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Kuma A, Tadesse SA, Girma A. Meningovascular Syphilis Presenting as Acute Ischemic Stroke in an HIV + Young Adult: A Case Report and a Brief Literature Review. Int Med Case Rep J 2024; 17:581-586. [PMID: 38854842 PMCID: PMC11162190 DOI: 10.2147/imcrj.s455675] [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: 01/01/2024] [Accepted: 05/28/2024] [Indexed: 06/11/2024] Open
Abstract
Background Meningovascular syphilis, a distinct classification of neurosyphilis, has gained attention for its association with cerebral ischemia, particularly among individuals living with HIV. This unique manifestation of syphilis affects the meningeal and vascular structures of the central nervous system, leading to cerebrovascular complications. In this case report, we present the case of a young man diagnosed with neurosyphilis and HIV after presenting with an ischemic stroke. We discuss the challenges associated with diagnosing neurosyphilis, given its frequent atypical presentations that can mimic other diseases. Furthermore, we explore the management approach for these coexisting conditions. Case Presentation A right-handed male patient presented with a sudden paresis of the right upper and lower extremities, along with facial deviation to the left, and demonstrated low verbal output, limitation in constructing sentences, and conveying thoughts or ideas effectively. Upon admission, the patient's neurological examination revealed a FOUR coma scale of 16. He exhibited motor aphasia, right facial paralysis sparing the forehead, and right upper and lower extremity spastic hemiparesis with a strength of 3 out of 5 on the Medical Research Council scale. The Plantar reflex was positive on the affected side. Brain magnetic resonance imaging revealed left middle cerebral artery infarction (cortical and lenticulostriate territory acute infarction). Conclusion This case highlights the need for treating physician to have a high index of suspicion towards meningovascular syphilis as a potential cause of stroke in young individuals. This is crucial, especially when there is also a concurrent HIV infection, as it requires specific treatment.
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Affiliation(s)
- Abera Kuma
- Department of Internal Medicine, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Sinetibeb Amsalu Tadesse
- Department of Internal Medicine, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Abdulkerim Girma
- Department of Radiology, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
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2
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King CJ, Ngo TH, Constante M. Meningovascular Neurosyphilis Presenting as Multiple Ischemic Infarcts in a Young Adult. Cureus 2023; 15:e36405. [PMID: 37090294 PMCID: PMC10115213 DOI: 10.7759/cureus.36405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 04/25/2023] Open
Abstract
Neurosyphilis occurs when the spirochete Treponema pallidum invades the cerebrospinal fluid (CSF). Clinical presentation depends on an individual's immune response and invasion location, with all possible involvement of meningeal, vascular, and/or parenchymatous tissues. Meningovascular neurosyphilis occurs when both the meninges and vasculature are affected and can lead to headaches, photophobia, neck stiffness, cranial nerve palsies, and/or ischemic brain infarctions due to infectious arteritis. The following report describes the rare case of a 32-year-old male patient presenting with multiple ischemic brain infarctions of varying ages. The stepwise diagnostic approach as described allowed the medical team to reach the final diagnosis of meningovascular neurosyphilis with concomitant acquired immunodeficiency syndrome (AIDS). This case emphasizes the importance of maintaining high clinical suspicion in all young adult patients who present with acute neurological deficits.
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Affiliation(s)
| | - Teresa H Ngo
- Neurology, Western University of Health Sciences, Pomona, USA
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3
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Lu ZN, Yao SJ, Cao Y, Cheng Y, Li XT, Guo HS, Zhang XD. Aberrant gray matter structure in neurosyphilis without conventional MRI abnormality: a pilot study with voxel and surface-based morphology. Acta Radiol 2022; 64:1985-1993. [PMID: 36471581 DOI: 10.1177/02841851221142019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Zi-Ning Lu
- Graduate School, Tianjin Medical University, Tianjin, PR China
- Department of radiology, Tianjin first central hospital, Tianjin, PR China
| | - Sheng-Juan Yao
- Department of radiology, Tianjin second people's hospital, Tianjin, PR China
| | - Yu Cao
- Department of radiology, Tianjin second people's hospital, Tianjin, PR China
| | - Yue Cheng
- Department of radiology, Tianjin first central hospital, Tianjin, PR China
| | - Xiao-Tian Li
- Department of radiology, Tianjin first central hospital, Tianjin, PR China
- School of Medicine, Nankai University, Tianjin, PR China
| | - Hong-Shuai Guo
- Tianjin Key Laboratory of Cognitive Computing and Application, College of Intelligence and Computing, Tianjin University, Tianjin, PR China
| | - Xiao-Dong Zhang
- Department of radiology, Tianjin first central hospital, Tianjin, PR China
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4
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Garcia JJB, Coralde JL, Bagnas MAC, Khu KJO. Isolated Cranial Nerve VI Palsy and Neurosyphilis: A Case Report and Review of Related Literature. IDCases 2022; 27:e01377. [PMID: 35036319 PMCID: PMC8749207 DOI: 10.1016/j.idcr.2022.e01377] [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: 11/13/2021] [Revised: 01/02/2022] [Accepted: 01/04/2022] [Indexed: 11/26/2022] Open
Abstract
An isolated cranial nerve VI palsy is a rare initial manifestation of undiagnosed neurosyphilis. A 33-year-old male presented with a one month history of progressive headache and diplopia. Neurologic examination only revealed an isolated abducens palsy on the left. Cranial imaging was unremarkable. Examination of his cerebrospinal fluid revealed lymphocytic predominant leukocytosis and elevated protein. Microbiologic work-up were all negative. Further work-up revealed the patient to be serum Rapid Plasma Reagin and Enzyme Immunoassay reactive. Enzyme-linked immunosorbent assay for Human Immunodeficiency Virus also tested positive. His cerebrospinal fluid was then sent for Rapid Plasma Reagin to confirm the diagnosis of neurosyphilis. He completed 14 days of intravenous penicillin and was eventually discharged with partial resolution of the abducens palsy. We describe the second case of neurosyphilis presenting only with an isolated cranial nerve VI involvement. On further review, ours was the first case documented on an individual who had an undiagnosed Human Immunodeficiency Virus infection. There are various differentials for an isolated cranial neuritis but infectious causes, particularly neurosyphilis, should be considered among young individuals with known risk factors despite their apparently benign medical history.
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Key Words
- AIDS, Acquired Immunodeficiency Syndrome
- CALAS, Cryptococcal Antigen Latex Agglutination System
- CDC, Centers for Disease Control and Prevention
- CN, cranial nerve
- CNS, central nervous system
- CSF, erebrospinal fluid
- EIA, Enzyme immunoassay
- FTA-ABS, Fluorescent Treponemal Antibody Absorption
- HIV, Human Immunodeficiency Virus
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- RBC, red blood cells
- RPR, Rapid Plasma Reagin
- USA, United States of America
- VDRL, Venereal Disease Research Laboratory
- WBC, white blood cells
- abducens nerve
- casse report
- cranial nerve VI
- neuritis
- neurosyphilis
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Affiliation(s)
- Jao Jarro B. Garcia
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Philippines
| | - Jalea L. Coralde
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Philippines
| | | | - Kathleen Joy O. Khu
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Philippines
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5
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Pujari SS, Kulkarni RV, Duberkar D, Nirhale S, Nadgir D, Dhonde P, Sakale T, Shembalkar P, Meshram C. Neurosyphilis, A True Chameleon of Neurology. Ann Indian Acad Neurol 2021; 24:566-572. [PMID: 34728952 PMCID: PMC8513946 DOI: 10.4103/aian.aian_28_21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 01/26/2021] [Accepted: 02/12/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Neurosyphilis (NS) is a rarely encountered scenario today. Manifestations are heterogeneous, and their characteristics have changed in the antibiotic era. A differential diagnosis of NS is not commonly thought of even with relevant clinical-radiological features, as it mimics many common neurological syndromes. Objectives: To study the manifestations of NS in the present era and the process of diagnosis. Method: The data of ten patients with NS was collected and analyzed. Their background data, clinical features, investigations, the process of reaching the diagnosis, management and outcomes were recorded. Observations and Results: The manifestations of NS in our cohort included six patients with cognitive decline/encephalopathy and one each with meningitis with cranial nerve palsies, cerebellar ataxia, myelitis and asymptomatic NS. The presence of Argyll Robertson pupil helped to clinch diagnosis in one patient. Treponemal tests were ordered in two patients only after alternative etiologies were looked at, to begin with, whereas in six patients treponemal test was requested as a part of standard workup for dementia/ataxia. Conclusions: NS dementia and behavior changes are mistaken for degenerative, vascular, nutritional causes, autoimmune encephalitis or prion disease. Meningitis has similarities with infective (tubercular), granulomatous (sarcoidosis, Wegener's), collagen vascular disease and neoplastic meningitis, and myelitis simulates demyelination or nutritional myelopathy (B12 deficiency). Rarely, NS can also present with cerebellar ataxia. Contemplate NS as one of the rare causes for such syndromes, and its early treatment produces good outcomes.
