Neurosyphilis: mighty imitator forays with benign presentation and unique neuroimaging findings

Neurosyphilis with sequential respiratory complications: A case report highlighting diagnostic and treatment challenges

In this case report, we describe the presentation and clinical course of a 25-year-old male with a complex medical history and a fatal outcome due to neurosyphilis. The diagnosis of neurosyphilis-related complications. Neurosyphilis, a variant of tertiary syphilis, is a rare condition but can present with a wide range of neurological symptoms. This makes its diagnosis challenging. The study aims to report and discuss neurosyphilis in a young male, resulting in respiratory complications, and explore the clinical presentation, diagnostic and process, treatment challenges it poses to a tertiary care setup of a third-world country regimen, and the profound significance of this particular case.

Serological testing for syphilis in the differential diagnosis of cognitive decline and polyneuropathy in geriatric patients

BACKGROUND

In the 19th century, neurosyphilis was the most frequent cause of dementia in Western Europe. Now dementia caused by syphilis has become rare in Germany. We studied whether routine testing of patients with cognitive abnormalities or neuropathy for antibodies against Treponema pallidum has therapeutic consequences in geriatric patients.

METHODS

A Treponema pallidum electrochemiluminescence immunoassay (TP-ECLIA) is routinely performed in all in-patients treated at our institution with cognitve decline or neuropathy and no or insufficient previous diagnostic workup. Patients with a positive TP-ECLIA treated from October 2015 to January 2022 (76 months) were retrospectively evaluated. In cases of positive TP-ECLIA, further specific laboratory investigations were performed to assess whether antibiotic therapy was indicated.

RESULTS

In 42 of 4116 patients (1.0%), TP-ECLIA detected antibodies directed against Treponema in serum. Specifity of these antibodies was ensured by immunoblot in 22 patients (11 × positiv, 11 × borderline values). Treponema-specific IgM was detectable in the serum of one patient, in 3 patients the Rapid Plasma Reagin (RPR) test, a modified Venereal Disease Research Laboratory test (VDRL), in serum was positiv. CSF analysis was performed in 10 patients. One patient had CSF pleocytosis. In 2 other patients, the Treponema-specific IgG antibody index was elevated. 5 patients received antibiotic therapy (4 × ceftriaxone 2 g/d i.v., 1 × doxycycline 300 mg/d p.o.).

CONCLUSION

In approx. 1‰ of patients with previously undiagnosed or not sufficiently diagnosed cognitive decline or neuropathy, the diagnostic workup for active syphilis resulted in a course of antibiotic treatment.

Neurosyphilis with ocular involvement and normal magnetic resonance imaging results affirmed by metagenomic next-generation sequencing

The rapid and accurate identification of pathogenic agents is the key to guide clinicians on diagnosis and medication, especially for intractable diseases, such as neurosyphilis. It is extremely challenging for clinicians to diagnose neurosyphilis with no highly sensitive and specific test available. It is well known that the early transmission and immune evasion ability of Treponema pallidum have earned it the title of "stealth pathogen." Neurosyphilis has complex clinical manifestations, including ocular involvement, which is infrequent and often overlooked, but its neuroimaging results may be normal. Therefore, it is important to find a new test that can detect the presence or absence of Treponema pallidum immediately for the diagnosis of neurosyphilis. We reviewed all the patients admitted to the Sichuan Provincial People's Hospital between 2021 and 2022 who had ocular involvement and whose clinical samples were examined via metagenomic next-generation sequencing (mNGS), and we found 10 candidates for further analysis. The results of magnetic resonance imaging (MRI) were normal for four patients, and three of them met the diagnostic criteria for neurosyphilis confirmed by mNGS. In addition, the results of mNGS from the three patients were further validated using polymerase chain reaction (PCR). Five of the 10 patients had diplopia manifestations; two (20%) experienced abducens nerve palsies, two (20%) had eyelid drooping, and one (10%) had decreased vision. One of the 10 patients (10%) who was HIV positive and five patients had abnormal MRI results. To our knowledge, Treponema pallidum was detected by mNGS in patients with ocular involvement and normal MRI results for the first time. Given this situation, we recommend mNGS as a potential and supplementary tool for the diagnosis and differential diagnosis of neurosyphilis.

Comparison of Electroencephalography in Patients With Seizures Caused by Neurosyphilis and Viral Encephalitis

Background

Neurosyphilis (NS) lacks specificity in clinical and imaging features, and patients are frequently misdiagnosed as viral encephalitis when they present with seizures. This study aimed to compare electroencephalography (EEG) in patients with seizures resulting from the two diseases and provide guidance for differential diagnosis.

Methods

A retrospective study on patients diagnosed with neurosyphilis and viral encephalitis with seizures in the Department of Neurology, Zhongshan Hospital, Xiamen University from 2012 to 2020.

Results

A total of 39 patients with seizures caused by neurosyphilis and 40 patients with seizures caused by viral encephalitis were included. Chi-square test analysis showed that compared with patients with viral encephalitis, patients with neurosyphilis mainly developed in middle-aged and elderly people (p < 0.001), were more likely to have temporal epileptiform discharges (p < 0.001), and less likely to have status epilepticus (SE) (p = 0.029). There was difference between two groups in the EEG performance of lateralized periodic discharges (LPDs) (p = 0.085). The two groups were matched for age and sex by case-control matching, and 25 cases in each group were successfully matched. Patients with neurosyphilis were more likely to have temporal epileptiform discharges than those with viral encephalitis (p = 0.002), and there were no significant differences in LPDs (p = 0.077) and SE (p = 0.088) between two groups.

Conclusion

When EEG shows temporal epileptiform discharges, especially in the form of LPDs, we should consider the possibility of neurosyphilis.

