Cerebral Syphilitic Gumma: Case Report of a Brainstem Mass Lesion and Brief Review of the Literature

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.

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.

Cerebral syphilitic gumma presenting with intracranial gumma and pathologic vertebrae fractures

A 37-year-old female was admitted with worsening neurologic function. On arrival from an outside hospital, the patient was obtunded and intubated. Magnetic resonance imaging of the brain revealed nodular enhancement of the leptomeninges, intracranial osteolytic lesions, and diffuse vasogenic edema causing mass effect. Imaging of the thoracic spine revealed pathologic compression fractures of 4 thoracic vertebrae. On review of the patient's electronic medical record, the patient had previously received treatment for secondary syphilis with intramuscular benzathine penicillin G. Surgical biopsies of the frontal bone and dura showed diffuse, chronic inflammation while a biopsy of the adjacent brain parenchyma revealed replicating spirochetes. The patient was subsequently prescribed dexamethasone and benzathine penicillin G. She regained neurologic function but later signed out against medical advice without completing her treatment regimen.

Diagnosis and Treatment of Cerebral Syphilitic Gumma: A Report of Three Cases

Cerebral syphilitic gumma is very rare and is often pathologically confirmed following surgery. This study reports three patients with cerebral syphilitic gumma. The first case was a 62-year-old man who was admitted to our hospital due to speech arrest for 10 hours. Head MRI showed a nodular signal shadow with a significant enhancement and a significant centerline shift. He subsequently received surgery, and cerebral syphilitic gumma was confirmed by postoperative pathology. The second patient was a 66-year-old man who was admitted to our hospital due to complaints of gradually decreasing right eye vision and headache for nearly 50 days. Enhanced MRI at admission indicated irregular clumping of high-signal mixed with low-signal foci on the frontal lobe. Subsequently, he was operatively treated and was confirmed to have cerebral syphilitic gumma by postoperative pathology. The third patient was a 37-year-old man who was admitted to our hospital due to dizziness for approximately 15 days. Head MRI indicated a slightly abnormal lamellar and longer T1, T2 signal shadow on the left side. He did not receive surgery, and his symptoms disappeared after anti-syphilitic treatment. Hence, we recommend a critical interpretation of preoperative imaging data, understanding the unique changes that arise in the brain that can be detected through imaging, and an analysis of the patient history and laboratory tests to re-evaluate the value of surgery, with the ultimate goal of performing a stabilizing treatment for cerebral syphilitic gumma.