Enhancing clinical awareness: retrospective analysis of neurosyphilis cases and diagnostic predictors for early recognition and treatment

OBJECTIVE

This is a retrospective analysis of clinical data from individuals diagnosed with neurosyphilis, aiming to enhance healthcare professionals' understanding of the disease and expedite early diagnosis and intervention.

METHODS

A retrospective analysis was conducted on the clinical records of 50 patients who received a diagnosis of symptomatic neurosyphilis and were admitted to the Neurology Department during the period spanning January 2012 to December 2022.

RESULTS

Clinical manifestations encompassed diverse phenotypes, with syphilitic meningitis accounting for 16% of cases, characterized by symptoms such as headache, blepharoptosis, paralysis, blurred vision, and tinnitus. Meningovascular syphilis presented in 36% of cases, exhibiting episodic loss of consciousness, limb numbness, and limb convulsion. Paralytic dementia manifested in 36% of cases, featuring symptoms such as memory loss, sluggish response, and slow movement. Tabes dorsalis was observed in 12% of cases, presenting with weakness, numbness, and staggering. Routine cerebrospinal fluid (CSF) analysis indicated abnormal white blood cell counts in 60% of patients, while biochemical testing revealed abnormal protein content in 52% of patients. Notably, statistically significant differences were observed between patients with interstitial and parenchymatous neurosyphilis (Z = 2.023, P = 0.044) in terms of CSF protein content. Electroencephalogram (EEG) results were abnormal in six patients, and imaging studies unveiled diverse findings in 46 patients.

CONCLUSION

The study highlights the importance of neurological and/or ocular symptoms in diagnosing symptomatic neurosyphilis. Individuals with hypomnesia should be closely monitored for potential neurosyphilis. Integrating clinical manifestations, laboratory tests, EEG, and imaging can reduce misdiagnosis. This comprehensive approach shows promise in improving early identification and management of neurosyphilis.

Psychiatric manifestations of neurosyphilis over past two decades: Findings from a tertiary care neuropsychiatric hospital in south India

OBJECTIVE

To assess presentation of neurosyphilis with a focus on the psychiatric aspects.

METHOD

File review of the cases with a positive cerebrospinal fluid venereal disease research laboratory test between 1999 to 2020.

RESULTS

Medical records of 143 neurosyphilis patients were analysed. Hallucinations, delusions, and catatonia were the commonest psychiatric symptoms. Brain atrophy was the commonest neuroimaging finding. The number of neurosyphilis patients and the proportion with delirium or catatonia declined during the second decade (2010-2020).

CONCLUSION

Atypical presentation of psychiatric symptoms around the fifth decade, with associated neurological symptoms or brain imaging changes, should prompt evaluation for neurosyphilis.

Epstein-Barr virus-positive monoclonal lymphoplasmacytic proliferation associated with neurosyphilis in an immunocompetent patient: A case report

Syphilis is an infectious disease caused by the spirochete bacterium Treponema pallidum. Neurosyphilis results from the infection of the nervous system with Treponema pallidum, which can occur at any stage of syphilis. Neurosyphilis is often overlooked because of its rarity. Early-stage neurosyphilis with brain mass formation is rare. We present a case of early-stage neurosyphilis with prominent Epstein-Barr virus (EBV)-positive monoclonal lymphoplasmacytic proliferation in an immunocompetent patient. A 36-year-old man presented with a chief complaint of a progressively worsening headache, a newly developed skin rash, and a fever. Magnetic resonance imaging showed a mass lesion, which measured 18 mm in diameter, in the left frontal lobe of the cerebrum. The patient underwent an emergency operation to remove the abscess. A pathological investigation revealed complex findings. There was an abscess in the cerebrum. Lymphoplasmacytic meningitis was also noted. In addition, a vaguely nodular lesion, which was composed of plasmacytoid and lymphoid cells, was observed around the abscess. Immunohistochemically, an anti-Treponema pallidum antibody revealed numerous Treponemas around the abscess. In situ hybridization revealed that the plasmacytoid and lymphoid cells were Epstein-Barr encoding region (EBER)-positive; κ-positive cells were significantly more prevalent than λ-positive cells, suggesting light-chain restriction. Postoperatively, parenteral antibiotics were administered for four weeks. The patient has been free of recurrence for two years since the surgery. No association between neurosyphilis and EBV-positive lymphoplasmacytic proliferation has ever been reported. Mass formation in early-stage neurosyphilis is an exceptionally rare event. The present case indicates that in syphilis patients, lymphoproliferative disorders that lead to mass formation may be caused by concomitant EBV reactivation. Furthermore, when treating patients with mass lesions of the central nervous system, it is important to check their medical history and perform laboratory screening for infectious diseases to avoid overlooking syphilis infections.

Neurological manifestations of syphilis-HIV coinfection in South Africa

OBJECTIVE

Syphilis and HIV coinfection is highly prevalent in South Africa, and both can cause neurological complications. We describe the clinical presentation and outcome of neurosyphilis in patients with and without HIV coinfection diagnosed at a tertiary facility, Groote Schuur Hospital (GSH), in South Africa.

METHODS

We retrospectively analyzed folders of adults with positive cerebrospinal fluid (CSF) fluorescent treponemal antibody absorption test in 2018 and 2019, with follow-up data collected until 2022.