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Affiliation(s)
- Shripad S Pujari
- Neurology Department, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India.,Neurology Department, Noble Hospital, Pune, Maharashtra, India
| | - Rahul V Kulkarni
- Neurology Department, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India
| | | | - Satish Nirhale
- Department of Neurology, D. Y. Patil Medical College and Hospital, Pimpri, Pune, Maharashtra, India
| | - Dattatraya Nadgir
- Neurology Department, Brain and Nerve Clinic, Neurology and Neuro- Opthalmology, Hubli, Karnataka, India
| | - Pramod Dhonde
- Neurology Department, Dhonde Hospital, Nanded, Maharashtra, India
| | - Tejas Sakale
- Neurology Department, Ashoka Medicover Hospital, Nashik, Maharashtra, India
| | - Prafulla Shembalkar
- Neurology Department, Getwell Hospital and Research Institute, Nagpur, Maharashtra, India
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6
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Wu F, Shen K, Xie YI, Wang H, Sun Y, Wang Q. Gene Expression Profiling in Human Brain Microvascular Endothelial Cells in Response to Treponema pallidum Subspecies pallidum. AN ACAD BRAS CIENC 2020; 92:e20191234. [PMID: 33331441 DOI: 10.1590/0001-3765202020191234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 02/27/2020] [Indexed: 11/22/2022] Open
Abstract
Neurosyphilis (NS) is a neurological disorder caused by Treponema pallidum subspecies pallidum (T. pallidum), but how T. pallidum attach to and cross the blood-brain barrier (BBB) and how BBB response to this bacteria remain unclear. To explore how the human brain microvascular endothelial cells (HBMECs) response to T. pallidum, the Agilent SurePrint G3 Human Gene Expression 8×60K microarray was used. The results revealed that 249 genes were differentially expressed in HBMECs infected with T. pallidum. In particular, genes encoding proteins involved in bacterial adhesion, endothelial cell activation and immune response were regulated by T. pallidum. Furthermore, Gene Ontology (GO) enrichment analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis were performed to determine the biological functions of differentially expressed genes. In summary, T. pallidum changes the gene expression profile in HBMECs, and differentially expressed genes are associated with widespread biological and pathophysiological functions. Above all, this is the first paper reporting the effects of T. pallidum on HBMECs. These data develop a new platform for further molecular experiments on the pathogenesis of NS.
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Affiliation(s)
- Fan Wu
- Department of Dermatology, Sir Run Run Hospital, Nanjing Medical University, No. 109 Longmian Road, Molin District, Nanjing, 211100, China
| | - Kangjie Shen
- The First Clinical Medical College of Nanjing Medical University, No. 818 Tianyuandong Road, Molin District, Nanjing, 211100, China
| | - Y I Xie
- The First Clinical Medical College of Nanjing Medical University, No. 818 Tianyuandong Road, Molin District, Nanjing, 211100, China
| | - Hongye Wang
- The First Clinical Medical College of Nanjing Medical University, No. 818 Tianyuandong Road, Molin District, Nanjing, 211100, China
| | - Yifan Sun
- The First Clinical Medical College of Nanjing Medical University, No. 818 Tianyuandong Road, Molin District, Nanjing, 211100, China
| | - Qianqiu Wang
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 12 Jiangwangmiao Road, Xuanwuhu District, Nanjing, 210042, China
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Lampros A, Caumes E, Psimaras D, Galanaud D, Clarençon F, Peyre M, Deltour S, Bielle F, Lhote R, Haroche J, Amoura Z, Cohen Aubart F. [Infection associated cerebral vasculitis]. Rev Med Interne 2020; 42:258-268. [PMID: 32868117 DOI: 10.1016/j.revmed.2020.05.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/26/2020] [Accepted: 05/07/2020] [Indexed: 12/11/2022]
Abstract
Infections are a frequent cause of cerebral vasculitis, important to diagnose because a specific treatment may be required. Infection-associated vasculitis can be caused by angiotropic pathogens (varicella zoster virus, syphilis, aspergillus). They can be associated with subarachnoidal meningitis (tuberculosis, pyogenic meningitis, cysticercosis). They can appear contiguously to sinuses or orbital infection (aspergillosis, mucormycosis). Finally, they also may be due to an immune mechanism in the context of chronic infections (hepatitis B virus, hepatitis C virus, human immunodeficiency virus). Cerebral vasculitis are severe conditions and their prognosis is directly linked to early recognition and diagnosis. Infectious causes must therefore be systematically considered ahead of cerebral vasculitis, and the appropriate investigations must be determined according to the patient's clinical context. We propose here an update on the infectious causes of cerebral vasculitis, their diagnosis modalities, and therapeutic options.
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Affiliation(s)
- A Lampros
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Médecine Interne 2, Centre de Référence Maladies systémiques rares et Histiocytoses, 75013 Paris, France
| | - E Caumes
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service des maladies infectieuses et tropicales, 75013 Paris, France
| | - D Psimaras
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Neurologie 2, 75013 Paris, France
| | - D Galanaud
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Neuroradiologie, 75013 Paris, France
| | - F Clarençon
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Neuroradiologie, 75013 Paris, France
| | - M Peyre
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Neurochirurgie, 75013 Paris, France
| | - S Deltour
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service des Urgences cérébro-vasculaires, 75013 Paris, France
| | - F Bielle
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Neuropathologie, 75013 Paris, France
| | - R Lhote
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Médecine Interne 2, Centre de Référence Maladies systémiques rares et Histiocytoses, 75013 Paris, France
| | - J Haroche
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Médecine Interne 2, Centre de Référence Maladies systémiques rares et Histiocytoses, 75013 Paris, France
| | - Z Amoura
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Médecine Interne 2, Centre de Référence Maladies systémiques rares et Histiocytoses, 75013 Paris, France
| | - F Cohen Aubart
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de Médecine Interne 2, Centre de Référence Maladies systémiques rares et Histiocytoses, 75013 Paris, France.
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8
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HIV Associated Risk Factors for Ischemic Stroke and Future Perspectives. Int J Mol Sci 2020; 21:ijms21155306. [PMID: 32722629 PMCID: PMC7432359 DOI: 10.3390/ijms21155306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/11/2020] [Accepted: 07/22/2020] [Indexed: 12/12/2022] Open
Abstract
Although retroviral therapy (ART) has changed the HIV infection from a fatal event to a chronic disease, treated HIV patients demonstrate high prevalence of HIV associated comorbidities including cardio/cerebrovascular diseases. The incidence of stroke in HIV infected subjects is three times higher than that of uninfected controls. Several clinical and postmortem studies have documented the higher incidence of ischemic stroke in HIV infected patients. The etiology of stroke in HIV infected patients remains unknown; however, several factors such as coagulopathies, opportunistic infections, vascular abnormalities, atherosclerosis and diabetes can contribute to the pathogenesis of stroke. In addition, chronic administration of ART contributes to the increased risk of stroke in HIV infected patients. Concurrently, experimental studies in murine model of ischemic stroke demonstrated that HIV infection worsens stroke outcome, increases blood brain barrier permeability and increases neuroinflammation. Additionally, residual HIV viral proteins, such as Trans-Activator of Transcription, glycoprotein 120 and Negative regulatory factor, contribute to the pathogenesis. This review presents comprehensive information detailing the risk factors contributing to ischemic stroke in HIV infected patients. It also outlines experimental evidence demonstrating the impact of HIV infection on stroke outcomes, in addition to possible novel therapeutic approaches to improve these outcomes.
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9
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Singh S, Puranik P, Lin E, Marti M, Liu A. Neurosyphilis in AIDS patient presenting as isolated cranial nerve 6 palsy. Clin Case Rep 2020; 8:1877-1879. [PMID: 33088510 PMCID: PMC7562863 DOI: 10.1002/ccr3.3018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 04/14/2020] [Accepted: 05/15/2020] [Indexed: 12/23/2022] Open
Abstract
Early neurosyphilis can occur in an immunocompromised host. It has a widely varied presentation. Isolated CN6 as presenting symptom has not been described.
