Cerebral Syphilitic Gumma within 5 Months of Syphilis in HIV-Infected Patient

Cerebral syphilitic Gumma in the modern era: a report of an unusual case and brief review of recent published reports

BACKGROUND

Cerebral syphilitic gummas are rare. However, numerous case reports on them have been published recently, consistent with the resurgence of syphilis and its accompanying atypical manifestations. We here present a patient with a cerebral syphilitic gumma and an unusual clinical course and review recent case reports.

CASE PRESENTATION

A 49-year-old woman had a generalised seizure and was found by computed tomography and magnetic resonance imaging to have a brain mass that mimicked a brain abscess or malignant tumour. Further imaging with magnetic resonance spectroscopy and positron emission tomography did not contribute further to the differential diagnosis. Because treatment with ceftriaxone was ineffective, the lesion was resected. Serological tests on serum and cerebrospinal fluid were positive for syphilis and histopathological examination of the operative specimen revealed a syphilitic gumma. Antibiotic treatment is preferred over invasive interventions for cerebral syphilitic gumma. However, as in our case, radical resection is required when antibiotic treatment is ineffective.

CONCLUSIONS

It has recently been reported that the prevalence of syphilis is increasing in older individuals, including in patients without HIV infection or prior treatment for early syphilis. Though advanced imaging and molecular biological techniques are often used to help make a diagnosis, they are of limited value. Because the clinical and imaging features are nonspecific, some neurosurgeons do not include cerebral syphilitic gummas in their differential diagnoses. It is vital that this possibility be considered when a patient has a tumour-like cerebral mass and serum positivity for syphilis.

Gummatous neurosyphilisin an HIV-negative patient: Case report

Syphilis is a chronic infectious disease, which dates back to the XV century and is caused by the spirochete treponema pallidum, capable of invading the central nervous system in any of its stages- Its incidence has increased in parallel to the HIV/AIDS pandemic, and the synergism between both pathologies is such. that it has become a public health problem in recent years. Here we present the case of a 31-year-old female patient, who consulted for headache associated with decreased visual acuity and provided an unenhanced head CT showing hypodense lesions in both thalamic regions, serological tests for syphilis were reactive and those for HIV were not reactive. The brain MRI with spectroscopy was reported in favor of cerebral toxoplasmosis, which was later ruled out with a study of cerebrospinal fluid. Management with penicillin G sodium IV for 6 weeks was indicated, achieving complete imaging resolution of her lesions.

Challenges in the Diagnosis of Tertiary Syphilis: Case Report with Literature Review

Tertiary syphilis is a large diagnostic challenge. It is rarely the case that it affects the skin, bone tissue and the eyes at the same time. The presented case shows that extensive symptomatology of syphilis poses a challenge in making a proper diagnosis in patients whose history does not suspect STDs. The study aims to present the case of a young woman hospitalized with a suspected autoimmune disease, diagnosed with symptomatic late syphilis with involvement of the skin, bones and eyes.

Meningovascular Syphilis Presenting as a Brain Mass in an Immunocompetent Male

We present a case of a human immunodeficiency virus-negative man with syphilitic meningovascular disease with subjacent involvement of brain parenchyma leading to a mass-forming inflammatory lesion that was pathologically distinct from a typical gumma. Syphilis was diagnosed after tissue obtained from a brain biopsy demonstrated spirochetes consistent with Treponema pallidum and confirmed by 16S ribosomal RNA sequencing.

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.

An Atypical Case of Neurosyphilis in a Patient With HIV: A Case Report

Epidemiological trends have demonstrated re-emergence of neurosyphilis in the twenty-first century. As prevalence rises in clinical practice, neurosyphilis must be considered in the differential diagnosis even if initial diagnostic workup is unrevealing, especially in patients with human immunodeficiency virus (HIV). Co-infection of neurosyphilis and HIV can result in atypical presentations. In this report, we discuss a challenging diagnosis of neurosyphilis in a man with HIV who presented with atypical imaging findings and initially negative cerebrospinal fluid (CSF) nontreponemal testing. Our patient underwent repeated CSF evaluation and a comprehensive diagnostic workup, including brain biopsy, to arrive at the appropriate diagnosis. He received antibiotic treatment with excellent outcome. We review typical imaging features of neurosyphilis and highlight other neurological diseases that may mimic these radiographic findings. We discuss CSF testing and interpretation in this high-risk patient population.

Approach to an Intracranial Mass in Patients With HIV

PURPOSE OF REVIEW

Space-occupying lesions represent a diagnostic challenge among people with the human immunodeficiency virus, acquired immunodeficiency syndrome (HIV/AIDS). To determine the best diagnostic approach to the wide array of possible etiologies and provide a thorough interpretation of neuroimaging in order to narrow a hierarchical differential diagnosis among these patients. Given that there is no pathognomonic neuroimaging pattern in this clinical setting, we searched results from brain biopsies to best determine the etiology of commonly found lesions.

RECENT FINDINGS

Multimodal brain MRI and MRI spectroscopy (MRS) often provide the most valuable information in the study of focal masses among people with HIV/AIDS. Brain biopsy appears safe and provides high diagnostic yields in these patients. Among patients with HIV/AIDS who present with space-occupying intracranial lesions, brain MRI and MRS are useful tests. However, in cases of diagnostic uncertainty, brain biopsy is a safe procedure and should be performed. The role of metabolic studies like ²⁰¹Th-SPECT or PET is useful in the detection of primary central nervous system lymphoma.