RESULTS

HIV-coinfection was identified in 35% of the 69 included patients. Patients with HIV-coinfection were more likely to be female (58% vs 25% female, p < 0.01), and present earlier (median age = 31 years vs. 40 years, p < 0.001). Neuropsychiatric manifestations (confusion, dementia, psychosis), and strokes were the commonest clinical presentations in both groups. Those with HIV-coinfection were significantly less likely to be diagnosed with neurosyphilis by the treating clinician (71% vs. 91%, p < 0.05), as were those with a negative CSF Venereal Disease Research Laboratory (74% vs. 94%, p < 0.05). Accurate diagnosis of neurosyphilis was associated with an increased 12-month survival (alive: N = 36 [63%]) relative to those who did not receive an accurate diagnosis (alive: N = 2 [17%], p < 0.05). Those who were optimally treated with antibiotics had significantly higher 12-month survival (alive: N = 33, 63%) compared to those with suboptimal treatment (alive: N = 5, 29%), p < 0.01.

CONCLUSION

Neurosyphilis presented similarly in those with and without HIV-coinfection. Accurate identification and optimal antibiotic treatment of neurosyphilis, particularly in CSF VDRL negative patients and those with HIV-coinfection, is necessary to improve patient survival.

Neurosyphilis presenting as limbic encephalitis

A man in his 50s presented with focal seizures and was found to have an inflammatory cerebrospinal fluid (CSF) with bilateral mesiotemporal lobe hyperintensity on magnetic resonance imaging (MRI) of the brain. Corticosteroid treatment was initiated for management of limbic encephalitis. Focal seizures, imaging abnormalities and inflammatory CSF persisted despite treatment and the patient was found to have neurosyphilis after developing neuropsychiatric symptoms. Syphilis is a sexually transmitted bacterial infection with multisystem involvement including neurological and psychiatric manifestations. Case reports have emerged of neurosyphilis presenting as limbic encephalitis with CSF pleocytosis and temporal lobe hyperintensity on MRI of the brain. Persistence of CSF or MRI abnormalities despite immunosuppressive therapy for limbic encephalitis should prompt investigation for alternate causes of chronic meningoencephalitis, which can occasionally include neurosyphilis.

Neurosyphilis presenting with Guillain-Barre syndrome: a case report

BACKGROUND

Syphilis is associated with a wide variety of systemic presentations, earning it the moniker "The great mimicker". Neurosyphilis is classically associated with meningovasculitis in the acute-subacute stage and tabes dorsalis and dementia paralytica in later stages. However, one of the less well described presentations include Guillain-Barre Syndrome. This case presents a patient with an ascending polyneuropathy suspicious for Guillain-Barre Syndrome who also had other atypical findings including a truncal sensory loss, optic disc swelling, and rash ultimately found to have neurosyphilis. Electrodiagnostic testing was consistent with demyelination, supporting a diagnosis of neurosyphilis associated Guillain-Barre Syndrome.

CASE PRESENTATION

A 37-year-old female presented to the emergency department with a weakness and difficulty swallowing. She described a three-month history of symptoms, initially starting with a persistent headache followed by one month of a pruritic rash on her chest, palms, and soles. Two weeks prior to presentation, she developed progressive weakness in her arms, numbness in her arms and chest, and difficulty swallowing. Neurological exam was notable for multiple cranial neuropathies, distal predominant weakness in all extremities, length-dependent sensory loss, and hyporeflexia. Investigation revealed a positive Venereal Disease Research Laboratory in her cerebrospinal fluid without significant pleocytosis, contrast enhancement in cranial nerves V, VII, and VIII on MRI, and a demyelinating polyneuropathy on electrodiagnostic testing. She was diagnosed with Guillain-Barre syndrome, secondary to neurosyphilis. The patient acutely declined and required intubation, and ultimately made a full recovery after treatment with plasmapheresis and penicillin.

CONCLUSIONS

This case describes a clinical entity of syphilitic Guillain-Barre Syndrome and highlights the importance of including syphilis in the differential of any patient presenting with ascending polyradiculopathy, especially given the resurgence of syphilis.

A Cluster of Ocular Syphilis Cases with a Common Sex Partner - Southwest Michigan, 2022

Untreated syphilis can lead to ocular syphilis, otosyphilis, and neurosyphilis, conditions resulting from Treponema pallidum infection of the eye, inner ear, or central nervous system. During March-July 2022, Michigan public health officials identified a cluster of ocular syphilis cases. The public health response included case investigation, partner notification, dissemination of health alerts, patient referral to a public health clinic for diagnosis and treatment, hospital care coordination, and specimen collection for T. pallidum molecular typing. Five cases occurred among southwest Michigan women, all of whom had the same male sex partner. The women were aged 40-60 years, HIV-negative, and identified as non-Hispanic White race; the disease was staged as early syphilis, and all patients were hospitalized and treated with intravenous penicillin. The common male sex partner was determined to have early latent syphilis and never developed ocular syphilis. No additional transmission was identified after the common male partner's treatment. Due to lack of genetic material in limited specimens, syphilis molecular typing was not possible. A common heterosexual partner in an ocular syphilis cluster has not been previously documented and suggests that an unidentified strain of T. pallidum might have been associated with increased risk for systemic manifestations of syphilis. A high index of clinical suspicion and thorough sexual history are critical to diagnosing ocular syphilis, otosyphilis, and neurosyphilis. Coordination of disease surveillance with disease intervention specialist investigation and treatment referral can interrupt syphilis transmission.

A Rare Case of Blindness Caused by Syphilis with Malignant Hypertensive Nephropathy

The number of patients with syphilis has been rapidly increasing. Without treatment, syphilis can damage various organs and become life-threatening. We herein report a 29-year-old woman diagnosed with neurosyphilis, acute hydrocephalus, syphilitic uveitis combined with hypertensive retinopathy, and malignant hypertensive nephropathy. To our knowledge, this is the first report of syphilis complicated with malignant hypertensive nephropathy proven by a renal biopsy. Neurosyphilis was successfully treated with intravenous penicillin G, and severe hypertension subsequently resolved. However, delayed medical examinations and complications of syphilitic uveitis and hypertensive retinopathy resulted in irreversible visual loss. To prevent irreversible organ damage, early treatment is essential.