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Affiliation(s)
| | | | - Ethan Lin
- Department of Family Practice California Hospital Medical Center Los Angeles California USA
| | - Miriam Marti
- Department of Neurology Adventist Health White Memorial Los Angeles California USA
| | - Antonio Liu
- Department of Neurology Adventist Health White Memorial Los Angeles California USA
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10
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Krishnan D, Zaini SSM, Latif KA, Joseph JP. Neurosyphilis presenting as acute ischemic stroke. Clin Med (Lond) 2020; 20:95-97. [DOI: 10.7861/clinmed.2019-0368] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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11
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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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12
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Tiwana H, Ahmed A. Neurosyphilis: mighty imitator forays with benign presentation and unique neuroimaging findings. Sex Health 2019; 15:358-360. [PMID: 29706150 DOI: 10.1071/sh17088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 12/19/2017] [Indexed: 11/23/2022]
Abstract
Background Common causes of temporal lobe hyper intensities are central nervous system infections like herpes simplex encephalitis, Lyme disease, limbic encephalitis and vascular pathology like Cerebral Autosomal Dominant Arteriopathy with Subcortical infarcts and Leukoencephalopathy. METHODS Personal assessment, laboratory data analysis and neuroimaging for the patient who was admitted to a central Pennsylvania tertiary care referral centre were conducted. RESULTS A 52-year-old male presented with a 1-year history of diffuse dysesthesia in upper and lower extremities with associated intermittent headaches and neck stiffness. Evaluation with lumbar puncture revealed increased nucleated cells (50ul) with lymphocytic predominance (96%) and an elevated protein level of 109mg/dl. Magnetic resonance imaging (MRI) of the brain showed T2/FLAIR hyper intensity in bilateral subcortical temporal white matter, left-greater-than-right and associated volume loss in cerebral parenchyma. Additional abnormal work up included reactive serum reactive plasma regain and Treponema pallidum antibody particle agglutination. Diagnosis of neurosyphilis was made and the patient was treated with intramuscular (IM) penicillin for 3 weeks. At the time of discharge, his headache and neck stiffness resolved and dysesthesias were decreased in intensity. CONCLUSIONS The diagnosis of neurosyphilis is intricate, and no reference standard exists. Neuroimaging findings of neurosyphilis commonly are cerebral infarctions, leptomeningeal enhancement or non-specific white matter lesions. Less common features on fluid-attenuated inversion recovery (FLAIR) sequences are cortical atrophy and mesial temporal parenchymal signal changes. It is prudent to keep neurosyphilis in differential of mesial temporal lobe white matter changes, as early diagnosis and treatment results in better prognosis.
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Affiliation(s)
- Harmanpreet Tiwana
- MD Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania-17033, USA
| | - Aiesha Ahmed
- MD Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania-17033, USA
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13
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Elmouden H, Louhab N, Kissani N. Medullary involvement in neurosyphilis: a report of 12 cases and a review of the literature. Spinal Cord Ser Cases 2019; 5:38. [PMID: 31632699 PMCID: PMC6786502 DOI: 10.1038/s41394-019-0185-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 04/11/2019] [Accepted: 04/11/2019] [Indexed: 01/18/2023] Open
Abstract
Study design Retrospective case series. Objectives To describe the epidemiological, clinical, MRI and therapeutic features and the outcomes of patients with syphilitic myelitis in a third-level hospital in Marrakesh in southern Morocco. Setting The Neurology Department, University Hospital Mohamed VI Marrakesh, Morocco. Methods Twelve charts of persons with syphilitic myelitis over a period of 17 years were reviewed to determine demographics, presenting symptoms, clinical and radiological findings, biological features, treatment received and outcomes. Results There were 120 reports of neurosyphilis. Twelve patients (10%) had syphilitic myelitis. Eleven patients (92%) were male with mean age of 44 at presentation. Tabes dorsalis was the most common clinical form. Cerebrospinal fluid analysis showed lymphocytic meningitis in nine patients (75%). Spine MRI was abnormal in four patients (33%). All patients were treated with 30 million units of aqueous penicillin G IV per day for 10 days, every 3 months. In follow-up, two patients (17%) with clinical syphilitic meningomyelitis improved significantly, eight patients (66%) with tabes dorsalis and subacute transverse myelitis showed partial improvement but clinical status was stationary for two patients (17%) with Erb paraplegia. Conclusions All patients with myelopathy should undergo syphilitic serology because of nonspecific manifestations and curability of this disease.
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Affiliation(s)
- Hafida Elmouden
- Neurology Department, University Hospital Mohamed VI Marrakesh, Marrakesh, Morocco
| | - Nisserine Louhab
- Neurology Department, University Hospital Mohamed VI Marrakesh, Marrakesh, Morocco
| | - Najib Kissani
- Neurology Department, University Hospital Mohamed VI Marrakesh, Marrakesh, Morocco
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14
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Katelaris AL, Janson S, Ramachandran P, Spencer E. Medial medullary stroke due to neurosyphilis in a newly diagnosed HIV-positive man. Intern Med J 2019; 48:992-995. [PMID: 30133989 DOI: 10.1111/imj.13974] [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] [Received: 12/02/2017] [Revised: 02/16/2018] [Accepted: 02/16/2018] [Indexed: 11/28/2022]
Abstract
This case report presents the clinical record of a 37-year-old man who presented with a dense right hemiplegia, found to be caused by a left medial medullary stroke. The cause of the stroke was unclear, and bacterial endocarditis was initially suspected. However, he was ultimately found to have neurosyphilis on a background of undiagnosed human immunodeficiency virus and was treated with benzylpenicillin. This case report reviews the diagnosis of neurosyphilis and highlights the importance of considering neurosyphilis as a rare but important cause of stroke, especially given the increasing prevalence of syphilis in Australia.
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Affiliation(s)
- Anthea L Katelaris
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Department of Infectious Diseases, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Sonja Janson
- Department of Infectious Diseases, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | | | - Emma Spencer
- Department of Infectious Diseases, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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15
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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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16
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Ahbeddou N, El Alaoui Taoussi K, Ibrahimi A, Ait Ben Haddou EH, Regragui W, Benomar A, Yahyaoui M. Stroke and syphilis: A retrospective study of 53 patients. Rev Neurol (Paris) 2018; 174:313-318. [PMID: 29631855 DOI: 10.1016/j.neurol.2017.07.014] [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: 11/10/2016] [Revised: 02/18/2017] [Accepted: 07/12/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The aim of this study was to describe the clinical, biological and radiological characteristics of patients with syphilitic vasculitis, and to assess the outcome after treatment. METHODOLOGY A retrospective review was carried out based on the records of patients with ischemic stroke, and reactive CSF TPHA and VDRL results. None of these patients showed symptoms of any other diseases or had received high doses of penicillin. RESULTS A total of 53 patients with stroke met the diagnostic criteria for syphilitic arteritis. Their average age was 41±12 years. Nine patients had a history of genital ulcer (17%), and the median duration of illness after presenting a chancre was 8 [range: 1-14] years. A prodromal syndrome was seen in 27 patients (50.9%) and included changes in mental status in 14 patients (26.4%), seizures in 10 cases (18.9%), headache in eight (15.1%) and memory loss in seven (13.2%). Neurological events included focal motor deficits in 29 cases (54.7%), ataxia in 11 (20.8%) and movement disorders in 15 (28.3%). HIV serology was performed in 31 patients and proved negative in every case. Disease evolution was generally favorable: 12 patients (22.6%) were autonomous at the time of hospital discharge; 29 (54.7%) had partially recovered; and only seven (13.2%) still had signs of severe sequelae. CONCLUSION A diagnosis of syphilitic stroke should be suspected in young patients as a manifestation of syphilis, and tests for neurosyphilis should be routine in neurology departments to make a prompt diagnosis, thereby preventing psychological sequelae.
