CT and MR findings in HIV-negative neurosyphilis

Clinical and Laboratory Characteristics, Neuroimaging Alternations and Treatment Response of 25 HIV-Negative General Paresis Patients

Purpose

General paresis is a common type of neurosyphilis featuring progressive cognitive deterioration. The lack of a golden standard of diagnosis and its nonspecific clinical manifestations resulted in a high rate of misdiagnoses. This study aims to investigate the clinical, laboratory and radiological presentations of general paresis and enrich its knowledge for timely diagnoses.

Patients and methods

The study collected hospitalized patients admitted for general paresis from September 2002 to November 2022. Their socio-demographical and medical status, clinical presentations, cognitive assessments, laboratory and radiographical manifestations and treatment information were collected retrospectively.

Results

A total of 20 males and 5 females were included. Patients' ages ranged from 30 to 66 years (average 50.3 years). The average and median time for diagnosing general paresis was 14.1 months and 10.0 months respectively. The most frequent initial symptom is memory deterioration (68.0%). Impaired calculative ability and memory deterioration were the most frequent cognitive anomalies, as found in 50% and 45.4% of subjects during examination. The mean and median scores of MoCA was 16.7 and 17 respectively. Serological tests revealed positive TPPA for all patients and a median RPR titer at 1:64 positive. All CSF samples with TPPA and FTA-ABS results reported positivity. The MRI manifestations of general paresis include patchy or speckled hyperintensities (70.8%) and cerebral atrophy (45.8%). The most common lesioned sites in MRI were the ventricular and paraventricular area (50.0%) and temporal lobes (45.8%). For treatment, penicillin-based anti-syphilitic plans were adopted in 17 patients (68.0%).

Conclusion

The clinical features and radiological alternations of general paresis patients often exhibited diverse and nonspecific alternations. However, some specific clinical manifestations and auxiliary examinations can provide meaningful clues for the identification and differential diagnosis of this disease.

Aberrant gray matter structure in neurosyphilis without conventional MRI abnormality: a pilot study with voxel and surface-based morphology

Background

The underlying mechanism of neurosyphilis was not fully understood.

Purpose

To assess gray matter (GM) microstructure in patients with early-stage neurosyphilis without overt conventional magnetic resonance imaging (MRI) abnormality using voxel-based morphometry (VBM) and surface-based morphometry (SBM) analyses.

Material and Methods

Three-dimensional high-resolution T1-weighted imaging data from 19 individuals with neurosyphilis and 19 healthy controls were analyzed. A battery of neuropsychological tests was performed before each MRI examination. The differences of GM volume and cerebral cortical morphological data between the two groups were compared. The correlations between MRI metrics and neuropsychology/laboratory tests in the patient group were investigated.

Results

Regional decreased GM volumes in patients with neurosyphilis were found in the left frontal cortices (Rolandic operculum, middle frontal, and precentral) and bilateral temporal/occipital cortices (bilateral middle temporal, left lingual, and right middle occipital) ( P < 0.05, FDR correction). SBM analysis showed significant cortical thickness reduction in the right medial orbitofrontal lobe, and reduced gyrification index in the left insula in patients with neurosyphilis ( P < 0.05, FDR correction). Additionally, in the patient group, the GM volume in the middle frontal gyrus, the cortical thickness of right medial orbitofrontal lobe, and the gyrification index in the left insula were negatively correlated to the number connection test-A scores. The gyrification index was also negatively correlated to cerebrospinal fluid white blood cell count.

Conclusion

Early-stage neurosyphilis without conventional MRI abnormality presented regional GM volume reduction and cortical morphological changes, which might be related to cognitive impairment and intra-cranial infection. VBM and SBM analyses might be useful for understanding the underlying neural trait of neurosyphilis.