H - 29 Delivering Culturally Sensitive Neuropsychological Assessment Feedback: a Case Study of Atypical Neurosyphilis

OBJECTIVE

To demonstrate the neuropsychological correlates of atypical neurosyphilis and the importance of delivering assessment results in a culturally sensitive manner.

METHOD

The patient was a 52-year-old African American male with 12 years of education who was raised in a rural, southern town and worked as a delivery driver. He was hospitalized after three weeks of altered mental status, memory loss, and seizures. Electroencephalography (EEG) showed left lateralized periodic discharges. Magnetic resonance imaging (MRI) showed hyperintensities in the left hippocampus and amygdala consistent with limbic encephalitis. Cerebrospinal fluid studies revealed lymphocytic pleocytosis and hypoglycorrhachia. Rapid plasma regain and venereal disease tests were positive for syphilis in serum and CSF. He was initially treated with empiric antibiotics and antiseizures medications with modest improvement. His mental status improved after penicillin treatment, and he was discharged after 14 days. Repeat MRI showed cortical atrophy in the left medial frontal lobe and left hippocampus.

RESULTS

The patient demonstrated executive dysfunction (e.g., set-loss and source memory errors) and poor performance across verbal and visual memory tasks. He also demonstrated an inaccurate understanding of the possible causes of his illness. Feedback was delivered across two sessions: one session to discuss test results and a second session with the patient and his wife to discuss syphilis as a sexually transmitted infection and address the historical context of syphilis among African American men.

CONCLUSIONS

Neurosyphilis can present as limbic encephalitis and can mimic autoimmune encephalitis and other infectious diseases. Tailoring assessment feedback to a patient's sociocultural context is vital for encouraging continued treatment.

Neurosyphilis in a young man having HIV infection, blurring of vision and skin rash

We report a 22-year-old homosexual man, a known case of HIV-1 infection but non-compliant to medications, who presented with a 5-month history of progressive painless non-pruritic coin-shaped skin lesions and recent gradual bilateral blurring of vision. His history divulged a primary syphilitic event 1 year prior to the present clinical manifestations. Investigation led to the diagnosis of neurosyphilis with ocular involvement with concurrent signs of secondary syphilis. Treatment with aqueous crystalline penicillin G, ophthalmic steroid and tropicamide drops, and topical emollients resulted in significant clinical improvement of ocular symptoms and skin lesions. The diagnosis of neurosyphilis requires a high degree of clinical suspicion and should be included in the differential diagnosis of unexplained ocular symptoms, particularly in men who have sex with men and HIV-infected patients. This is necessary for the early diagnosis, appropriate management, and good outcome of these patients.

[Neurosyphilis or not - a case of a differential diagnostic challenge]

We report the case of a 42-year-old woman with paraparesis associated with transverse myelitis. For differential diagnostics detailed microbiological, cerebrospinal fluid (CSF) and neuroimaging examinations were performed. Syphilis was confirmed, but diagnosis of neurosyphilis was only probable based on the CSF microbiological test results. The beneficial treatment response to application of the therapeutic protocol for syphilis supported the supposed diagnosis of syphilis-associated myelitis in our case. In this case report we reviewed the differential diagnostic tools of myelopathies/myelitis.
Nowadays regarding to growing prevalence of syphilis worldwide physicians should face on its presence and medical consequences.

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Neurosyphilis among people with and without HIV infection: A Danish nationwide prospective, population-based cohort study 2015–2021

BACKGROUND

Comparative data on clinical presentation, laboratory characteristics, treatment, and outcome of neurosyphilis (NS) in people living with HIV (PLWH) and NS patients without HIV are scarce.

METHODS

Nationwide, population-based, prospective cohort study on all adults with NS diagnosed between 2015 and 2021 at departments of infectious diseases in Denmark.

RESULTS

We identified 108 patients with NS, which equals a yearly incidence of 0.3/100,000 adults. The median age was 49 years, 85 (79%) were male, 43 (40%) were men having sex with men and 20 (22%) were PLWH. Ninety-five (88%) had early NS, 37 (34%) had ocular or ocular and otogenic NS, and 27 (25%) had symptomatic meningitis. Most common symptoms were visual disturbance (44%), skin rash (40%), fatigue (26%) and chancre (17%). Median CSF leukocyte count was 27 × 10⁶ cells/L. PLWH less often had neurological deficits (p = 0.02). Unfavorable outcome was observed in 23 (21%) at discharge of whom 0 were PLWH (p = 0.01). Among the 88 NS patients without HIV a CSF leukocyte count of ≥ 30 × 10⁶ cells/L was associated with unfavorable outcome (OR = 3.3 (95% confidence interval: 1.1-10.4)).

CONCLUSIONS

PLWH with NS have better outcomes than NS patients without HIV infection.

Lumbar puncture for neurosyphilis investigation in asymptomatic patients with HIV-syphilis coinfection: a cross-sectional study among infectious disease specialists

BACKGROUND

Syphilis is a major public health issue worldwide. In people living with human immunodeficiency virus (PLHIV), there are higher incidences of both syphilis and neurosyphilis. The criteria for referring PLHIV with syphilis for lumbar puncture is controversial, and the diagnosis of neurosyphilis is challenging.