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Affiliation(s)
- N Ahbeddou
- Department of Neurology and Neurogenetics "B", Université Mohamed V Souissi, 10010 Rabat, Morocco.
| | - K El Alaoui Taoussi
- Department of Neurology and Neurogenetics "B", Université Mohamed V Souissi, 10010 Rabat, Morocco
| | - A Ibrahimi
- Department of Neurology and Neurogenetics "B", Université Mohamed V Souissi, 10010 Rabat, Morocco; Medical Biotechnology Lab, CRECET, Medical & Pharmacy School, Mohamed Vth Souissi University, Rabat, Morocco
| | - E H Ait Ben Haddou
- Department of Neurology and Neurogenetics "B", Université Mohamed V Souissi, 10010 Rabat, Morocco
| | - W Regragui
- Department of Neurology and Neurogenetics "B", Université Mohamed V Souissi, 10010 Rabat, Morocco
| | - A Benomar
- Department of Neurology and Neurogenetics "B", Université Mohamed V Souissi, 10010 Rabat, Morocco
| | - M Yahyaoui
- Department of Neurology and Neurogenetics "B", Université Mohamed V Souissi, 10010 Rabat, Morocco
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17
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Jiang Y, Weng R, Zhang Y, Fan R, Liu Y, Chen Z, Peng F, Chen Y, Chen X. The performance of rapid plasma reagin (RPR) titer in HIV-negative general paresis after neurosyphilis therapy. BMC Infect Dis 2018; 18:144. [PMID: 29606102 PMCID: PMC5879544 DOI: 10.1186/s12879-018-3062-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 03/25/2018] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Repeated nontreponemal serologic test for syphilis titers is recommended to evaluate treatment response. However, it is unknown whether serum rapid plasma reagin (RPR) titer can serve as a surrogate for determining the efficacy of treatment in general paresis (GP) remains unknown. METHODS We retrospectively reviewed data from 105 GP patients, who were divided into two groups (62 CSF RPR+ patients and 43 CSF RPR- patients) according to reactive RPR test status in CSF. Clinical assessment included the Mini-Mental State Examination (MMSE) scores, CSF examinations (WBC count, protein concentration and RPR titer), and serum tests (RPR titer and TPPA). Among the 105 GP patients, 13 CSF RPR+ patients and 6 CSF RPR- patients had a 12 months follow-up of CSF, serum measures and MMSE. RESULTS The median serum RPR titer was significantly higher in CSF RPR+ patients than that in CSF RPR- GP patients, 1:8 [IQR 1:4-1:32] vs. 1:4 [IQR 1:4-1:8] (P < 0.001). The number of CSF RPR+ patients with serum RPR titer≥1:32 was significantly higher when compared with CSF RPR- patients (P = 0.001). For CSF RPR+ patients, the MMSE scores improved or remained constantly after penicillin treatment. For CSF RPR+ patients, the CSF RPR titer declined four-fold in 85% (11/13) of the patients, whereas the serum RPR titer declined four-fold in only 46% (6/13) of the patients, the odds ratio is 6.4 (95% confidence interval 1.0-41.2). CONCLUSIONS A four-fold decline in CSF RPR titer is a good predictor for treatment efficacy in CSF RPR+ GP patients within 12 months after the completion of therapy.
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Affiliation(s)
- Ying Jiang
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China.
| | - Ruihui Weng
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China
| | - Yuefeng Zhang
- Department of Neurology, Guangzhou Brain Hospital, Affiliated Brain Hospital of Guangzhou Medical University, 36 Mingxin Road, Guangzhou, Guangdong, 510370, People's Republic of China
| | - Rong Fan
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China
| | - Yulun Liu
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Zhigang Chen
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China
| | - Yong Chen
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Xiaohong Chen
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China.
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18
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Hobbs E, Vera JH, Marks M, Barritt AW, Ridha BH, Lawrence D. Neurosyphilis in patients with HIV. Pract Neurol 2018; 18:211-218. [PMID: 29478035 DOI: 10.1136/practneurol-2017-001754] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2018] [Indexed: 01/26/2023]
Abstract
Syphilis is a resurgent sexually transmitted infection in the UK that is disproportionately diagnosed in patients living with HIV, particularly in men who have sex with men. Syphilis appears to present differently in patients with HIV, particularly in those with severe immunosuppression. Progression to neurosyphilis is more common in HIV coinfection and can be asymptomatic, often for several years. The presentations of neurosyphilis vary but can include meningitis, meningovascular disease, general paresis and tabes dorsalis. There is debate about the circumstances in which to perform a lumbar puncture, and the current gold standard diagnostics have inadequate sensitivity. We recommend a pragmatic approach to lumbar punctures, interpreting investigations and deciding when to consider treatment with a neuropenetrative antibiotic regimen.
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Affiliation(s)
- Emily Hobbs
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Jaime H Vera
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK.,Lawson Unit, Royal Sussex County Hospital, Brighton, UK
| | - Michael Marks
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrew William Barritt
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK.,Hurstwood Park Neurological Centre, Haywards Heath, UK
| | - Basil H Ridha
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK.,Hurstwood Park Neurological Centre, Haywards Heath, UK
| | - David Lawrence
- Lawson Unit, Royal Sussex County Hospital, Brighton, UK.,Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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19
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Jan K, Hoe Hui Min R, Seow Yen T, Ravindra Singh S. Ischemic Stroke in an HIV Positive Patient: An Initial Presentation of Neurosyphilis. Case Rep Neurol Med 2018; 2018:2410154. [PMID: 29666731 PMCID: PMC5831235 DOI: 10.1155/2018/2410154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/21/2018] [Indexed: 11/18/2022] Open
Abstract
Ischemic stroke occurring in patients with human immunodeficiency virus (HIV) needs to be approached with a vast differential diagnosis in mind. We report a case of middle-aged male patient with immune reconstituted HIV on therapy without known cardiovascular risk factors who had a right middle cerebral artery territory infarct. After a thorough evaluation, he received a final diagnosis of neurosyphilis-associated vasculitis leading to stroke. He recovered without any neurological deficits following treatment with intravenous benzylpenicillin. Neurosyphilis is an easily diagnosed and treatable cause of a stroke that can be an initial presentation of neurosyphilis but requires a high index of suspicion.
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Affiliation(s)
- Kalimullah Jan
- Department of Medicine, Changi General Hospital, Singapore
| | | | - Tan Seow Yen
- Department of Infectious Diseases, Changi General Hospital, Singapore
| | - Shekhawat Ravindra Singh
- Department of Neurology, Changi General Hospital, Singapore
- National Neuroscience Institute, Singapore
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20
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Incidence of asymptomatic neurosyphilis in serofast Chinese syphilis patients. Sci Rep 2017; 7:15456. [PMID: 29133821 PMCID: PMC5684362 DOI: 10.1038/s41598-017-15641-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/31/2017] [Indexed: 11/20/2022] Open
Abstract
More new diagnosed syphilis cases were reported in china, the incidence and relevant factors of asymptomatic neurosyphilis (ANS) in serofast syphilis patients were unclear. Clinical and laboratory data of 402 Human Immunodeficiency Virus (HIV) negative, serofast syphilis patients, who underwent lumbar puncture at the Peking University Ditan Teaching Hospital between September 2008 and August 2016, were collected. Incidence of ANS was verified and the relevant factors were further analyzed. According to the ANS criteria, 139 (34.6%) patients had ANS. Of these, 40 (28.8%) had reactive cerebrospinal fluid (CSF), rapid plasma reagin (RPR) positive, 115 (82.7%) had CSF white blood cell (WBC) count > 5 × 106/L, 28 (20.1%) had CSF protein concentration > 45 mg/dL (without other neurological diseases). Patients aged 51–60 years, of non-Han ethnicity, with serum RPR titer 1:32 and ≥ 1:64 were 2.28-fold, 9.11-fold, 5.12-fold and 5.69-fold, respectively, more likely to have ANS. The incidence of ANS was 34.6% among Chinese serofast syphilis patients. Age, ethnicity and serum RPR titer were associated with high risk of ANS.