Neurosyphilis: The Great Imitator

Syphilis is a sexually transmitted disease caused by spirochete Treponema pallidum, with a growing incidence documented in recent years. Its clinical course is divided into three phases - primary, secondary, and tertiary syphilis - and virtually any organ can be affected, resulting in diverse clinical manifestations, making the diagnosis challenging. Neurosyphilis is a progressive, destructive disease of the central nervous system (CNS) that can develop at any stage of the infection, leading to meningeal involvement, meningovascular disease, or parenchymal syphilis (including tabes dorsalis and general paresis). Its clinical manifestations are heterogeneous and vary from focal neurologic signs to neuropsychiatric manifestations. The diagnosis is based mainly on the clinical picture and study of cerebrospinal fluid. Neuroimaging is helpful and sometimes essential, with magnetic resonance imaging being the most sensitive radiologic method, although there are no pathognomonic radiologic signs. Treatment of all forms of neurosyphilis is based on parenteral penicillin. We present a case of neurosyphilis in a patient presenting with a subacute confusional state and initial imaging findings suggestive of metastatic CNS lesions.

Locked-in Syndrome Due to Meningovascular Syphilis: A Case Report and Literature Review

We herein report a 46-year-old man presenting with locked-in syndrome secondary to meningovascular syphilis. Brain magnetic resonance imaging (MRI) demonstrated multiple acute infarctions in the left ventromedial pons, right basis pontis, and left basal ganglia. His locked-in syndrome was hypothesized to have been caused by thrombosis of the small paramedian branches of the basilar artery due to syphilitic arteritis. This is a unique case of bilateral ventromedial pontine infarction caused by meningovascular syphilis that presented as locked-in syndrome. Meningovascular syphilis should be included in the differential diagnosis of uncommon stroke, particularly in young men.

Neurosyphilis with a rare magnetic resonance imaging pattern confirmed by metagenomic next-generation sequencing: a case report

Background

Neurosyphilis refers to infection of the central nervous system by Treponema pallidum. The clinical presentation is variable and nonspecific. Neuroimaging findings are complex and that the diagnosis is based on clinical presentation, cerebrospinal fluid (CSF) parameters, and serologic and CSF evidence of syphilis. To date, there is no case report describing Treponema pallidum detected by metagenomic next-generation sequencing (mNGS) in CSF.

Case presentation

In this report, we describe a case of neurosyphilis in a HIV-negative, 29-year-old man, who was admitted to our hospital with an epileptic seizure and progressive cognitive impairment. Brain magnetic resonance imaging (MRI) revealed fluid-attenuated inversion recovery (FLAIR) high signal intensities in bilateral medial and anterior temporal lobes, insula, right pulvinar of the thalami, precuneus, frontal and temporo-occipital lobes. Laboratory examination showed positive results by means of nontreponemal or specific treponemal test in serum and CSF. mNGS of the CSF was also performed to identify Treponema pallidum for the first time.

Conclusions

This case underscores the importance of considering neurosyphilis as a potential cause of mesiotemporal abnormality. In addition, the rapid improvement and wide usability of mNGS technology will bring new breakthroughs in the clinical diagnosis of neurosyphilis.

Regional Cerebral Blood Flow Abnormalities in Neurosyphilis: A Pilot SPECT Study

Objective: Clinical and radiological findings on neurosyphilis are fairly non-specific and there is a paucity of functional neuroimaging studies on neurosyphilis other than case reports and case series. The purpose of this study was to investigate brain perfusion abnormalities in patients with neurosyphilis. Methods: Four HIV-negative neurosyphilis patients and 4 healthy controls underwent clinical evaluation, brain technetium-99m ethyl cysteinate dimer (99mTc-ECD) single-photon emission computed tomography (SPECT) imaging, and neuropsychological assessments which included the Mini-Mental State Examination (MMSE), Clinical Dementia Rating (CDR), Clinical Dementia Rating-Sum of Boxes (CDR-SOB), and Global Deterioration Scale (GDS). Voxel-wise differences in regional cerebral blood flow were compared between the two groups. Results: Neuropsychological test results indicated cognitive impairment in all patients. SPECT analysis revealed multifocal hypoperfusion predominantly in the frontal, insular, and posterior cingulate regions in neurosyphilis patients compared with healthy controls (family-wise error corrected p < 0.05). Conclusions: Together with previous findings, our results suggest that the hypoperfusion in the frontal, insular, and posterior cingulate regions may reflect cognitive impairments observed in neurosyphilis patients. Further studies with larger samples are needed to confirm our findings.