OBJECTIVE

To describe the knowledge, attitudes, and practices of infectious disease specialists and residents in the context of care for asymptomatic HIV-syphilis coinfection using close-ended questions and case vignettes.

DESIGN AND SETTING

Cross-sectional study conducted in three public health institutions in São Paulo (SP), Brazil.

METHODS

In this cross-sectional study, we invited infectious disease specialists and residents at three academic healthcare institutions to answer a self-completion questionnaire available online or in paper form.

RESULTS

Of 98 participants, only 23.5% provided answers that were in line with the current Brazilian recommendation. Most participants believed that the criteria for lumbar puncture should be extended for people living with HIV with low CD4+ cell counts (52.0%); in addition, participants also believed that late latent syphilis (29.6%) and Venereal Disease Research Laboratory (VDRL) titers ≥ 1:32 (22.4%) should be conditions for lumbar puncture in PLHIV with no neurologic symptoms.

CONCLUSION

This study highlights heterogeneities in the clinical management of HIV-syphilis coinfection. Most infectious disease specialists still consider syphilis stage, VDRL titers and CD4+ cell counts as important parameters when deciding which patients need lumbar puncture for investigating neurosyphilis.

[A case of meningovascular syphilis presenting with bilateral oculomotor nerve palsy, cerebral aneurysm, and cerebral hemorrhage]

The patient was a 32-year-old man with no HIV infection and possible syphilis infection at the age of 22 years. At the age of 29 years, he visited an ophthalmologist for diplopia due to right oculomotor nerve palsy. He underwent diplopia strabismus surgery for unexplained oculomotor nerve palsy. At the age of 31 years, he had a left oculomotor nerve palsy and was referred to our department. He was diagnosed with neurosyphilis based on positive serum and cerebrospinal fluid syphilis antibodies. MRI showed aneurysm, asymptomatic cerebral hemorrhage, and contrast enhancement of the left oculomotor nerve, leading to the diagnosis of meningovascular syphilis. The patient's symptoms improved with penicillin and corticosteroids. The oculomotor nerve palsy may be due to microcirculatory disorder caused by syphilitic cerebral endarteritis.

Neurosyphilis presenting as autoimmune limbic encephalitis: A case report and literature review

RATIONALE

Neurosyphilis presenting as limbic encephalitis (LE) is an important differential diagnosis of autoimmune LE (ALE) defined by Graus in 2016. However, data on the clinical differences and similarities between neurosyphilis presenting as LE and ALE are limited. Herein, we report neurosyphilis presenting as ALE that fulfilled the main items of the Graus ALE criteria. Moreover, a literature review of neurosyphilis presenting as LE was performed.

PATIENT CONCERNS

A 66-year-old Japanese man developed nonconvulsive status epilepticus. He presented with progressive personality change and working memory deficits within 3 months prior to admission. A hyperintense lesion localized in the bilateral medial temporal area was observed on T2-weighted fluid-attenuated inversion recovery brain magnetic resonance imaging. Cerebrospinal fluid analysis showed mild pleocytosis and the presence of oligoclonal band. However, in-house assays did not detect antineuronal antibodies. Electroencephalogram showed lateralized rhythmic delta activity in the right temporal area. The serum and cerebrospinal fluid serological and antigen tests for syphilis had positive results.

DIAGNOSIS

ALE was initially suspected based on the patient's symptoms and ancillary test findings that fulfilled the Graus ALE criteria. However, based on the positive confirmatory test results for syphilis, a diagnosis of neurosyphilis was eventually made.

INTERVENTION

The patient received intravenous midazolam, oral levetiracetam, and lacosamide to control nonconvulsive status epilepticus. In addition, he was treated with intravenous benzylpenicillin at a dose of 24 million units/day for 14 days.

OUTCOMES

The patient's cognitive function relatively improved after antibiotic treatment. However, he presented with persistent mild working memory deficit, which was evaluated with the Wechsler Adult Intelligence Scale, 3rd edition. Therefore, on day 103 of hospitalization, he was transferred to another hospital for rehabilitation and long-term care due to limitations in performing activities of daily living.

LESSONS

The present case was diagnosed with neurosyphilis presenting as ALE, but meanwhile, in most case, neurosyphilis presenting as LE developed at a slower progressive rate, and it had a broader or restricted involvement on brain MRI than ALE based on the literature review. Therefore, an appropriate differential diagnosis of LE can be obtained by identifying clinical differences between the 2 conditions.

Upward trends of syphilis in the non-pregnant adults: A six-year report on clinical and epidemiological profile of syphilis from a tertiary care center, India

Since 2000, a resurgence of syphilis has been noted in many developed and developing countries, especially among men who have sex with men (MSM). Incidence and prevalence of syphilis in pregnant women have been reduced drastically by mandatory screening in early pregnancy. Insufficient data in other populations especially from developing countries limit targeted public health interventions. This study aimed to describe the clinical and epidemiological profile of serologically confirmed syphilis cases among the non-pregnant high-risk group reporting to a tertiary care center in Southern India. A retrospective study was carried out in a tertiary care center in Southern India for 6 years from 2015 to 2020. A total of 265 serologically confirmed syphilis patients were included. A statistically significant increase in positivity from 0.52 to 2.1% was observed in this study (2015 to 2020). Among risk factors, high-risk behavior with multiple heterosexual partners was the commonest (51.3%), followed by marital partners who tested positive (9.4%) and MSM (7.5%). The majority of the patients were diagnosed at the latent stage (79%), followed by secondary syphilis (10%) and tertiary syphilis (8%). A quarter of patients (23%) were coinfected with HIV. Serological non-responsiveness was more common among HIV infected (47 vs. 24%). Sixteen had neurosyphilis and six had ocular involvement. HIV co-infection complicated 50% (8/16) of neurosyphilis patients. Syphilis is still prevalent, especially in high-risk groups including those are attending STI clinics. Further prospective multicentric studies are needed to identify and implement public health measures.