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21
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Benito-León J, Laurence M. The Role of Fungi in the Etiology of Multiple Sclerosis. Front Neurol 2017; 8:535. [PMID: 29085329 PMCID: PMC5650687 DOI: 10.3389/fneur.2017.00535] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 09/25/2017] [Indexed: 01/07/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disorder of the central nervous system. Infectious triggers of MS are being actively investigated. Substantial evidence supports the involvement of the Epstein-Barr virus (EBV), though other viruses, bacteria, protists, and fungi are also being considered. Many links between fungi and diseases involving chronic inflammation have been found recently. Evidence linking MS and fungi is reviewed here. The HLA-DRB1*15 allele group is the most important genetic risk factor of MS, and is a risk factor in several other conditions linked to fungal infections. Many biomarkers of MS are consistent with fungal infections, such as IL-17, chitotriosidase, and antibodies against fungi. Dimethyl fumarate (DMF), first used as an industrial fungicide, was recently repurposed to reduce MS symptoms. Its mechanisms of action in MS have not been firmly established. The low risk of MS during childhood and its moderate association with herpes simplex virus type 2 suggest genital exposure to microbes (including fungi) should be investigated as a possible trigger. Molecular and epidemiological evidence support a role for infections such as EBV in MS. Though fungal infections have not been widely studied in MS, many lines of evidence are consistent with a fungal etiology. Future microbiome and serological studies should consider fungi as a possible risk factor for MS, and future clinical studies should consider the effect of fungicides other than DMF on MS symptoms.
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Affiliation(s)
- Julián Benito-León
- Department of Neurology, University Hospital “12 de Octubre”, Madrid, Spain
- Department of Medicine, Faculty of Medicine, Complutense University, Madrid, Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
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22
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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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23
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Subacute Hypophysitis with Panhypopituitarism as First Presentation of HIV and Syphilis Coinfection. Case Rep Infect Dis 2017; 2017:1489210. [PMID: 28567314 PMCID: PMC5439250 DOI: 10.1155/2017/1489210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 03/06/2017] [Indexed: 11/18/2022] Open
Abstract
Infection by Treponema pallidum still represents a clinical challenge due to its various forms of presentation. HIV coinfection added diversity and changed the natural history of syphilis as a systemic infection. We present a rare case of subacute hypophysitis and panhypopituitarism due to an early active neurosyphilis in a previously unknown HIV coinfected patient.
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24
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Njiru E, Abdulkadir J, Kamuren Z, Kigen G. Early neurosyphilis presenting with facial palsy and an oral ulcer in a patient who is human immunodeficiency virus positive: a case report. J Med Case Rep 2017; 11:134. [PMID: 28499407 PMCID: PMC5429523 DOI: 10.1186/s13256-017-1297-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 04/18/2017] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Neurosyphilis is the tertiary stage of Treponema pallidum infection that involves the central nervous system, which occurs within days or weeks after an initial syphilis infection, especially in immunocompromised patients. The diagnosis of neurosyphilis is quite challenging as it is uncommon and often presents with obscure symptoms since any organ system may be involved. CASE PRESENTATION We describe a case of a 40-year-old African man who is human immunodeficiency virus positive with early neurosyphilis who presented with a stiff neck, headache, confusion, restlessness, and a left-sided chest pain; he did not respond to an empiric treatment of ceftriaxone and fluconazole for meningitis, and tramadol for headache. Ten days after admission, he developed generalized tonic-clonic convulsions; on examination he had ipsilateral facial nerve palsy and an oral ulcer, and responded well to benzathine penicillin treatment. CONCLUSIONS Laboratory diagnosis of neurosyphilis is challenging because to date there is no single laboratory test which is considered sensitive enough for diagnosis of the disease, especially in resource-limited settings. Clinical judgment is still an important part of diagnosis; and neurosyphilis should be considered a diagnostic differential in patients with Human Immunodeficiency Virus presenting with central nervous system involvement and in other high-risk patients.
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Affiliation(s)
- Evangeline Njiru
- Department of Internal Medicine, Moi University School of Medicine, P.O. Box 4606, 30100, Eldoret, Kenya
| | - Jamil Abdulkadir
- Department of Internal Medicine, Moi University School of Medicine, P.O. Box 4606, 30100, Eldoret, Kenya
| | - Zipporah Kamuren
- Department of Pharmacology and Toxicology, Moi University School of Medicine, P.O. Box 4606, 30100, Eldoret, Kenya
| | - Gabriel Kigen
- Department of Pharmacology and Toxicology, Moi University School of Medicine, P.O. Box 4606, 30100, Eldoret, Kenya.
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25
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Tang W, Huang S, Chen L, Yang L, Tucker JD, Zheng H, Yang B. Late Neurosyphilis and Tertiary Syphilis in Guangdong Province, China: Results from a Cross-sectional Study. Sci Rep 2017; 7:45339. [PMID: 28338084 PMCID: PMC5364404 DOI: 10.1038/srep45339] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/22/2017] [Indexed: 11/09/2022] Open
Abstract
Due to challenges in diagnosis and the need for complex laboratory tests, misdiagnosis of neurosyphilis and tertiary syphilis is common in China. We validated the diagnosis and examined the treatment of late neurosyphilis and tertiary syphilis in Guangdong Province, China. A cross-sectional study was conducted to collect data from late neurosyphilis and tertiary syphilis cases reported between 2009 and 2014 in Guangdong, China. Descriptive analysis, bivariate analyses and multiple logistic regressions were performed to determine the structural factors associated with correct diagnosis and standard treatment of late neurosyphilis and tertiary syphilis. Among the 3805 respondents (3805/3936, 96.7%), 1,837 (48.3%) met the misdiagnosed criteria. The misdiagnosis rate decreased over the study period (54.2% in 2009 and 41.8% in 2014). Only 27.1% and 24.9% of the correctly diagnosed late neurosyphilis and tertiary syphilis cases received standard treatment, respectively. Multiple logistic regression revealed that departments of dermatology or STDs [aOR = 3.24, 95% CI: 2.66-3.95], county or township level hospitals [aOR = 2.89, 95% CI: 2.14-3.89], and hospitals situated outside of Pearl River Delta area [aOR = 1.70, 95% CI: 1.46-1.97] had higher likelihood in misdiagnosis of neurosyphilis, compared to the reference groups. Targeted trainings for physicians and expanded syphilis screening services are urgently needed.
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Affiliation(s)
- Weiming Tang
- Dermatology Hospital of Southern Medical University, Guangzhou, China.,Guangdong Provincial Dermatology Hospital, Guangzhou, China.,Guangdong Center for Skin Diseases and STI Control, Guangzhou, China.,University of North Carolina Project-China, Guangzhou, China
| | - Shujie Huang
- Dermatology Hospital of Southern Medical University, Guangzhou, China.,Guangdong Provincial Dermatology Hospital, Guangzhou, China.,Guangdong Center for Skin Diseases and STI Control, Guangzhou, China
| | - Lei Chen
- Dermatology Hospital of Southern Medical University, Guangzhou, China.,Guangdong Provincial Dermatology Hospital, Guangzhou, China.,Guangdong Center for Skin Diseases and STI Control, Guangzhou, China
| | - Ligang Yang
- Dermatology Hospital of Southern Medical University, Guangzhou, China.,Guangdong Provincial Dermatology Hospital, Guangzhou, China.,Guangdong Center for Skin Diseases and STI Control, Guangzhou, China
| | - Joseph D Tucker
- University of North Carolina Project-China, Guangzhou, China
| | - Heping Zheng
- Dermatology Hospital of Southern Medical University, Guangzhou, China.,Guangdong Provincial Dermatology Hospital, Guangzhou, China.,Guangdong Center for Skin Diseases and STI Control, Guangzhou, China
| | - Bin Yang
- Dermatology Hospital of Southern Medical University, Guangzhou, China.,Guangdong Provincial Dermatology Hospital, Guangzhou, China.,Guangdong Center for Skin Diseases and STI Control, Guangzhou, China
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26
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Sabre L, Braschinsky M, Taba P. Neurosyphilis as a great imitator: a case report. BMC Res Notes 2016; 9:372. [PMID: 27465246 PMCID: PMC4964046 DOI: 10.1186/s13104-016-2176-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 07/21/2016] [Indexed: 11/18/2022] Open
Abstract
Background Neurosyphilis is defined as any involvement of the central nervous system by the bacterium Treponema pallidum. Movement disorders as manifestations of syphilis have been reported quite rarely. Case presentation We report a case of a 42-year-old Russian man living in Estonia with rapidly progressive dementia and movement disorders manifesting as myoclonus, cerebellar ataxia and parkinsonism. The mini mental state examination score was 12/30. After excluding different neurodegenerative causes, further diagnostic testing was consistent with neurosyphilis. Treatment with penicillin was started and 6 months later his mini mental state examination score was 25/30 and he had no myoclonus, parkinsonism or cerebellar dysfunction. Conclusion Since syphilis is easily diagnosed and treatable, it should be considered and tested in patients with cognitive impairment and movement disorders. Electronic supplementary material The online version of this article (doi:10.1186/s13104-016-2176-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Liis Sabre
- Department of Neurology, Neurology Clinic, Tartu University Hospital, 8 L. Puusepa Street, 51014, Tartu, Estonia. .,Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia.