Neurosyphilis in disguise

PURPOSE

Neurosyphilis can mimic different diseases, not only in its clinical presentation but also on imaging. Treponema pallidum is also known as the "great imitator." Having an ultimate diagnosis of neurosyphilis is quite critical as this can affect management drastically. Herein, we discuss the case of a 69-year-old female who was treated for neurosyphilis, while having an atypical imaging finding of anterior temporal lobe enhancement that simulated an infection with herpes simplex virus (HSV); we also review the available literature on different imaging findings in both the early and late stages of the disease.

METHODS

We performed a literature search using the new PubMed in June 2021. The terms "neurosyphilis", "MRI", and "neuroimaging" were used either alone or in combination with "early neurosyphilis" or "late neurosyphilis". Data on neurosyphilis and imaging findings was mainly derived from review articles, cohort studies, case series, and individual reports.

CONCLUSION

Neurosyphilis can present with an extensive variation and different patterns on the MRI, and clinicians must be aware of the wide variety in radiological presentations. Anterior temporal lobe involvement is a rare presentation and requires evaluating for neurosyphilis to prevent a missed diagnosis and treatment.

Analysis of Fourteen New Cases of Meningovascular Syphilis: Renewed Interest in an Old Problem

Neurosyphilis (NS) remains a public health problem. Several recent reports suggest a worldwide increase in the incidence of this condition. Various syndromes can occur in NS, such as syphilitic meningitis, meningovascular syphilis, parenchymatous and gummatous neurosyphilis. Syphilis meningovascular will be the focus of this study. We report 14 new observations of meningovascular syphilis. A review of demographic and clinical features, neuroimaging findings, cerebrospinal fluid changes, treatment and outcome, pathophysiology mechanism of meningovascular syphilis are presented.

Neurosyphilis

PURPOSE OF REVIEW

This article focuses on the epidemiology, clinical presentation, diagnosis, and management of neurosyphilis, with an emphasis on clinically relevant issues faced by the practicing neurologist.

RECENT FINDINGS

The incidence of primary and secondary syphilis, the sexually transmissible stages of infection, has been on the rise for the past 2 decades. A concerning recent trend is the surge in cases of syphilis in women and of congenital syphilis. Neurosyphilis remains a relatively common complication that can occur at any stage of syphilis. Along with meningitis, meningovascular syphilis, which has been historically described as a late presentation of neurosyphilis, now frequently occurs as a manifestation of early infection. Late forms of neurosyphilis, including tabes dorsalis and general paresis, are less prevalent in the era of widespread penicillin use. As more laboratories adopt the reverse-sequence algorithm for syphilis testing, patients with serodiscordant results (ie, a reactive serum treponemal test with a nonreactive nontreponemal test) may present an increasingly encountered diagnostic challenge for neurologists. Although the CSF Venereal Disease Research Laboratory (VDRL) remains a mainstay of diagnostic testing for neurosyphilis, using a higher titer cutoff (greater than 1:320) for the Treponema pallidum particle agglutination assay (TPPA) from the CSF may improve the utility of the TPPA as a supporting criterion for the diagnosis of neurosyphilis. Penicillin G is the treatment of choice for neurosyphilis, although ceftriaxone may be a reasonable alternative therapy.

SUMMARY

A high index of suspicion and awareness of the variable clinical presentations of neurosyphilis are essential to the approach to this treatable infection. Neurologists should be mindful of the limitations of serologic testing in the diagnosis of neurosyphilis and exercise clinical judgment to determine the likelihood of the diagnosis.

Neurosyphilis: a series of 178 cases at the 3rd-level hospital of Marrakesh (Morocco)

