NEUROSYPHILIS

Infectious optic neuropathy

A wide variety of infectious agents are known to cause optic neuropathy. This article will consider the bacteria, spirochetes, fungi, and viruses that most commonly affect the optic nerve. Clinical presentation is variable, but some pathogens often produce a characteristic funduscopic pattern. Diagnosis is usually made on the basis of clinical suspicion and serologic testing. Polymerase chain reaction is also increasingly utilized. Most infectious agents can be effectively treated but visual recovery is highly variable.

A case of cerebral gumma presenting as brain tumor in a human immunodeficiency virus (HIV)-negative patient

Syphilis, along with the recent increase of human immunodeficiency virus (HIV) patients, has also been on the rise. It has a broad spectrum of clinical manifestations, among which cerebral gumma is, a kind of neurosyphilis, however, it is rare and can be cured by penicillin. Thus, cerebral gumma needs to be differentially diagnosed from other brain masses that may be present in syphilis patients. We have experienced a case where the patient was first suspected of brain tumor, but confirmed by surgery to be cerebral gumma due to neurosyphilis. This is the first such case encountered in Korea, therefore, we report it here in. A 40-year old woman complaining of headaches was found to have a brain mass on her CT scans and MRI. Suspecting a brain Tumor, a resection was performed on the patient, and histological results revealed that the central portion of the mass contained necrotic material and the peripheral region was infiltrated with plasma cells. Warthin-Starry staining of the region revealed spirochetes, and the patient was thus diagnosed as brain gumma. Venereal Disease Research Laboratory (VDRL) of cerebrospinal fluid (CSF) was reactive. After an operation, penicillin-G at a daily dose of 24 x 10(6) U was given for 10 days from post-operative day 10, and thereafter, the mass disappeared.

Incidence and clinical presentation of neurosyphilis: a retrospective study of 81 cases

Aim of the report was the study of the clinical features of neurosyphilis in the last 40 years (1965-2005). The investigation was based on the retrospective review of patients with neurosyphilis hospitalized in our hospital from 1965 to 2005 (period A: 1965-1984 and B: 1985-2005). Eighty one patients with neurosyphilis were studied. Typical forms represent 68.6% of cases of neurosyphilis in period A. In period B, 85.7% of the cases are presented with atypical clinical patterns. Typical forms of the disease were no longer common, while atypical and masked clinical patterns prevailed. Neuropsychiatric symptoms were the most common manifestations of the disease.

Neurosyphilis presenting as psychiatric symptoms: an unusual case report

OBJECTIVE

Neurosyphilis remains a differential diagnosis for a wide variety of psychiatric syndromes, including dementia, mood disorders and psychosis. However, the incidence of neurosyphilis presenting initially with psychiatric symptomalogy is unclear. In this article, a clinical case is reported so as to illustrate some of the issues involved.

CASE PRESENTATION

A 33-year-old married man was admitted because of a depressive episode associated with somatic preoccupations and a gradual loss of ability to function a year prior to his admission. The symptoms described above raised the question of an organic brain syndrome associated with the psychotic depression. Some laboratory and additional examinations were performed. Serological tests for syphilis were positive for both the hemagglutination test, Treponema pallidum hemaglutination (TPHA), and the immunofluorescent antibody test, fluorescent treponemal antibody-absorption (FTA-ABS). Based on these findings, the diagnosis of neurosyphilis was made. The patient was treated with benzathine penicillin (2 400 000 units i.m. once a week) for 3 weeks and venlafaxine (150 mg daily) and olanzapine (5 mg daily). His depression disappeared gradually, and he was discharged in partial remission.

CONCLUSION

High-risk groups such as patients with neuropsychiatric diseases should be screened with serological tests so as to prevent morbidity and help eliminate syphilis.

Neurosyphilis: A Current Review

Neurosyphilis continues to be a difficult diagnosis for clinicians. The decision to perform a lumbar puncture, interpretation of cerebrospinal fluid findings, clear diagnostic guidelines, establishment of definitive therapy (including alternatives to penicillins), and approach to the follow-up of patients with neurosyphilis are all areas that pose ongoing challenges to clinicians. Coinfection with HIV has also further complicated the already challenging arena of neurosyphilis presentation, diagnosis, and management. Clinicians must recognize the recent changes in the epidemiology of syphilis and know when to initiate appropriate screening. This article highlights the limitations and controversies related to neurosyphilis diagnosis and treatment, and current recommendations on management of patients with neurosyphilis, including those coinfected with HIV.