Neuroimaging findings of cerebral syphilitic gumma

Cerebral syphilitic gumma is a rarely reported disease of the central nervous system. Magnetic resonance imaging (MRI) is an important diagnostic method for syphilitic gumma. The present study aimed to describe and characterize neuroimaging results from 6 patients with pathologically diagnosed cerebral syphilitic gumma. The 6 patients (age, 32–61 years) underwent brain CT and MRI, with 1 patient also undergoing whole-body 2-deoxy-2-(fluorine-18)fluoro-D-glucose-positron emission tomography/CT (18F-FDG PET/CT). Non-enhanced CT, conventional T1 weighted imaging (T1WI) and T2WI, diffusion weighted imaging (DWI) and gadolinium-enhanced T1WI images were acquired for all patients. The CT and MRI scans were retrospectively reviewed by two experienced radiologists for consensus on the location, number, size, T1WI, T2WI and DWI signal intensity characteristics, extent of vasogenic oedema, and enhancement patterns. In total, the 6 patients exhibited 10 lesions, nine of which were located in the cerebral hemisphere, primarily in the grey matter. The remaining lesion was located in the fourth ventricle, leading to mild-to-moderate hydrocephalus. The diameters of the identified 10 lesions ranged from 0.9–6.5 cm, with a mean diameter of 3.9 cm. The main feature observed in CT was low density and in MRI the features were T1WI and DWI hypointensity and T2WI hyperintensity. A single case exhibited syphilis gumma with massive haemorrhage. Ring-like or strip-like signs (n=5), accompanied by the dural tail sign (n=2) and homogeneous enhancement (n=1), were noted on T1WI with gadolinium. The 18F-FDG PET/CT performed in one patient of a cerebral syphilis gumma revealed low uptake and metabolism. The present study indicated that gadolinium-enhanced MRI combined with 18F-FDG PET/CT and laboratory examinations are helpful in distinguishing cerebral syphilitic gumma from brain tumors and infectious diseases, therefore avoiding unnecessary surgery.

Cerebral Syphilitic Gumma in Immunocompetent Man, Japan

Although cerebral syphilitic gummas are generally considered to be rare manifestations of tertiary syphilis, many reports exist of early cerebral syphilitic gumma. Our finding of cerebral syphilitic gumma in an HIV-negative man within 5 months after syphilis infection suggests that this condition should be considered in syphilis patients who have neurologic symptoms.

Time to development of ocular syphilis after syphilis infection

To provide an estimate of the incubation period of ocular syphilis based on serology using both clinical data and stored serum samples, we retrospectively reviewed patients with HIV-1 infection who presented with ocular syphilis between August 1997 and July 2015 in a tertiary hospital in Japan. The incubation period of ocular syphilis was defined as the time from syphilis infection to the development of ocular symptoms due to ocular syphilis. During the study period, 20 patients were diagnosed with ocular syphilis and 8 patients were enrolled in the present study. All patients were Japanese men who have sex with men with a median age of 46 years (IQR 41.5-53.5). The median CD4 count was 668.5/μL (IQR 567.8-734.3) and 5 of the 8 patients had HIV-1 viral load of less than 50 copies/mL. All study patients presented to our clinic because of the development of ocular symptoms, and they did not have any other symptoms compatible with primary, secondary, or tertiary syphilis. The median time between syphilis infection and development of ocular symptoms was 11 months (IQR 4-19, range 2.5-45). Seven out of eight (87.5%) cases developed ocular syphilis within 2 years of syphilis infection. Ocular syphilis should be suspected even in patients with early syphilis who present with ocular symptoms. Moreover, routine serologic screening for syphilis among patients with HIV-1 infection is critical for prevention of irreversible visual loss in ocular syphilis cases.

The immunological response to syphilis differs by HIV status; a prospective observational cohort study

Background

It is not known if there is a difference in the immune response to syphilis between HIV-infected and uninfected individuals.

Methods

We prospectively recruited all patients with a new diagnosis of syphilis and tested their plasma for IFNα, IFNγ, IL-1β, IL-12p40, IL-12p70, IP-10, MCP-1, MIP-1α, MIP-1β, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10 and IL-17A at baseline pre-treatment and 6 months following therapy.

Results

A total of 79 HIV-infected [44 primary/secondary syphilis (PSS) and 35 latent syphilis (LS)] and 12 HIV-uninfected (10 PSS and 2 LS) cases of syphilis and 30 HIV-infected controls were included in the study. At the baseline visit, compared to the control group, concentrations of IL-10 were significantly elevated in the HIV-infected and uninfected groups. The level of IL-10 was significantly higher in the HIV-infected compared to the HIV-uninfected PSS group (25.3 pg/mL (IQR, 4.56–41.76) vs 2.73 pg/mL (IQR, 1.55–9.02), P = 0.0192). In the HIV-infected PSS group (but not the HIV-infected LS or HIV-uninfected PSS groups) the IP-10, MIP-1b, IL-6 and IL-8 were raised compared to the controls. IL-10 levels decreased but did not return to control baseline values by 6 months in HIV infected PSS and LS and HIV uninfected PSS.

Conclusion

PSS and LS in HIV-infected individuals is characterized by an increase in inflammatory and anti-inflammatory cytokines such as IL-10. The increase of IL-10 is greater in HIV-infected than uninfected individuals. Further work is required to ascertain if this is part of an immunological profile that correlates with adverse outcomes such as serofast syphilis and neurosyphilis, in HIV-infected individuals.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2201-7) contains supplementary material, which is available to authorized users.