Neurosyphilis (NS) is an infection of the central nervous system (CNS), caused by Treponema pallidum. Up to 4-10% of patients with untreated syphilis may develop NS which still constitutes a health challenge. The aim of this study is to analyze epidemiological, clinical, paraclinical, therapeutic, and progression profiles of NS in the south of Morocco. Authors analyzed retrospectively 178 files of patients with neurosyphilis, collected in the Neurology Department of Marrakesh over 25 years from January 1994 to March 2019. In our study, the mean age was 46 years (17-75 years). The number of males was dominant (87.6%). The most common presentation was meningoencephalitis. Four cases were atypical (late congenital syphilis, amyotrophic lateral sclerosis, neurosyphilis associated with neuro-Behcet's disease, and acute polyradiculoneuropathy). All patients had positive TPHA and VDRL serologies in blood; CSF-TPHA was positive in all patients, and CSF-VDRL was positive in 64.0% of patients. CT scan and brain MRI showed cortical atrophy in the majority of cases. One hundred seventy-seven patients were treated with intravenous injection of aqueous penicillin G. Neurosyphilis is still a significant medical problem in developing countries, and its occurrence in HIV infection is the reason for a growing number of new cases in developed countries. Given the frequent atypical manifestations of the disease, screening for neurosyphilis should be considered in all patients with neurological or psychiatric symptoms.

Imaging Characteristics of Brain SPECT, PET, and MRI in Neurosyphilis

The incidence of neurosyphilis has declined since effective penicillin therapy against Treponema pallidum was introduced. However, the diagnosis of neurosyphilis early in the disease course is very important in order to select appropriate antibiotic therapy. We report brain MRI, SPECT with Tc-99m ECD, and PET with F-18 FDG findings before antibiotic therapy in a neurosyphilis patient with neurological symptoms. The cerebral cortices showed hypoperfusion with a patchy distribution on SPECT and foci with high signal intensity on MRI, suggesting ischemia. Brain PET showed areas with hypometabolism in the temporoparietal lobes bilaterally.

Neuroimaging Features, Follow-Up Analyses, and Comparisons Between Asymptomatic and Symptomatic Neurosyphilis

Introduction

Many studies have explored the imaging characteristics of patients with neurosyphilis, but no systematic study has been made on the neuroimaging changes after anti-syphilitic treatment. The purpose of this study was to examine neuroimaging differences before and after treatment, comparing patients with asymptomatic and symptomatic neurosyphilis.

Methods

A total of 102 patients with neurosyphilis, including 60 cases of symptomatic neurosyphilis and 42 cases of asymptomatic neurosyphilis, were identified between December 2012 and June 2019. Their demographics, medical histories, serological tests of peripheral blood and cerebrospinal fluid, and especially neuroimaging features before and after anti-syphilitic treatment were collected and analyzed.

Results

The patients presented with variable clinical and neuroimaging features, including cerebral infarction or hemorrhage, atrophy, demyelination, arteritis, encephalitis, and hippocampal sclerosis. A total of 29 neuroradiological re-examinations were performed in 19 patients treated with anti-syphilitic medicine. The results indicated that some patients still presented neuroradiological progression after treatment, including 42.1% showing infarction lesions, 47.4% mild to severe brain atrophy, and 15.8% white matter demyelination.

Conclusion

The clinical and neuroimaging features of neurosyphilis patients are diverse, and their follow-up neuroimaging continued to show progression even with standardized treatment.

Electronic supplementary material

The online version of this article (10.1007/s13555-020-00361-3) contains supplementary material, which is available to authorized users.

Clinical and neuropsychological characteristics of general paresis misdiagnosed as primary psychiatric disease

BACKGROUND

Neurosyphilis is caused by the invasion of Treponema pallidum into the central nervous system. General paresis (GP) is a type of neurosyphilis. The main manifestation of general paresis is dementia; however, this is different from the other types of dementia, which can be cured by adequate doses of penicillin in the early stage. Neurosyphilis is the "great imitator" because it can mimic many types of medical disorders. In addition, the manifestations of neurosyphilis are not typical. Psychiatric disorders as a cause of general paresis have become more common due to the use of antibiotics. Patients with a psychiatric manifestation are often misdiagnosed. The purpose of this study was to explore the differences in the clinical and neuropsychological characteristics of general paresis between patients misdiagnosed as having a primary psychiatric disease and patients diagnosed correctly upon seeing a doctor. The results may assist clinicians in the early identification of neurosyphilis with a mental disorder.

METHOD

The demographic and clinical manifestations, laboratory tests, and neuroimaging and neuropsychological characteristics were analysed in 55 general paresis patients with psychiatric disorders, including 29 patients misdiagnosed as primary psychiatric disease and 26 patients diagnosed as having general paresis after being seen once by a doctor.