| | - Mark Braschinsky
- Department of Neurology, Neurology Clinic, Tartu University Hospital, 8 L. Puusepa Street, 51014, Tartu, Estonia.,Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | - Pille Taba
- Department of Neurology, Neurology Clinic, Tartu University Hospital, 8 L. Puusepa Street, 51014, Tartu, Estonia.,Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
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27
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Benjamin LA, Bryer A, Lucas S, Stanley A, Allain TJ, Joekes E, Emsley H, Turnbull I, Downey C, Toh CH, Brown K, Brown D, Ison C, Smith C, Corbett EL, Nath A, Heyderman RS, Connor MD, Solomon T. Arterial ischemic stroke in HIV: Defining and classifying etiology for research studies. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2016; 3:e254. [PMID: 27386505 PMCID: PMC4929887 DOI: 10.1212/nxi.0000000000000254] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 05/04/2016] [Indexed: 12/13/2022]
Abstract
HIV infection, and potentially its treatment, increases the risk of an arterial ischemic stroke. Multiple etiologies and lack of clear case definitions inhibit progress in this field. Several etiologies, many treatable, are relevant to HIV-related stroke. To fully understand the mechanisms and the terminology used, a robust classification algorithm to help ascribe the various etiologies is needed. This consensus paper considers the strengths and limitations of current case definitions in the context of HIV infection. The case definitions for the major etiologies in HIV-related strokes were refined (e.g., varicella zoster vasculopathy and antiphospholipid syndrome) and in some instances new case definitions were described (e.g., HIV-associated vasculopathy). These case definitions provided a framework for an algorithm to help assign a final diagnosis, and help classify the subtypes of HIV etiology in ischemic stroke.
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Affiliation(s)
- Laura A Benjamin
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Alan Bryer
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Sebastian Lucas
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Alan Stanley
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Theresa J Allain
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Elizabeth Joekes
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Hedley Emsley
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Ian Turnbull
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Colin Downey
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Cheng-Hock Toh
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Kevin Brown
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - David Brown
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Catherine Ison
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Colin Smith
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Elizabeth L Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Avindra Nath
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Robert S Heyderman
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Myles D Connor
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
| | - Tom Solomon
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme (L.A.B., E.L.C., R.S.H.) and Department of Medicine (L.A.B., T.J.A.), University of Malawi College of Medicine, Blantyre; Institute of Infection and Global Health (L.A.B., H.E., T.S.), University of Liverpool; Walton Centre NHS Foundation Trust (L.A.B., T.S.), Liverpool, UK; Department of Medicine (A.B., A.S.), Division of Neurology, Groote Schuur Hospital, University of Cape Town, South Africa; Department of Histopathology (S.L.), St. Thomas Hospital, London; Radiology Department (E.J.) and Haematology Department (C.D., C.-H.T.), Royal Liverpool Hospital; Preston Hospital (H.E.); North Manchester General Hospital (I.T.); Virus Reference Department (K.B., D.B.) and Syphilis Reference Department (C.I.), Public Health England, London; Centre for Clinical Brain Sciences (C.S.) and Division of Clinical Neurosciences (M.D.C.), University of Edinburgh; Department of Clinical Research (E.L.C.), London School of Hygiene and Tropical Medicine, UK; National Institutes of Health (A.N.), Bethesda, MD; Division of Infection and Immunity (R.S.H.), University College London; NHS Borders (M.D.C.), Melrose, UK; School of Public Health (M.D.C.), University of the Witwatersrand, South Africa; and National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections (T.S.), Liverpool, UK
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A Singular Case of Neurosyphilis Manifesting Through a Meningovascular Chronic Inflammatory Process in Association with the Occurrence of Two Aneurysms Involving the Distal A2 Segment of Both Anterior Cerebral Arteries: A Case Report and Review of the Literature. World Neurosurg 2016; 87:662.e13-8. [DOI: 10.1016/j.wneu.2015.10.085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 10/23/2015] [Accepted: 10/24/2015] [Indexed: 11/18/2022]
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Abstract
Syphilis has reemerged as an important cause of neurological disease, affecting any part of the neuraxis at any stage of infection. What was once a dwindling diagnosis is now redoubling, particularly in the HIV-positive and in men who have sex with men populations. In the era of antibiotics and HIV coinfection, neurosyphilis presentations are protean, making diagnosis notoriously challenging. Advanced disease may be irreversible, and so early detection and treatment are ideal. Herein, we review recent advances in understanding neurosyphilis.
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Guarner J, Jost H, Pillay A, Sun Y, Cox D, Notenboom R, Workowski K. Evaluation of treponemal serum tests performed on cerebrospinal fluid for diagnosis of neurosyphilis. Am J Clin Pathol 2015; 143:479-84. [PMID: 25779998 DOI: 10.1309/ajcpwsl3g8rxmcqr] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVES We evaluated the use of treponemal serum tests in cerebrospinal fluid (CSF) to diagnose neurosyphilis since CSF-Venereal Disease Research Laboratory (VDRL) is specific but lacks sensitivity. METHODS We tested CSF specimens using the following treponemal serum tests: INNO-LIA, Treponema pallidum particle agglutination (TP-PA), Trep-Sure, and Maxi-Syph. The reference standard to calculate sensitivity and specificity was having two or more reactive/positive tests on CSF. RESULTS The reference standard group included 11 cases that fulfilled the definition of neurosyphilis (reactive CSF-VDRL plus symptoms) and three cases that did not fulfill the definition: two cases had neurologic symptoms but a nonreactive CSF-VDRL, and one had several positive CSF syphilis tests (reactive VDRL and positive treponemal and syphilis polymerase chain reaction) but no history (referred sample). Controls included 18 patients in whom a CSF-VDRL was performed the same week as patients in the reference group. The sensitivity was 85.7% (12/14) for CSF-VDRL, 92.9% (13/14) for Trep-Sure, 100% (10/10) for Maxi-Syph, 92.3% (12/13) for INNO-LIA, and 83.3% (10/12) for TP-PA. Specificity was 100% for all tests. CONCLUSIONS Treponemal serum tests performed on CSF were useful in identifying two patients with nonreactive CSF-VDRL.
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Affiliation(s)
- Jeannette Guarner
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
| | - Heather Jost
- Syphilis Laboratory Reference and Research Branch, Centers for Disease Control and Prevention, Atlanta, GA
| | - Allan Pillay
- Syphilis Laboratory Reference and Research Branch, Centers for Disease Control and Prevention, Atlanta, GA
| | - Yongcheng Sun
- Syphilis Laboratory Reference and Research Branch, Centers for Disease Control and Prevention, Atlanta, GA
| | - David Cox
- Syphilis Laboratory Reference and Research Branch, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Kimberly Workowski
- Program Development and Quality Improvement Branch, Centers for Disease Control and Prevention, Atlanta, GA
- Department of Medicine, Emory University, Atlanta, GA
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Stroke after Initiating IV Penicillin for Neurosyphilis: A Possible Jarisch-Herxheimer Reaction. Case Rep Neurol Med 2014; 2014:548179. [PMID: 25431710 PMCID: PMC4238263 DOI: 10.1155/2014/548179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 09/29/2014] [Accepted: 10/13/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction. Syphilis incidence has increased in the US in the last decade. Jarisch-Herxheimer reaction (JHR) is a well-documented adverse effect of penicillin treatment in syphilis. Stroke has not been reported as part of its phenomenology. Case Report. A 57-year-old man presented with worsening memory. His minimental status examination score was 14/30. Serum RPR test was positive and VDRL test in the CSF was reactive. Within six hours of first dose of IV crystalline penicillin G, he was found to have hemineglect and difficulty moving the left leg. MRI of the brain showed multiple acute ischemic strokes. Immediate MRA ruled out vascular occlusion. Penicillin treatment was stopped. Four hours later, he was found to be febrile and had two episodes of generalized tonic-clonic seizures. Conclusions. We report a case of confirmed neurosyphilis with no known modifiable stroke risk factors, who developed acute ischemic stroke and other constitutional symptoms consistent with JHR after IV penicillin. This is the first reported case in literature where an acute ischemic stroke can be attributed to Jarisch-Herxheimer reaction. Given an increase in incidence of syphilis in recent years, our case underlies the importance of keeping in mind potential catastrophic drug adverse reactions in neurosyphilis patients.