A Case of Neurosyphilis and Review of Manifestations, Diagnosis, and Treatment

Diagnosis of neurosyphilis remains a challenge due to no existing standardized testing, but it is often made based on a combination of clinical and cerebrospinal fluid (CSF) analysis findings. Neurosyphilis is uncommon now compared to the era before the introduction of penicillin. Syphilis if left untreated may lead to debilitating complications including paresis, progressive dementia, and even death. Presence of ocular or hearing manifestations with positive serum treponemal and non-treponemal tests are diagnostic for neurosyphilis, regardless of presence or absence of CSF abnormalities. The preferred regimen for neurosyphilis is intravenous penicillin G for 2 weeks. Other regimens are not shown to be as effective as penicillin. Here we discuss an interesting case presenting with neurosyphilis along with manifestations consistent with primary and secondary stages of syphilis.

A Rare Case of Neurosyphilis Presenting As Normal Pressure Hydrocephalus Syndrome

Neurosyphilis, a chronic infection of the nervous system by Treponema pallidum can present in all stages of syphilis. Recently, it is found that neurosyphilis presents with novel manifestations. Here, we report a young patient who had neurosyphilis presenting as Normal Pressure Hydrocephalus (NPH) with bilateral optic atrophy. The patient showed improvement with treatment for neurosyphilis. Hence, it is evident that in young patients presenting with NPH and associated features, secondary etiologies should be investigated.

Neurosyphilis in a suspected case of giant cell arteritis

A 67-year-old man had a few month history of deteriorating visual acuity. He had originally presented to ophthalmology with right-sided visual blurring. This subsequently progressed to involve the left eye. At this point, he was empirically treated with high-dose glucocorticoids, both orally and intravenously, with the suspicion that giant cell arteritis was causing acute visual deterioration of his left eye. Unfortunately, his symptoms did not improve. During an admission to hospital for a pneumonia, he underwent further investigations for this bilateral visual loss. He was diagnosed with left neuroretinitis and right vitritis. A thorough workup revealed positive syphilis serology and cerebrospinal fluid was positive on venereal disease research laboratory testing. He was diagnosed and treated for neurosyphilis with intravenous benzylpenicillin 4 million units 4 hourly for 14 days. His left-sided vision improved but he still suffers from severe visual impairment in his right eye.

Diagnosis of Syphilitic Bilateral Papillitis Mimicking Papilloedema

Syphilis produces myriad nonspecific signs and symptoms. For example, optic disk swelling might be seen in patients with syphilis as a result of cranial hypertension (papilloedema), inflammatory optic neuritis with papillitis, or optic perineuritis. We report a case involving differential diagnosis of syphilitic bilateral papillitis mimicking papilloedema.

Syphilis with diplopia

BACKGROUND

Syphilis is a sexually transmittable infectious disease caused by the spirochaete Treponema pallidum, which classically causes symptoms in three stages.

CASE PRESENTATION

A previously healthy male in his thirties was admitted to our department after suffering from diplopia and unilateral ptosis for two days. Clinical examination revealed a left-sided oculomotor palsy with an ipsilateral ptosis. Supplementary cerebral computer tomography with angiography and magnetic resonance imaging was normal except for lymphadenopathy in the neck and mediastinum. As the patient was homosexual, we chose to test for HIV. The doctor on duty, being from Belarus where syphilis was recognised as endemic during her studies, also screened for syphilis. The HIV test was negative, while the syphilis test was positive. Lumbar puncture showed moderate pleocytosis and positive serology for syphilis, confirming the diagnosis of neurosyphilis. The patient recovered fully after a course of penicillin.

INTERPRETATION

Even though syphilis remains uncommon in Norway, the incidence has been increasing in recent decades, especially in male homosexual communities. Patients may subsequently present with a diversity of symptoms.

Re-emerging Neurosyphilis in Korea as a Possible Etiology of Psychotic Disorders with Pleomorphic Symptoms and Cognitive Dysfunction: a Case Report and Literature Review

Infectious diseases of immigrant populations have recently become important issues for the health of both Korean nationals and foreigners living in Korea. This case report of general paresis is intended to raise awareness about re-emerging neurosyphilis in Korea as a possible etiology of psychotic disorders. A 68-year-old male Chinese resident came to Korea in 2019 with disorientation, auditory hallucination, persecutory delusion, and aggressive behavior, and was admitted to a psychiatric ward for further evaluation and treatment via the emergency department. He was confirmed to have neurosyphilis by serum test, analysis of cerebrospinal fluid, and brain magnetic resonance imaging. After treatment with antibiotics, including intravenous penicillin, in combination with atypical antipsychotics for 6 weeks, his disorientation, auditory hallucination, delusion, and aggressive behavior had attenuated. Neurosyphilis should still be included as a possible etiology of psychotic disorders in Korea. At the initial evaluation, syphilis screening serum tests are recommended for psychotic patients, especially those with pleomorphic symptoms and cognitive dysfunction.

Neurocognitive disorder due to neurosyphilis: a case report

INTRODUCTION

Neurosyphilis is a chronic infectious disease caused by Treponema pallidum that can cause a great variety of neuropsychiatric signs and symptoms, which complicates its diagnosis.