RESULT

All of the patients had positive assay results for cerebral spinal fluid (CSF) Treponema pallidum hemagglutination (TPHA). Only 43.3 % of misdiagnosed patients and 30.8 % of general paresis patients had positive results for the CSF rapid plasma reagin (RPR) test; 96.4 % patients had abnormal neuroimaging. Mood disturbances were the most common psychiatric disorder in the general paresis patients, especially agitation, between the two groups (patients with general paresis who were misdiagnosed as having primary psychiatric disease and patients who had never been misdiagnosed) (p = 0.011).

CONCLUSION

Our findings reinforce the importance of performing serologic testing for syphilis. This should be a part of the evaluation of patients with psychiatric disorders, especially patients with cognitive impairment. When the syphilis serology is positive, the patient should be examined thoroughly for neurosyphilis by lumbar puncture. Brain imaging could also aid the physician in discriminating these patients from those with a functional mental disorder.

Susceptibility-weighted imaging in parenchymal neurosyphilis: identification of a new MRI finding

BACKGROUND

General paresis (GP) is a late form of parenchymal neurosyphilis causing dementia and neuropsychiatric disorders. The diagnosis is often difficult since the clinical signs are protean. So far, neuroimaging has played a minor role as radiological findings are not specific.

METHODS

We studied three immunocompetent patients, admitted to hospital for cognitive impairment. The diagnosis of neurosyphilis was formulated on the basis of serological texts and cerebrospinal fluid analysis. The patients underwent a 3 T MR examination including susceptibility-weighted imaging (SWI) sequence before and after the initiation of penicillin therapy.

RESULTS

In all patients, SWI revealed cortical hypointensity, mostly distributed in frontal and temporal lobes. In drug-naive patients, the hypointensity extended over the whole cortical thickness, from the cortical/subcortical junction to the pial surface. After starting the penicillin therapy, the cortical hypointensity partially reversed, involving only the deep cortical layers.

CONCLUSIONS

The MRI pattern at SWI observed in patients with GP was not reported in other infectious or inflammatory disease of the central nervous system, thus we suggest it could be a peculiar radiological finding of the disease. On the basis of previous pathological data, we hypothesise that cortical SWI hypointensity could be expression of iron deposits within activated microglia.

Clinical and laboratory characteristics in patients suffering from general paresis in the modern era

BACKGROUND

No gold standard currently exists for the diagnosis of general paresis (GP), thus often resulting in unnecessarily delayed therapeutic decision.

METHODS

A retrospective chart review was performed for 85 inpatients with GP in Zhongshan Hospital, Medical College of Xiamen University, and the characteristics of their clinical profiles, serum and cerebrospinal fluid (CSF) examinations, neuroimaging examination, and electroencephalogram (EEG) data were analyzed.

RESULTS

Among the 85 GP patients, the clinical symptoms that were frequently observed upon admission included a variety of psychiatric-behavioral symptoms and varying degrees of cognitive impairment. All of the patients had positive serum Treponema pallidum particle agglutination (TPPA) assays, 96.47% of the patients had positive CSF TPPA assays, and 41.18% of the patients had both CSF pleocytosis and elevated CSF protein levels. Focal atrophy in one cerebral region or in multiple regions was evident in neuroimages. The EEG data primarily showed slightly abnormal EEG activity.

CONCLUSION

These results demonstrate the complexity of the clinical characteristics of GP and highlight the importance of early diagnosis.

Neurosyphilis Is a Long-forgotten Disease but Still a Possible Etiology for Dementia

We herein report a heterosexual Japanese man in his forties who had been suffering from advanced dementia and personality change for 4 years. Positive results of a serological test for syphilis, Treponema pallidum hemagglutination assay, and fluorescent treponemal antibody-absorption test of both serum and cerebral spinal fluid led to the diagnosis of neurosyphilis. Jarisch-Herxheimer reaction was seen shortly after the first dose of penicillin was administered to the patient. His cognitive function did not recover after treatment. The incidence of syphilis has been reported to be increasing. Neurosyphilis should not be overlooked as an etiology for progressive dementia even in this post-antibiotic era.

