Cerebral gumma showing linear dural enhancement on magnetic resonance imaging--Case report

[A clinical suspected case of cerebral syphilitic gumma showing spontaneous regression]

A 46-years-old man who complained of headache for 4 months was transported our hospital due to vertigo and nausea. Gadolinium-enhanced T₁WI showed ring-like enhancements in the right pedunculus cerebellaris medius and left frontal lobe on the brain surface. Additionally, FLAIR images showed high intensity area indicating perilesional edema. We diagnosed the patient as neurosyphilis with his serum and cerebrospinal fluid findings, and considered him as cerebral syphilitic gumma because of brain MRI findings. An HIV test was negative. Follow-up MRI before treatment demonstrated spontaneous regression of these lesions, and after intravenous treatment with penicillin G for 14 days complete regression. Since then, he has had no sign of recurrence. Although there are some characteristic brain MRI findings of cerebral syphilitic gumma, spontaneous regression of these lesions in this case was an unusual finding.

Syphilitic Gummata in the Central Nervous System: A Narrative Review and Case Report about a Noteworthy Clinical Manifestation

Infection with Treponema pallidum is on the rise. In this narrative literature review, we show that the incidence of rare manifestations of syphilis, such as intracerebral gummata, is increasing and should be considered in the differential diagnosis of intracerebral lesions. With the exemplary case that we present here, we aim to raise awareness of the resurgence of this disease, which should be considered in the differential diagnosis of intracerebral lesions, especially for patients who have a risk profile for syphilis, and serological testing for T. pallidum prior to surgery should be discussed in order to avoid an unnecessary operation.

[Neurosyphilis with cerebellar ataxia, personality change and cognitive decline one year after onset of cerebral infarction]

A 51-year-old man with a cerebral lacunar infarction of the midbrain that had occurred two years before, was transferred from a regional psychiatric hospital with chronic progressive psychiatric symptoms including cognitive decline, irritability and hallucinations. Neurological examinations upon admission revealed cerebellar ataxia including dysarthria, ataxic gait and bilateral intention tremor. Brain FLAIR MRI on day 2 revealed abnormal hyperintense lesions in the bilateral insular cortex and temporal pole. Treponemal and non-treponemal specific antibodies were positive in both serum and cerebrospinal fluid (CSF), indicating a diagnosis of neurosyphilis. Treatment with intravenous penicillin (24 × 10⁶ units/day × 28 days) improved his psychiatric symptoms, ataxia, imaging abnormalities and inflammatory CSF findings. Cerebellar ataxia is a rare symptom of neurosyphilis. Nonetheless, the possibility of neurosyphilis should be considered if a young adult ataxia accompanied by psychiatric symptoms.

Occipital lobe gumma: a case report and review of the literature

Syphilis has plagued humanity for thousands of years. Despite the measures of precaution against its transmission and the advancement of modern pharmacology, late-stage phenomena like intracerebral gumma are not uncommon even today. We present a complex case, which has misled the physicians twice. Additionally, we performed a review of the contemporary literature about the common location, clinical findings and up-to-date treatment of intracerebral gummas.

Neurosyphilis

No portion of the central nervous system is immune to the ravages of syphilis. Infection by Treponema pallidum can affect the meninges, brain, brainstem, spinal cord, nerve roots, and cerebral and spinal blood vessels. As a consequence, the disease may present in diverse and, at times, diagnostically challenging fashions. Neurologic manifestations of syphilis may develop within months of the initial infection or, alternatively, take decades to appear. Although approximately one-third of individuals infected by T. pallidum display cerebrospinal fluid abnormalities suggestive of invasion of the central nervous system by the organism, only a fraction of these develop clinically significant neurologic manifestations. The features of neurosyphilis may be modified by the concomitant presence of immunosuppressive agents or conditions such as HIV/AIDS. The epidemiology of neurosyphilis has largely paralleled that of syphilis in general. A dramatic decline occurred by the early 1950s as a consequence of public health measures and the widespread use of antibiotics. The incidence had increased by the onset of the AIDS pandemic and has since corresponded with the adoption of safe sex practices. The CSF Venereal Disease Research Laboratory (VDRL) test remains the "gold standard" for diagnosis, but is not invariably positive. Penicillin remains the most effective and recommended therapy.

Acquired neurosyphilis presenting as movement disorders

After a significant decline in the second half of the 20th century, rates of infection with syphilis are again on the rise. Long known as the "great mimicker," syphilitic infection can be difficult to recognize clinically and this particularly holds true for neurologic manifestations of the disease. Gait dysfunction and sensory ataxia have been historically well described in neurosyphilis literature; however, other movement disorders have been reported to a lesser extent. Here we review reports of movement disorders in acquired neurosyphilis. Given its increasing incidence, it is important to be cognizant of its diverse presentation and retain a high index of suspicion for syphilis, particularly as it is completely curable in the early stages.

Cerebral syphilitic gummata: a case presentation and analysis of 156 reported cases

OBJECTIVE

Cerebral syphilitic gummata are rare manifestations of tertiary, meningovascular syphilis. No extensive characterization of these lesions has been published recently, and only a few small reviews containing imaging findings have been published to date. To better characterize cerebral gummata, we present a case seen at Tulane University, followed by an extensive review of the literature.

CLINICAL PRESENTATION

A 56-year-old man with a history of treated syphilis presented with seizures and confusion. A rapid plasma reagin titer was reactive in serum but Venereal Disease Research Laboratory results were negative in cerebrospinal fluid. Neuroimaging demonstrated an occipital lesion and the patient underwent subtotal resection. The pathological examination demonstrated a syphilitic gumma containing Treponema pallidum visualized by fluorescence immunostaining.

METHODS

An extensive literature search was performed for published case reports of cerebral gummata.

RESULTS

One hundred fifty-six cases containing 185 lesions were located. Patients presented with signs and symptoms based on location. Lesions are more common in men (64%) and those aged 18 to 39 years. Cerebrospinal fluid syphilis tests were positive in 64%. Lesions are located everywhere but are most common on the convexities (66%). Computed tomography usually reveals a hypodense lesion that enhances. Magnetic resonance imaging usually demonstrates hypointensity on T1, hyperintensity on T2, and enhancement with gadolinium. Most patients are responsive to antiluetic therapy, with the majority demonstrating complete or near-complete imaging and symptom resolution.

CONCLUSION

Cerebral gummata are rare lesions. Intravenous penicillin G with imaging follow-up is recommended for most patients. Surgery should be reserved for those unresponsive to antibiotics or those with acutely elevated intracranial pressure.

Oculomotor motion disorders: current imaging of cranial nerves 3, 4, and 6

The eye movements are controlled by the cranial nerves 3, 4, and 6 working in close cooperation under the supervision of the voluntary cortex. Clinically, the most common presentation of abnormal ocular motor motion is double vision. A thorough clinical examination can usually separate a local orbital cause which can produce a restriction of the muscles moving the eye from a neurogenic cause due to an abnormality of one of the three nerves or their association pathways. Recent articles in the scientific literature have described major advances in our understanding of the anatomy and vascular relationships of the three ocular motor nerves (cranial nerves 3, 4, and 6) and of the diagnosis and treatment of a variety of pathological processes that damage these nerves, including ischemia, inflammation, and compression.