CASE DESCRIPTION

This case occurred in a 40-year-old man who consulted the Emergency Department because of a convulsion (de novo) which was related to a chronic condition of cognitive impairment and psychosis. The appropriate studies were performed for the diagnosis of neurosyphilis and the recommended treatment was initiated. The patient presented clinical improvement and was discharged.

DISCUSSION

Positive VDRL serology results and imaging findings of marked cortical atrophy conducted to consider a late-stage parenchymatous neurosyphilis with serious cognitive impairment and associated psychosis. Treatment with crystalline penicillin was formulated, which reduced the intensity of the patient's symptoms; however, the patient's lack of interest to attend the check-ups significantly reduces his chances of an adequate recovery.

CONCLUSIONS

Neurosyphilis must be suspected in patients with clinically evident neurological or psychiatric symptoms. Analysis of VDRL serology and neuroimaging studies are important as an initial evaluation of the patient and must be complemented with cognitive tests or mental examination to determine the state of cognitive impairment.

Neuropsychiatric manifestations in General Paralysis of Insane (GPI)

General paralysis of insane is a form of neurosyphilis which brings parenchymatous changes in the central nervous system. Its manifestations include a variety of neuropsychiatric symptoms ranging from cognitive impairment to overt psychosis. Clinicians face difficulties in proper diagnosis as variety of symptoms changes from one form to other within a short period of time. Rarity of the disease at this modern era of penicillin is also another factor in timely diagnosis and management of such cases. Here we present a case of general paralysis of insane who presented with variety of neuropsychiatric symptoms and have had great difficulties to reach into the diagnosis.

A man in his forties with acute onset of speech impairment and unilateral paresis

BACKGROUND

Stroke has several causes and the diagnostic investigation can be challenging. Neurosyphilis occurs when Treponema pallidum infects the central nervous system, and is a rare cause of stroke.

CASE PRESENTATION

A man in in his late forties with diabetes mellitus and overweight presented with headache, speech impairment and right-sided stroke symptoms. He also had cognitive impairment and psychiatric symptoms. He underwent intravenous thrombolysis, and standardised stroke investigation was without clear findings. Cerebral MRI demonstrated non-specific subtle changes in the primary motor cortex in the left frontal lobe. However, lumbar puncture revealed elevated white blood cell count, and syphilis tests were positive.

INTERPRETATION

Diagnosis of syphilis is often difficult and requires specific suspicion. Due to increasing incidence of the disease and its therapeutic consequences, alertness around the condition is important. Neurosyphilis should be suspected in young patients with stroke symptoms in the absence of risk factors and/or with cryptogenic strokes, especially in the presence of risk factors for syphilis infection and in patients from endemic areas.

Young male with syphilitic cerebral arteritis presents with signs of acute progressive stroke: A case report

INTRODUCTION

Neurosyphilis is a chronic infection of the central nervous system that is commonly found in adult with long latency periods. Neurosyphilis-attributed deaths in young patients have grown exponentially in the past decade, yet there have been few studies on the early stages of neurosyphilis.

PATIENT CONCERNS

A young male patient with syphilitic cerebral arteritis was evaluated in our clinic for the clinical signs of progressive ischemic stroke.

DIAGNOSIS

The progression of syphilitic cerebral arteritis was observed through computed tomography imaging, magnetic resonance imaging, magnetic resonance angiogram, and transcranial color Doppler. The pathological changes and clinical outcomes were reviewed. In this specific case, the development of syphilitic cerebral arteritis was dynamic, continuous, and rapid. The pathogenesis was related to Heubner arteritis, in which the formation of a mural thrombus (MT) causes the severe obstruction of blood flow without complete occlusion, leading to an increased risk of infarction. In this patient, formation of the MT resulted in the infarction of the smaller vessels and narrowing of the larger vessels. The partial dislodgment of the MT from the arterial wall of the larger vessels occluded the smaller vessels, leading to infarction.

INTERVENTIONS

Standard pharmacotherapy for the treatment of the cerebral infarction and a single course of penicillin were applied.

OUTCOMES

Muscle strength was recovered. The Glasgow Coma Scale score was 15, whereas the NIH Stroke Scale score was 0. The increase in blood flow of the right MCA was accompanied by severe stenosis with compensation of the anterior communicating artery. In addition, moderate to severe stenosis of the right vertebral artery and the basilar artery was suspected. There was a possibility that the right posterior communicating artery was recruited for compensation.

CONCLUSION

Progressive stroke was the initial symptom of the neurosyphilis. Disease progression is rapid and difficult to control with a single course of penicillin.

Neurosyphilis complicated with pial arteriovenous fistula: A rare case report

INTRODUCTION

Neurosyphilis is a chronic, infectious disease of the central nervous system. Pial arteriovenous fistulae (PAVF) are rare vascular malformations. Both can cause vascular damage, but it is quite rare for both to present at the same time.

PATIENT CONCERNS

Here we present a 66-year-old man with affective disorder, hypomnesia, and recent convulsions. Magnetic resonance imaging revealed cerebral swelling, hyperintensity in the cortex/subcortex, and multiple lacunar cerebral infarctions. Computed tomography angiography revealed the presence of a pial arteriovenous fistula.

DIAGNOSES

Based on laboratory tests and imaging, diagnoses of neurosyphilis and pial arteriovenous fistula were made.

INTERVENTIONS

Antisyphilis therapy was provided.

OUTCOMES

Symptoms improved and antisyphilis treatment continued as an outpatient. No intracranial hemorrhage was seen 6 months later.

CONCLUSION

Treponema pallidum infection may be related to the formation of PAVF, and may also promote the progression of it; however, further work is required to confirm this.