Mesiotemporal changes on magnetic resonance imaging in neurosyphilis

We report a case of neurosyphilis with magnetic resonance imaging (MRI) brain scan findings compatible with a diagnosis of herpes simplex encephalitis with negative testing for herpes simplex virus in the cerebral spinal fluid. An extensive review of the literature has been undertaken revealing 24 cases worldwide where there are mesiotemporal changes on MRI concurrent with a diagnosis of neurosyphilis. Therefore, it is now well established that neurosyphilis, 'the great imitator', should be considered in the differential diagnosis in all patients demonstrating mesiotemporal changes on MRI, changes usually seen in herpes simplex encephalitis.

MRI findings and early diagnosis of general paresis of the insane

The objective of this study was to improve the knowledge of the clinical and MRI presentation of general paresis of the insane (GPI) and achieve its early diagnosis. Fifteen patients with GPI were gathered. Their clinical data and brain MRI information were analyzed. The age range was 33-62 years (mean: 48·8 years). The disease lasted 34 days-28 months (mean: 10·87 months). Treponema pallidum hemagglutination assays (TPHAs) on the cerebrospinal fluid (CSF) and sera were positive. All patients were human immunodeficiency virus (HIV) negative and primarily showed progressive cognitive impairment, mostly accompanied with emotional disturbance and psychosis. The accompanying symptoms included epilepsy (n  =  7), ataxia (n  =  5), cerebral vascular disease (n  =  3), and limbs tremor (n  =  2). Typical Argyll Robertson's pupil was observed in two cases. A CSF examination showed elevated white blood cell (WBC) and protein level. Purely cerebral atrophy was found in three cases. Abnormal high signals were found in nine cases in different brain area, mainly in bilateral temporal, insular, and frontal lobes and hippocampus in T2-weighted and fluid-attenuated inversion recovery (FLAIR), which was accompanied by cerebral and/or hippocampus atrophy. Purely atrophy of bilateral or unilateral hippocampus was found in two cases. Cerebral infarction lesions were found in three cases. Contrary to the previous reports, the hippocampal atrophy and bilateral abnormal signals of hippocampus and temporal lobe in brain MRI were more common in cases with GPI. Abnormal signals were probably related to proliferation of glial cells rather than cytotoxic edema. The pathogenesis of the abnormal signals needs to be further explored. General paresis of the insane has a wide variety of central nervous system manifestations, either clinically or neuroradiologically. Identification of these presentations could be important for early diagnosis.

Clinical and imaging findings in patients with neurosyphilis: a study of a cohort and review of the literature

BACKGROUND

Most patients with neurosyphilis are considered asymptomatic. The diagnosis is challenging and the role of neuroimaging is not yet well established. The present study was conducted to focus on the clinical findings and further characterize the imaging features of the disease, along with a review of the pertinent literature.

METHODS

Six male patients with neurosyphilis based on abnormal cerebrospinal fluid findings, five of whom were asymptomatic at presentation, underwent cranial computerized tomography (CT) and magnetic resonance imaging (MRI). They also underwent a complete physical, neurological, and ophthalmological examination, with special attention paid to atherosclerotic vascular risk factors. In addition, all were examined for cardiac involvement using electrocardiography and cardiac ultrasound.

RESULTS

The meticulous neurological and ophthalmological examination revealed abnormalities in five patients, most commonly cranial nerve involvement (three patients) and hemiparesis (two patients). The CT and MRI studies revealed abnormalities in five of the six patients, and in all six patients, respectively. The most common findings were brain infarcts, which were demonstrated in four of the six patients. MRI was found to be more sensitive than CT in detecting these brain infarcts, as expected.

CONCLUSIONS

Vascular insult was the most common neuroimaging finding in our patients with neurosyphilis, probably due to meningovascular endarteritis. Neurosyphilis should always be considered in young patients with unexplained brain infarcts.

[A case of neurological syphilis mimicking Horton's disease and polymyalgia rheumatica]

BACKGROUND

Syphilis has been making a comeback over the last 10 years. Neurosyphilis can occur at any stage of the infection but is difficult to diagnose because of the existence of misleading forms, of which we describe an example below.

