Transverse Myelitis and Optic Neuropathy Associated with Syphilitic Meningomyelitis and Human Immunodeficiency Virus Infection: A Case Report and Review of the Literature. Intern Med 2017; 56:2067-2072. [PMID: 28768983 PMCID: PMC5577089 DOI: 10.2169/internalmedicine.56.8236] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The incidence of co-infection with Treponema pallidum and human immunodeficiency virus (HIV) is increasing in developing and developed countries. The neurological complications of both infections occasionally occur simultaneously during a clinical course. We herein report the case of an HIV carrier with syphilitic meningomyelitis and subclinical optic neuropathy. The patient presumably had latent syphilis and slowly developed longitudinally extensive transverse myelitis (LETM). A cerebrospinal fluid examination confirmed the diagnosis of active neurosyphilis based on an elevated T. pallidum hemagglutination assay index. A change in the patient's immune status, possibly due to HIV, might have converted the syphilis from latent to active, leading to LETM of the spinal cord.
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Affiliation(s)
- Rie Tohge
- Department of Neurology, Osaka Red Cross Hospital, Japan
| | - Yuya Shinoto
- Department of Neurology, Osaka Red Cross Hospital, Japan
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Monticelli J, Bazzocchi G, Luzzati R. A Luetic Cauda Equina Meningoradiculitis Mimicking a Central Nervous System Lymphoma. Sex Transm Dis 2016; 43:122-4. [PMID: 26766528 DOI: 10.1097/olq.0000000000000391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We report a case of peculiar neurosyphilis, initially misinterpreted as a lymphoproliferative disorder. This is also the first report to evaluate the utility of positron emission tomography-computed tomography in spinal cord syphilis. Cauda equina radiculitis is a rare manifestation of neurosyphilis whose diagnosis can be supported by the typical syphilitic exanthema.
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Affiliation(s)
- Jacopo Monticelli
- From the *Infectious Diseases Unit and †Medical Imaging Unit, University Hospital, Trieste, Italy
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Hanebali M, Evrard G, Gil-Jardiné C, Tellier E, Valdenaire G. Une neurosyphilis révélée par un tableau psychiatrique. ANNALES FRANCAISES DE MEDECINE D URGENCE 2016. [DOI: 10.1007/s13341-016-0672-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Drago F, Merlo G, Ciccarese G, Agnoletti AF, Cozzani E, Rebora A, Parodi A. Changes in neurosyphilis presentation: a survey on 286 patients. J Eur Acad Dermatol Venereol 2016; 30:1886-1900. [PMID: 27306850 DOI: 10.1111/jdv.13753] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 01/06/2016] [Indexed: 11/28/2022]
Abstract
Although neurosyphilis (NS) keeps plaguing worldwide, often with oligosymptomatic and atypical manifestations, the most recent reports fail to provide useful information, like details of the clinical history and even of the previous early therapy. We conducted a survey of the literature of the last 5 years on the clinical presentation of NS, recording the aforementioned inaccuracies. One hundred and thirty-seven articles were collected, reporting on 286 patients. General paresis was the commonest form (49%), often manifesting with cognitive impairment and psychiatric symptoms. Syphilitic meningitis was found in 63 patients (22%), mainly with ocular or auditory involvement. Meningovascular and tabetic form were both found in 12% of cases. Gummatous and epileptic manifestations were rare. Perusal of the literature confirms that NS prevalence is increasing, often with manifestations that are atypical for timing and type of lesions. Unfortunately, many articles are lacking of critical information, like an accurate clinical history and timing of the therapy making difficult to assess the effectiveness of penicillin in preventing NS.
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Affiliation(s)
- F Drago
- Di.S.Sal. Section of Dermatology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - G Merlo
- Di.S.Sal. Section of Dermatology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy.
| | - G Ciccarese
- Di.S.Sal. Section of Dermatology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - A F Agnoletti
- Di.S.Sal. Section of Dermatology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - E Cozzani
- Di.S.Sal. Section of Dermatology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - A Rebora
- Di.S.Sal. Section of Dermatology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - A Parodi
- Di.S.Sal. Section of Dermatology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
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Crozatti LL, de Brito MH, Lopes BNA, de Campos FPF. Atypical behavioral and psychiatric symptoms: Neurosyphilis should always be considered. AUTOPSY AND CASE REPORTS 2015; 5:43-7. [PMID: 26558247 PMCID: PMC4636106 DOI: 10.4322/acr.2015.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 09/04/2015] [Indexed: 12/16/2022] Open
Abstract
Syphilis still remains a major health concern worldwide because of the possibility of serious medical and psychological consequences, long-term disability, and death. Neurosyphilis (NS) may occur at any stage of infection. Its clinical presentation has been changing over recent years including psychiatric and neurocognitive symptoms. Several recent studies have described cases with these symptoms as the principal signs of NS. We present the case of neurosyphilis with a psychiatric presentation characterized by mood disturbance and auditory and visual hallucinations.
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Affiliation(s)
- Lucas Lonardoni Crozatti
- Department of Internal Medicine - Hospital das Clínicas - Faculty of Medicine - University of São Paulo, São Paulo/SP - Brazil
| | - Marcelo Houat de Brito
- Department of Internal Medicine - Hospital das Clínicas - Faculty of Medicine - University of São Paulo, São Paulo/SP - Brazil
| | - Beatriz Noele Azevedo Lopes
- Department of Internal Medicine - Hospital das Clínicas - Faculty of Medicine - University of São Paulo, São Paulo/SP - Brazil
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