Lesson of the month 1: Neurosyphilis mimicking viral encephalitis and ischaemic stroke

With the incidence of syphilis more than doubling over the last decade, knowledge of its manifestations is of increasing importance. Yet, today's clinicians are less experienced in the recognition of syphilis than the physicians of Osler's day.In this case, a 56-year-old man presented with acute confusion and a history suggestive of encephalitis. Neuroimaging revealed cystic infarcts. He was subsequently tested for HIV and syphilis and found to be positive for both. HIV co-infection had accelerated the rate of neurosyphilis progression. After timely diagnosis and treatment of both conditions, cognitive testing returned to baseline.This case highlights that neuroimaging can often show non-specific infarcts and haemorrhages instead of characteristic syphilitic gummae. This variability adds to the challenge of diagnosis. Thus syphilis serology screening should be sent in those presenting with acute confusion and neuroimaging abnormalities. In cases of cryptogenic stroke, syphilis serology should be added to the screening tests.

Neurosyphilis: Concordance between cerebrospinal fluid analysis and subsequent antibiotic strategy for patients undergoing evaluation of a diagnosis of neurosyphilis

INTRODUCTION

The confirmation or analysis and exclusion of a diagnosis of neurosyphilis has long presented a challenge for infectious diseases clinicians. The authors reviewed the concordance between cerebrospinal fluid (CSF) analysis and the subsequent antibiotic strategy for patients undergoing evaluation of a diagnosis of neurosyphilis.

METHODS

All patients with positive serum syphilis serology referred for CSF analysis between January 2009 and May 2016 were included. Indications for CSF analysis were determined by review of the hospital electronic medical records. CSF parameters were determined from the hospital pathology database. Cases were defined as either 'confirmed', 'supportive' of, or 'not supportive' of a diagnosis of neurosyphilis based on existing definitions. Subsequent therapy was defined as for neurosyphilis, late latent primary syphilis or no therapy based on existing guidelines.

RESULTS

Of 131 patients reviewed, 95.4% were male and HIV co-infected (74%). A confirmed diagnosis of neurosyphilis was met by fourteen patients (10.7%). All but two of these were treated with a neurosyphilis-directed regimen. Of the 58 patients treated with neurosyphilis antibiotics, 17.2% had no CSF findings suggestive of the diagnosis. Seventy-three patients were not treated for neurosyphilis; however 35 of these met the CSF criteria for a diagnosis supportive of neurosyphilis.

CONCLUSIONS

The results of routine CSF analysis in patients with a possible diagnosis of neurosyphilis are inconsistently applied in the clinical setting, calling into question the value of routine CSF. Empirical neurosyphilis treatment should be considered up front in patients with high pre-test probability of the diagnosis.

Spinal Cord Syphilitic Gumma Presenting with Brown-Séquard Syndrome: A Case Report and Literature Review

BACKGROUND

Spinal neurosyphilis manifesting as a solitary syphilitic gumma is exceedingly rare. There are non-specific imaging findings and challenges in the diagnosis of spinal syphilitic gumma, which could be easily misdiagnosed as tumor lesions and require surgical resection or biopsy.

CLINICAL PRESENTATION

We report the case of a 45-year-old female patient who was diagnosed with Spinal syphilitic gumma. Our case is the first reported case of spinal cord syphilitic gumma with intradural-extramedullary and intramedullary involvement.

CONCLUSION

Spinal syphilitic gumma exhibits diverse clinical manifestations, lacks specific imaging features, accompanied by the patient's history deliberately concealed. Since clinicians do not have sufficient knowledge about such rare cases, misdiagnosis and missed diagnosis will be likely. When there is clinical suspicion for spinal syphilitic gumma, clinicians should pay close attention to relevant medical history, carry out a comprehensive physical examination and specific serological tests and cerebrospinal fluid (CSF) analysis. In summary, in cases with stable neurologic conditions, a trial administration of intravenous penicillin with follow-up imaging may be the optimal treatment option, and in cases with rapid progression or acute exacerbation, a surgical resection together with systemic antibiotic treatment for syphilis after surgery may be the best treatment strategy.

Early neurosyphilis presenting with multiple cranial nerve palsies: A case report of management by combined penicillin-corticosteroid treatment

Early neurosyphilis commonly appears in basilar meninges, and its meningeal inflammation can spread to neighboring cranial nerves, resulting in some cranial nerve palsies. Herein, we report a case of a 51-year-old man who presented with right peripheral facial nerve palsy. His symptoms completely disappeared with prednisolone monotherapy without antibiotics use and were not exacerbated during clinical treatment. However, 2 months after remission of seventh cranial neuropathy, fifth and eighth cranial neuropathies appeared on the right side. Serologic tests for syphilis were revealed to be abnormal. Finally, the patient was diagnosed with early neurosyphilis with multiple cranial palsies. His neurological symptoms were markedly improved by combined penicillin-corticosteroid treatment. Systemic corticosteroids could be effective as adjunctive therapy to ameliorate neurological sequelae in early neurosyphilis.

[A case of relapsed neurosyphilis with progressive left hemiparesis]

A 52-year-old man presented with progressive dementia and left hemiparesis. He was treated for neurosyphilis at 44 years old in another hospital. An initial MRI revealed a widespread high-intensity area in the right temporal lobe on DWI. Findings on MRA were normal. He was treated initially with intravenous edaravone and glyceol, but neurological finding did not improved. Serological tests of serum and CSF demonstrated high titers of antibodies to Treponema pallidum. He was treated for relapsed neurosyphilis with daily penicillin G injections without improvement. Penicillin G was switched to erythromycin. After administration of erythromycin, neurological symptoms improved and MRI abnormality showed progression. This case could be considered as Lissauer form of general paresis because of left hemiparesis and MRI findings. Neurosyphilis should be considered in a case with revealing high density area in DWI.