Study on the Features of Clinical Imaging Diagnosis of Arteriosclerotic Encephalopathy

This paper discusses the imaging diagnostic features of arteriosclerotic encephalopathy and combines the spatial context information of local features to study the clinical imaging image copy detection algorithm. Moreover, this paper proposes a clinical imaging copy detection algorithm that combines the BOW model and spatial context embedding and a clinical imaging copy detection algorithm that combines the BOW model and global context verification. In addition, this paper applies the algorithm to the imaging diagnostic features of arteriosclerotic encephalopathy and sets up a controlled experiment to start research. The experimental research shows that the application of imaging diagnosis to the detection of subcortical arteriosclerotic encephalopathy has good clinical effects and rapid remission of patients' symptoms. The effectiveness of this method can be verified by a large number of clinical practices in follow-up studies.

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.

Clinical, laboratory and brain Magnetic Resonance Imaging (MRI) characteristics of asymptomatic and symptomatic HIV-negative neurosyphilis patients

INTRODUCTION

There are few studies concerning the differences between asymptomatic neurosyphilis (ANS) and symptomatic neurosyphilis (SNS). This study aimed to summarize clinical, laboratory and brain Magnetic Resonance Imaging (MRI) characteristics of HIV-negative patients with ANS and SNS.

METHODS

Data from 43 HIV-negative patients with ANS and 59 HIV-negative patients with SNS were retrospectively collected from our hospital between December 2012 and December 2018.

RESULTS

Compared with the ANS group, SNS group had more patients that were male, age≥45 years, had brain MRI abnormalities, and exhibited higher serum/cerebrospinal fluid (CSF) TRUST titer, CSF WBC count, CSF protein concentration (P < 0.05). Multivariate regression analysis revealed that male sex, age ≥45 years and CSF TRUST titer were risk factors for SNS [odds ratio (OR) = 7.946,P = 0.001;OR = 3.757, P = 0.041; OR = 2.713, P = 0.002; respectively]. The brain MRI findings of 78 patients without comorbidities showed that ischemic infarct lesions presented in 17/37 (45.95%) of patients with ANS; infarct ischemic stroke (73.17%) especially multiple cerebral infractions (46.34%), cerebral atrophy (48.78%) were also common presentations in the SNS group.

CONCLUSIONS

Patients with HIV-negative ANS and SNS presented different clinical, laboratory and brain MRI features. Male sex, age ≥45 years and elevated CSF TRUST titer may have an increased risk of developing neurological symptoms. Brain MRI abnormalities may present prior to clinical symptoms. Multiple cerebral infarctions without explained reasons or cerebral atrophy should alert clinicians the possibility of SNS.

German guidelines on the diagnosis and treatment of neurosyphilis

Introduction

In view of the importance of neurosyphilis and the difficulties encountered in diagnosing it, the S1 guideline "Neurosyphilis" has been published by the German Society for Neurology (DGN) in accordance with the stipulations of the Association of the Scientific Medical Societies in Germany (AWMF). The present article is an abridged translation of that German guideline.

Main recommendations

(a) Neurosyphilis can manifest as early neurosyphilis (meningitis, meningovascular neurosyphilis or syphilitic gummas) or late neurosyphilis (tabes dorsalis, general paresis). (b) The following diagnostic criteria help to establish the presence of probable neurosyphilis (always point iv, accompanied by any two of points i to iii): (i) subacute or chronic neuro-psychiatric symptoms; (ii) increased cerebrospinal fluid (CSF) cell count or signs of blood-CSF barrier disruption; (iii) positive effect of anti-neurosyphilis antibiotic therapy on clinical course and CSF findings; (iv) positive TPHA/TPPA or FTA test in serum. (c) The diagnosis of neurosyphilis is confirmed by the subsequent detection of intrathecal production of antibodies against Treponema pallidum. (d) In neurosyphilis, treatment with intravenous penicillin or ceftriaxone for 14 days is recommended. (e) The following parameters can be used to assess a therapeutic effect: clinical findings, serum VDRL, and CSF cell count.

Conclusion

The German guideline on the diagnosis and treatment of neurosyphilis is a practical tool to support clinicians in diagnosing and treating patients with neurosyphilis. This article is an abridged translation of this guideline (Klein MW, J.; Angstwurm, K.; Esser, S.; Hahn, K.; Matschke, M.; Scheithauer, S.; Schoefer, H.; Sturzenegger, M.; Wildemann, B. Neurosyphilis, S1-Leitlinie. Deutsche Gesellschaft für Neurologie, Leitlinien für Diagnostik und Thearpie in der Neurologie 2020).

Neurosyphilis in the modern era: Literature review and case series

The term of neurosyphilis (NS) refers to infection of central nervous system by Treponema pallidum. Classically, it has been divided into early (meningitis, meningovascular) and late forms (general paresis and tabes dorsalis). The availability of penicillin and high sensitivity of Treponema pallidum to this antibiotic has led to a widely held perception about rarity of syphilitic forms with central nervous system involvement. However, patient can exhibit atypical clinical presentation. Recently different clinical cases with autoimmune encephalitis-mimicking presentation or atypical movement disorders were described. In this article we presented clinical case series with different clinical and MRI presentation and discuss diagnostic and treatment challenges. During our screening period at neurological department we revealed 6 NS cases. Three of them have an atypical presentation. The first patient was misdiagnosed as acute disseminated encephalomyelitis, the second patient had hippocampal sclerosis and epileptic seizures. Another patient had cognitive decline and autoimmune encephalitis-like MRI lesions. We put an emphasis on widening of indication for lumbar puncture and NS tests in patients with syphilitic anamnesis and neurological manifestations.