Syphilis and HIV: a dangerous combination

HIV and syphilis affect similar patient groups and co-infection is common. All patients presenting with syphilis should be offered HIV testing and all HIV-positive patients should be regularly screened for syphilis. Syphilis agent may enhance the transmission of the other, probably through increased incidence of genital ulcers. Detection and treatment of syphilis can, therefore, help to reduce HIV transmission. Syphilis may present with non-typical features in the HIV-positive patient: there is a higher rate of symptomless primary syphilis and proportionately more HIV-positive patients present with secondary disease. Secondary infection may be more aggressive and there is an increased rate of early neurological and ophthalmic involvement. Diagnosis is generally made with serology but the clinician should be aware of the potential for false-negative serology in both primary and, less commonly, in secondary syphilis. All HIV-positive patients should be treated with a penicillin-based regimen that is adequate for the treatment of neurosyphilis. Relapse of infection is more likely in the HIV-positive patient and careful follow-up is required.

Syphilis in clinical psychiatry: a review

Syphilis is a potentially fatal infectious disease that has a long history of association with psychiatry. Recent developments in epidemiology, diagnosis, and treatment guidelines warrant a review of the current relationship of syphilis to clinical psychiatry. After a recent peak of incidence in the United States, syphilis is once again on the decline. Although the prevalence of syphilis remains endemic in certain locations, it has been targeted for elimination. Meanwhile, diagnostic testing remains complex and imperfect, especially for the detection of late stages of infection and neurosyphilis. The U.S. Public Health Service recently revised guidelines for the evaluation and management for syphilis. This paper discusses these developments and their specific implications to psychiatric practice. The likelihood of discovering previously unsuspected cases through screening and recommendations on high-risk groups to screen are discussed. A case example illustrates some of the key concepts.

Syphilitic Posterior Uveitis: Correlative Findings and Significance

Twenty-one patients with syphilitic posterior uveitis were investigated retrospectively to study the disease spectrum, associations with neurosyphilis, and therapeutic implications. Ophthalmologic manifestations of syphilitic posterior uveitis are differentiated into acute and chronic uveitides. The several distinct acute uveitic syndromes are usually florid and are associated with early syphilis, with VDRL-positive syphilitic meningitis, and frequently with human immunodeficiency virus coinfection. The chronic posterior uveitides are often insidious, a manifestation of late syphilis, and associated commonly with subclinical neurosyphilis. All patients with acute cases and 54% of patients with chronic cases in our study received penicillin therapy appropriate for neurosyphilis. The frequent association of syphilitic posterior uveitis with neurosyphilis and the analogous spirochetal sequestration beyond the blood-brain and the blood-ocular barriers suggest that all patients with syphilitic posterior uveitis, irrespective of ocular disease intensity, should undergo evaluation of cerebrospinal fluid and be treated with penicillin regimens appropriate for neurosyphilis.

Central Nervous System Opportunistic Infections in HIV-1 Infection

Neurologic disease is commonly encountered in the population infected with human immunodeficiency virus type 1 (HIV-1). Although HIV-1 is responsible for many of these neurologic complications, other organisms will affect the nervous system as the immune deficiency state progresses. With the wide use of potent antiretroviral therapy, the mortality from and incidence of opportunistic infections (OIs) among persons with advanced HIV-1 infection has decreased. Nevertheless, these diseases are still seen frequently, especially among those with limited access to new antiretroviral therapies. Therefore, it remains important to recognize the most common OIs of the central nervous system (CNS) as well as primary CNS lymphoma, which will be the focus of this review.

Nodular tertiary syphilis mimicking granuloma annulare

We describe a 47-year-old man with annular plaques on the arms and torso that were treated as granuloma annulare, based on clinical and histopathologic findings. Exacerbation of the lesions during treatment with topical corticosteroids prompted a search for an infectious cause, which proved to be syphilis in the tertiary stage. The clinician should maintain a high index of suspicion for syphilis in the differential diagnosis of unusual annular skin lesions in a patient with noncaseating granulomas seen on skin biopsy.

Missed diagnoses in consultation liaison psychiatry

In this article, an experienced consultation liaison psychiatrist presents several cases in detail that illustrate the wide range and complex natures of psychiatric patients seen on the medical and surgery floors. The cases presented appear as they would to the psychiatrist consulting within the hospital and represent a challenging test of the clinician's diagnostic skills, an experience encountered daily by the consultation liaison psychiatrist.