PATIENTS AND METHODS

A 56-year-old woman presented symptoms evoking polymyalgia rheumatica and giant-cell arteritis in a context of ibuprofen treatment for a few weeks. She also had myodesospsia, syphilids and syphilitic roseola, together with laboratory indicators of inflammation. A lumbar puncture revealed lymphocytic meningitis and a positive Treponema Pallidum Haemagglutination Assay (TPHA) for cerebrospinal fluid, thus confirming the diagnosis of neurosyphilis. Moreover, the ophthalmologic examination showed optic neuritis with papilla lesions of syphilitic origin. This was successfully treated with a 3-week course of penicillin G infusions.

CONCLUSION

Symptoms evocative of Horton's disease and polymyalgia rheumatica can reveal syphilis, a disease dubbed "the great simulator" on account of the variety of clinical forms it can take.

Neuroimaging of six neurosyphilis cases mimicking viral encephalitis

BACKGROUND

Neurosyphilis is known as "the great imitator" due to its wide range of clinical symptoms and abnormalities upon magnetic resonance imaging (MRI). Typical findings of both neurosyphilis and viral encephalitis include unilateral or bilateral MR hyperintensities in mesiotemporal lobes upon T2-weighted imaging or fluid attenuation inversion recovery (FLAIR) imaging. Accordingly, patients with neurosyphilis are frequently misdiagnosed with viral encephalitis, which prevents them from receiving appropriate treatment and often results in greater neurologic damage.

METHODS

Clinical characteristics and MRI changes of 6 neurosyphilis patients admitted to our hospital between March 2012 and November 2012 were retrospectively reviewed.

RESULTS

All 6 cases were tested positive for assays measuring Treponema pallidum hemagglutination (TPHA), rapid plasma reagin (RPR), and antibodies against syphilis in the serum and cerebrospinal fluid (CSF). Likewise, all patients were negative for antibodies against viral pathogens. T2-weighted or FLAIR MRI of the brains in all cases revealed either unilateral or bilateral hyperintensities in the mesiotemporal lobes, including the hippocampi. Electroencephalography showed relevant, localized slow or spiked waves. Patient prognoses were good in the 4 cases that received early anti-syphilis treatment, but the 2 cases that received delayed treatment due to misdiagnoses did not see substantial symptomatic improvements.

CONCLUSIONS

Neurosyphilis should be considered when there is mesiotemporal involvement upon MRI. Early treatment for syphilis is critical for positive outcomes.

Serum and cerebrospinal fluid profiles for syphilis in Thai patients with acute ischaemic stroke

The diagnosis of neurosyphilis is complicated in elderly patients who have cerebrovascular risk factors and present with ischaemic stroke. We performed an analysis of serum and cerebrospinal fluid (CSF) profiles for neurosyphilis in acute stroke patients, particularly in those with atherosclerotic risk factors. In sera, the rapid plasma reagin (RPR) test and Treponema pallidum haemagglutination assay (TPHA) were used. In CSF, the RPR and fluorescent treponemal antibody-absorption tests were used together with CSF white blood cell (WBC) count and protein level. Baseline characteristics, including atherosclerotic risk factors, severity of stroke and computed tomography brain scan images were collected. Of the total 284 patients, 24 (8.4%) had TPHA-positive sera, from which 29.2% had a positive CSF for syphilis. Seven stroke patients (2.5%), with a mean age of 65.7 years, were diagnosed with symptomatic neurosyphilis, and 71% of them had atherosclerotic risk factors. Most symptomatic patients (85.7%) had CSF WBCs>20 cells/mm3, with a mean of 98.6 ± 136.0 versus 3.2 ± 7.3 in non-neurosyphilitic patients ( P = 0.0009). Less than 50% of the symptomatic patients had CSF protein levels >50 mg/dL, and the protein levels of neurosyphilitic and non-neurosyphilitic groups were not significantly different, with means of 52.0 ± 12.9 and 51.8 ± 15.9 mg/dL, respectively. There were no significant differences in age and stroke severity. Interpretation of CSF findings, particularly of CSF WBC counts and protein levels, must be appropriate to ascertain true symptomatic neurosyphilis cases and to reduce false-positive diagnoses, particularly in countries with a high prevalence of T. pallidum infection.