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Arentzen M, Jubt F, Evers S, Hesselmann V, Fiori W, Reichelt D, Oelker-Grueneberg U, Schwindt W, Dziewas R, Husstedt IW. Cerebrovascular events in HIV-infected patients: an analysis of a cohort of 3203 HIV+ patients during the times of cART. Int J Neurosci 2014; 125:601-11. [PMID: 25158008 DOI: 10.3109/00207454.2014.956870] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE/AIM Cerebrovascular events (CVE) in HIV infected patients have become an increasingly relevant neurological complication. Data about the prevalence and clinical features of CVE in HIV infected patients since the introduction of combined Anti-Retroviral Therapy (cART) are rare. METHODS A retrospective study of HIV-infected patients with a CVE was performed from 2002 to 2011. During this time period 3203 HIV-infected patients were admitted to the University hospital of Münster, Germany. All patients had access to regular and long term treatment with cART. The clinical features were analyzed and the prevalence of ischemic stroke (IS), transient ischemic attack (TIA) and intracerebral bleeding (ICB) was calculated. RESULTS The total prevalence of all CVE was at 0.6% (95% CI: 0.3, 0.8) (0.4% for IS (95% CI: 0.2, 0.6), 0.2% for TIA (95% CI: 0.0, 0.3) and 0.1% for ICB (95% CI: 0.0, 0.2)) and the crude annual incidence rate at 59 per 100.000 for all events. The median CD4 cell count was 405/μl (25th to 75th percentile: 251-568). The majority of patients had AIDS. The median age was at 49 years (25th to 75th percentile: 40-69). Some events were associated with HIV-associated vasculopathy or viral co-infections. Most patients presented with multiple vascular risk factors. CONCLUSION The study confirms that CVE occur in HIV-infected patients with a good immune status and at a young age. HIV infection has to be considered in young stroke patients. The rate of CVE in this study was constant when comparing to the pre-cART era. HIV associated vasculopathy and viral co-infections need to be considered in the diagnostics of stroke.
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Affiliation(s)
- Max Arentzen
- 1Department of Neurology, University of Münster, Germany
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Abstract
OBJECTIVE Neurosyphilis is caused by dissemination into the central nervous system of Treponema pallidum. Although the incidence of syphilis in the Netherlands has declined since the mid-1980s, syphilis has re-emerged, mainly in the urban centres. It is not known whether this also holds true for neurosyphilis. METHODS The epidemiology of neurosyphilis in Dutch general hospitals in the period 1999-2010 was studied in a retrospective cohort study. Data from the Dutch sexually transmitted infection (STI) clinics were used to analyse the number of patients diagnosed with syphilis in this period. RESULTS An incidence of neurosyphilis of 0.47 per 100 000 adults was calculated, corresponding with about 60 new cases per year. This incidence was higher in the western (urbanised) part of the Netherlands, as compared with the more rural areas (0.6 and 0.4, respectively). The number of patients diagnosed with syphilis in STI clinics increased from 150 to 700 cases in 2004 and decreased to 500 new cases in 2010. The sex ratio was in favour of men, yielding a percentage of 90% of the syphilis cases and of 75% of the neurosyphilitic cases. The incidence of neurosyphilis was highest in men aged 35-65 years, and in women aged 75 years and above. The most frequently reported clinical manifestation of neurosyphilis was tabes dorsalis. In this study, 15% of the patients were HIV seropositive. CONCLUSION The incidence of neurosyphilis in a mixed urban-rural community such as the Netherlands is comparable to that in other European countries. Most patients are young, urban and men, and given the frequent atypical manifestations of the disease reintroduction of screening for neurosyphilis has to be considered.
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Abstract
OBJECTIVE To consider associations between the latest/nadir CD4 cell count, and time spent with CD4 cell count less than 200 cells/μl (duration of immune depression), and myocardial infarction (MI), coronary heart disease (CHD), stroke, or cardiovascular disease (CVD) (CHD or stroke) in 33 301 HIV-positive individuals. DESIGN Longitudinal cohort study. METHODS Analyses were undertaken using Poisson regression. To investigate whether analyses of stroke were robust to the type of endpoint, we additionally included stroke-like events and rejected strokes into the stroke endpoint. RESULTS Participants experienced 716 MI, 1056 CHD, 303 stroke, and 1284 CVD events. Whereas there was no evidence of a higher MI/CHD risk in those with lower latest/nadir CD4 cell counts after adjustment [current CD4 <100 cells/μl: relative rate (95% confidence interval) 0.96 (0.62-1.50) for MI, 0.89 (0.30-2.36) for CHD; nadir CD4 <100 cells/μl: 1.36 (0.57-3.23) for MI, 0.98 (0.45-2.16) for CHD], stroke and CVD rates were higher in those with a latest CD4 cell count less than 100 cells/μl [2.26 (1.29-3.94) and 1.14 (0.84-1.56), respectively]. All events occurred less frequently in those who had not experienced immune depression, although evidence for a linear association with duration of immune depression was weak. The association between stroke risk and the latest CD4 cell count strengthened as stroke-like and rejected strokes were included; conversely, associations with established stroke risk factors weakened. CONCLUSION We do not find strong evidence that HIV-positive individuals with a low CD4 cell count are more likely to experience MI/CHD. Although strokes appear to occur more commonly at low CD4 cell counts, this may be partly explained by misclassification or other biases.
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Abstract
Bacterial CNS infections comprise a wide spectrum of diseases, which may be acquired outside or inside the hospital, affect immunocompetent or immunocompromised patients, and be associated with trauma or procedures, as well as other exposures.
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Affiliation(s)
- Katharina M Busl
- Department of Neurological Sciences, Section of Neurocritical Care, Rush University Medical Center, 1725 West Harrison Street, POB Suite 1121, Chicago, IL, 60612, USA,
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Acute hypophysitis and hypopituitarism in early syphilitic meningitis in a HIV-infected patient: a case report. BMC Infect Dis 2013; 13:481. [PMID: 24134407 PMCID: PMC3853997 DOI: 10.1186/1471-2334-13-481] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 10/14/2013] [Indexed: 11/10/2022] Open
Abstract
Background Sexually transmitted diseases and most notably syphilis-infections are rising amongst men who have sex with men. In HIV-co-infected patients, an accelerated clinical course of syphilis neurological involvement is known. Case presentation A 46 year old HIV-positive male patient came in to our emergency department in the late evening with acute fever, rapidly progressive cephalgia and photophobia. Palmar skin efflorescence was evocative of an active syphilis infection. A reactive Treponema pallidum particle agglutination (TPPA) assay with positive Treponema pallidum-specific IgG/IgM immunofluorescence as well as a highly reactive Veneral diseases research laboratory (VDRL) test confirmed the diagnosis. Liquor pleocytosis, liquor protein elevation and a highly positive VDRL test in cerebrospinal fluid (CSF) were interpreted in context of the clinical symptoms as neurosyphilitic manifestations within an early syphilis infection (stage II). Cranial nuclear magnetic resonance scans of the sella turcica, which were performed due to low thyroidea stimulation hormone (TSH) and thyroxin levels, showed signs of hypophysitis such as pituitary gland enlargement and inhomogeneous contrast enhancement. Advanced endocrine laboratory testing revealed hypopituitarism. Fourteen days of intravenous ceftriaxone treatment and levothyroxine- and hydrocortisone-substitution led to complete disappearance of all clinical symptoms. Two months later, nuclear magnetic resonance scan showed normal pituitary size and that the syphilis serology had normalized. Conclusion We report to the best of our knowledge the first case of a HIV-positive patient with acute hypophysitis and hypopituarism due to early neurosyphilis infection. Ceftriaxone treatment and levothyroxine- and hydrocortisone-substitution led to the disappearance of all clinical symptoms. We strongly recommend to exclude syphilis infection in every clinical situation unclear in HIV-patients, especially when additional risk factors are known.
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[A case of neurological syphilis mimicking Horton's disease and polymyalgia rheumatica]. Ann Dermatol Venereol 2013; 140:619-22. [PMID: 24090892 DOI: 10.1016/j.annder.2013.04.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 03/18/2013] [Accepted: 04/10/2013] [Indexed: 11/21/2022]
Abstract
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.