Neurosyphilis versus Herpes Encephalitis in a Patient with Confusion, Memory Loss, and T2-Weighted Mesiotemporal Hyperintensity

Acute confusion and memory loss associated with asymmetrical mesiotemporal hyperintensity on T2-weighted MRI are characteristic of herpes encephalitis. The authors report the case of a patient with these symptoms and MRI presentation who had neurosyphilis. Recently clinical and imaging patterns usually associated with herpes simplex encephalitis have been seen in patients with neurosyphilis. Because syphilis is "The Great Pretender" not only clinically but also in imaging and because its numbers are rising, it must be sought as a differential diagnosis.

Meningovascular neurosyphilis as the cause of ischemic cerebrovascular disease in a young man

Authors report a case of a 35-year-old male with right-sided mild paresis, incontinence, dysexecutive syndrome, short-term memory loss and behavioral changes. Bilateral cerebral infarcts in the region of the caudate nuclei and the adjacent white matter were proved by brain MRI and multiple stenoses of the branches of Willis-circle were confirmed by MR angiography. Elevated protein level and pleocytosis were found in the cerebrospinal fluid with intrathecal IgG synthesis. Serum rapid plasma reagin, Treponema pallidum Particle Agglutination test, Treponema pallidum ELISA, liquor Venereal Disease Research Laboratory tests were positive. Meningovascular neurosyphilis was diagnosed. 24M U/day intravenous penicillin-G treatment was given for 14 days. The patient has vascular dementia due to the bilateral strategic infarcts disconnecting the prefrontal circuits; his symptoms are similar to general paresis. Laboratory and radiologic improvement was observed. Still, the patient have severe residual cognitive decline. Orv. Hetil., 2011, 152, 763–767.

The successful treatment of disinhibition due to a possible case of non-human immunodeficiency virus neurosyphilis: a proposed pathophysiological explanation of the symptoms and treatment

The psychiatric presentation of advanced neurosyphilis is well documented, yet there is no set protocol to treat these occurrences. This report indexes a 61-year-old African-American male with no known psychiatric history but with a pertinent medical history of neurosyphilis (non-human immunodeficiency virus). He developed an acute episode of disinhibition involving violence and poor executive judgment. The authors' propose that this patient's symptoms of disinhibition may have resulted from syphilitic invasion of frontal-subcortical structures, resulting in either top-down or bottom-up dysregulation and deterioration of social behavior. His episode resolved with administration of monotherapy carbamazepine.

Clinical presentation and imaging of general paresis due to neurosyphilis in patients negative for human immunodeficiency virus

The clinical presentations and MRI of six patients with general paresis due to neurosyphilis were reviewed. Diagnosis was based on neurological and psychiatric symptoms, positive Treponema pallidum hemagglutination in cerebrospinal fluid (CSF) and sera, and serology that was negative for human immunodeficiency virus by enzyme-linked immunosorbent assay. Most patients had lymphocytic, monocytic pleocytosis and high protein levels in their CSF. One patient had periodic lateral epileptiform discharges, one patient had epileptiform discharges and three patients had slowing of background activity on electroencephalography. Two patients had hyperintense signal abnormalities in the anterior and mesial temporal lobe, while four patients were found by MRI to have cerebral atrophy. Three patients developed white matter lesions. Therefore, clinical, electroencephalography and MRI findings are valuable in the diagnosis of general paresis of neurosyphilis.

Magnetic resonance imaging of infections of the white matter

Infections of the nervous system are a common and serious occurrence. Neuroimaging has allowed to improve early detection and thus to initiate treatment earlier. Magnetic resonance (MR) imaging has become the method of choice in investigating a patient with suspicion of an infection of the central nervous system. Newer modalities such as MR spectroscopy and MR diffusion and perfusion will further help to improve diagnostic accuracy of the technique. For the investigation of infections of white matter, techniques such as diffusion imaging are essential.

MRI of neurosyphilis presenting as mesiotemporal abnormalities: a case report

The high signal intensities in bilateral mesiotemporal lobes on T2-weighted images are typical findings of herpes encephalitis or paraneoplastic limbic encephalitis. We report a case of neurosyphilis with mesiotemporal involvement on MRI. Positive antibodies in the cerebrospinal fluid confirmed the diagnosis. The results suggest that neurosyphilis should be considered when MRI results indicate mesiotemporal abnormalities.