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Chien LN, Chi NF, Hu CJ, Chiou HY. Central nervous system infections and stroke -- a population-based analysis. Acta Neurol Scand 2013; 128:241-8. [PMID: 23550811 DOI: 10.1111/ane.12116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chronic central nervous system (CNS) infections have been found to associate with cerebrovascular complications. Acute CNS infections are more common than chronic CNS infections, but whether they could increase the risk of vascular diseases has not been studied. METHODS The study cohort comprised all adult patients with diagnoses of CNS infections from Taiwan National Health Insurance Research Database during 2000-2009 (n = 533). The comparison group were matched by age, sex, urbanization, diagnostic year, and vascular risk factors of cases (cases and controls = 1:5). Patients were tracked for at least 1 year. Kaplan-Meier analysis was used to compare the risk of stroke and acute myocardial infarction (AMI) after adjusting censoring subjects. RESULTS After adjusting the patients demographic characteristics and comorbidities, the risk of patients with CNS infections developing stroke was 2.75-3.44 times greater than their comparison group. More than 70% of the stroke events were occurring within 1 year after CNS infections. The risk of AMI was not found as we compared patients with and without CNS infections. CONCLUSIONS The population-based cohort study suggested that adult patients with CNS infections have higher risk to develop stroke but not AMI, and the risk is marked within a year after infections.
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Affiliation(s)
- L.-N. Chien
- School of Health Care Administration; College of Public Health and Nutrition; Taipei Medical University; Taipei; Taiwan
| | | | | | - H.-Y. Chiou
- School of Public Health; College of Public Health and Nutrition; Taipei Medical University; Taipei; Taiwan
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Pastuszczak M, Wojas-Pelc A. Current standards for diagnosis and treatment of syphilis: selection of some practical issues, based on the European (IUSTI) and U.S. (CDC) guidelines. Postepy Dermatol Alergol 2013; 30:203-10. [PMID: 24278076 PMCID: PMC3834708 DOI: 10.5114/pdia.2013.37029] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 06/18/2013] [Accepted: 06/23/2013] [Indexed: 01/15/2023] Open
Abstract
Syphilis continues to be an important epidemiologic problem. For a few years a steady increase in the incidence of this sexually transmitted disease has been observed. Advances in medical science obligate the doctor to use only such diagnostic and therapeutic approaches that are scientifically proven. Based on the European (IUSTI) and U.S. (CDC) guidelines, in this manuscript, we present some selected practical issues concerning diagnosis and treatment of syphilis. We truly hope that the present review will help all doctors taking care of syphilitic patients to systematize the current knowledge.
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Affiliation(s)
- Maciej Pastuszczak
- Department of Dermatology, Jagiellonian University Medical College, Krakow, Poland. Head: Prof. Anna Wojas-Pelc MD, PhD
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GORODNICHEV PV, KLEMENOVA IA, BELOVA AN, MISHANOV VR. Current clinical and epidemiological features of neurosyphilis. VESTNIK DERMATOLOGII I VENEROLOGII 2012. [DOI: 10.25208/vdv750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
The authors present the results of the analysis of the dynamics of the neurosyphilis incidence rate based on the state statistical reporting data in the Volga Federal District in 2003—2011. According to the authors, there is a growth in new neurosyphilis cases against the background of the reduced incidence rate of syphilis. The authors also revealed that late forms of neurosyphilis dominate in the neurosyphilis incidence structure. They conducted an analysis of anamnestic and clinical data of patients who were diagnosed with neurosyphilis, and discovered and a number of particular features in the current clinical picture of the disease. According to the authors, basal meningitis mainly affecting the optic, oculomotor and eighth cranial nerve is diagnosed most often in case of early-onset neurosyphilis. Latent and often mono-symptom forms with prevalent intellectual, memory and emotional-volitional disorders are characteristic of late neurosyphilis.
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Benjamin LA, Bryer A, Emsley HCA, Khoo S, Solomon T, Connor MD. HIV infection and stroke: current perspectives and future directions. Lancet Neurol 2012; 11:878-90. [PMID: 22995692 PMCID: PMC3460367 DOI: 10.1016/s1474-4422(12)70205-3] [Citation(s) in RCA: 181] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
HIV infection can result in stroke via several mechanisms, including opportunistic infection, vasculopathy, cardioembolism, and coagulopathy. However, the occurrence of stroke and HIV infection might often be coincidental. HIV-associated vasculopathy describes various cerebrovascular changes, including stenosis and aneurysm formation, vasculitis, and accelerated atherosclerosis, and might be caused directly or indirectly by HIV infection, although the mechanisms are controversial. HIV and associated infections contribute to chronic inflammation. Combination antiretroviral therapies (cART) are clearly beneficial, but can be atherogenic and could increase stroke risk. cART can prolong life, increasing the size of the ageing population at risk of stroke. Stroke management and prevention should include identification and treatment of the specific cause of stroke and stroke risk factors, and judicious adjustment of the cART regimen. Epidemiological, clinical, biological, and autopsy studies of risk, the pathogenesis of HIV-associated vasculopathy (particularly of arterial endothelial damage), the long-term effects of cART, and ideal stroke treatment in patients with HIV are needed, as are antiretrovirals that are without vascular risk.
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Affiliation(s)
- Laura A Benjamin
- Brain Infections Group, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- Malawi-Liverpool-Wellcome Major Overseas Clinical Research Programme, Blantyre, Malawi
- Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Alan Bryer
- Division of Neurology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Hedley CA Emsley
- Royal Preston Hospital, Preston, UK
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Saye Khoo
- Tropical and AIDS Related Disease Research Group, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Tom Solomon
- Brain Infections Group, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
- Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Myles D Connor
- NHS Fife, Kirkaldy, UK
- Division of Clinical Neuroscience, University of Edinburgh, Edinburgh, UK
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients. J Neurol Sci 2012; 317:35-9. [PMID: 22482824 DOI: 10.1016/j.jns.2012.03.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 03/08/2012] [Accepted: 03/12/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Neurosyphilis is known as "the great imitator" or "the great impostor" because of its wide range of clinical symptoms. A high misdiagnosis rate of ischemic stroke was observed among neurosyphilis patients in clinical practice, which prevents patients from receiving the most appropriate treatment, and often results in more severe neurologic damage. METHODS A total of 149 neurosyphilis patients were retrospectively reviewed. The control group comprised 1570 non-neurosyphilitic ischemic stroke patients. The proportion of patients with ischemic stroke as the primary symptom of the different types of neurosyphilis and the misdiagnosis rate of neurosyphilitic ischemic stroke were analyzed, including the risk factors for cardiovascular disease. RESULTS Among the 149 neurosyphilis patients, 21 (14.09%) developed ischemic stroke as a primary symptom, including three cases of syphilitic meningitis and 18 cases of meningovascular neurosyphilis. Only four of the neurosyphilis patients had histories of ischemic stroke and recurrence. The other 17 cases were treated for the first time in the emergency department; however, none of the patients were initially suspected of neurosyphilitic ischemic stroke. All of the patients were only diagnosed with neurosyphilis during their follow-up treatment. The misdiagnosis rate of neurosyphilitic ischemic stroke was as high as 80.95% (17/21). Furthermore, except for hypertension, no significant differences in cardiovascular risk factors were observed between the groups (P>0.05). CONCLUSIONS In clinical practice, particularly during emergencies, any ischemic stroke patient should be screened for neurosyphilis.
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Yri H, Wegener M, Jensen R. Syphilis mimicking idiopathic intracranial hypertension. BMJ Case Rep 2011; 2011:bcr.09.2011.4813. [PMID: 22674114 DOI: 10.1136/bcr.09.2011.4813] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a condition of yet unknown aetiology affecting predominantly obese females of childbearing age. IIH is a diagnosis of exclusion as raised cerebrospinal fluid pressure may occur secondary to numerous other medical conditions. An atypical phenotype or an atypical disease course should alert the physician to reevaluate a presumed IIH-diagnosis. The authors report a case of a 32-year-old non-obese male with intracranial hypertension, secondary to a syphilitic central nervous system infection, initially misdiagnosed as being idiopathic. Upon relevant antibiotic treatment, signs and symptoms of elevated intracranial pressure resolved completely. Syphilis is a rare, but very important, differential diagnosis that in this case was clinically indistinguishable from IIH.
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Affiliation(s)
- Hanne Yri
- Neurology Department, Glostrup University Hospital, Glostrup, Denmark.
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