The clinical and laboratory features of neurosyphilis in HIV-infected patients: A retrospective study in 92 patients

Neurosyphilis (NS) is an important component of central nervous system diseases among HIV-infected patients. However, its characteristics are not very clear. A retrospective analysis of clinical and laboratory findings was performed in 92 NS patients with HIV infection from a tertiary hospital in Shanghai, China. The patients had a median age of 38 years and a median CD4 count of 198 cells/μL. In all, 44.6% (41/92) were diagnosed as asymptomatic NS (ANS), 23.9% (22/92) as syphilitic meningitis, 17.4% (16/92) as cerebrovascular NS, and 14.1% (13/92) as parenchymal syphilis. A quarter of patients (23/92) complicated with ocular syphilis (OS), 60.9% (14/23) of which were ANS. The serum tolulized red unheated serum test (TRUST) titers were ≤1:8 in 15 patients (16.3%), 1:16-1:128 in 51 patients (55.4%), and ≥1:256 in 26 patients (28.3%). Sixty-nine patients (75.0%) had both cerebrospinal fluid (CSF) TRUST and Treponema pallidum particle assay reactive. CSF pleocytosis and protein elevation were found in 58.7% and 53.3% of patients, respectively. Syphilitic meningitis was more likely to present with CSF pleocytosis than ANS (P = .001), cerebrovascular NS (P < .001), and parenchymal NS (P < .001). The proportion of patients with CSF elevated protein was lower in ANS group than that in syphilitic meningitis (P = .003), cerebrovascular NS (P = .001), and parenchymal NS groups (P = .025), and was higher in sero-TRUST titers ≤1:8 group than that in 1:16-1:128 (P = .01) and 1:256-1:1024 groups (P = .005).This study revealed that ANS was the most common clinical type of NS in HIV-infected patients, which should be considered in HIV and syphilis co-infection patients without neurologic symptoms, especially in those with OS. Different patterns of NS might have different CSF features which may also vary with sero-TRUST titers.

[Neurosyphilis as differential diagnosis in psychiatry]

A 46-year-old previously healthy man was referred to a psychiatric department after debuting with persecutory delusions. He had symptoms of Parkinson's disease as well as a significant impairment of memory and cognitive function. Neurological tests detected discrete balance and rigidity problems. Paraclinical tests were normal, and neurologists explained the symptoms as side effects to the antipsychotic medication. A lumbar puncture showed high concentrations of leukocytes and protein, and syphilis screening was positive. Neurosyphilis often debuts with psychiatric symptoms as seen in this case.

Neurosyphilis - the white matter disintegration? - two case reports

BACKGROUND

There is evidence for neurosyphilis being associated with the central nervous system vasculitis involving medium and small vessels. As the hemispheric white matter is the major target of these vascular alterations the white matter axonal and myelination disruption may be observed employing measure for the rate of water molecule diffusion. High apparent diffusion coefficient (ADC) correspond to unimpeded water diffusion and indicating white matter disintegration.

CASE REPORTS

In a retrospective study exploringcentral nervous system magnetic resonance (MR) images of two subjects presenting with neurosyphilis the ADC values were found to be increased as related to normal values being accompanied with normal appearing white matter of hemispheres.

CONCLUSIONS

Applying ADC analysis to evaluate the brain in patients with neurosyphilis may reveal undetectable changes and explain the scale of abnormalities that occur in CNS. The increased mean ADC valuesin the normal appearing white matter of the hemispheres may correlate with neuropsychoatric symptomatology in syphilis.

Neurosyphilis presenting with cognitive deficits - a report of two cases

BACKGROUND

Neurosyphilis is an infection of the brain or spinal cord caused by Treponema pallidum. In the third phase of syphilis involving the central nervous system it may manifest in a widespread dysfunctions including psychiatric manifestations being often underestimated in the differential diagnosis.

CASE REPORTS

Two patients demonstrating rapid cognitive decline as the primary symptom for neurosyphillis are described with particular focus on the diagnostic process complexity and adequate treatment delivery.

CONCLUSIONS

Clinical manifestations as well as psychiatric symptoms of syphilis are diverse and often non-specific. The symptomatology of mood disorders in neurosyphilis is frequently atypical, intermittent, and pleomorphic and fails to meet DSM-5 diagnostic categories. Neurocognitive decline although could be one of the key symptoms domains in neurosyphilis. Those two cases emphasise the importance of specific differential diagnosis with rapid onset cognitive decline with spotlight to sexually transmitted diseases as syphilis.

DIAGNOSIS OF ENDOCRINE DISEASE: Expanding the cause of hypopituitarism

Hypopituitarism is defined as one or more pituitary hormone deficits due to a lesion in the hypothalamic-pituitary region. By far, the most common cause of hypopituitarism associated with a sellar mass is a pituitary adenoma. A high index of suspicion is required for diagnosing hypopituitarism in several other conditions such as other massess in the sellar and parasellar region, brain damage caused by radiation and by traumatic brain injury, vascular lesions, infiltrative/immunological/inflammatory diseases (lymphocytic hypophysitis, sarcoidosis and hemochromatosis), infectious diseases and genetic disorders. Hypopituitarism may be permanent and progressive with sequential pattern of hormone deficiencies (radiation-induced hypopituitarism) or transient after traumatic brain injury with possible recovery occurring years from the initial event. In recent years, there is increased reporting of less common and less reported causes of hypopituitarism with its delayed diagnosis. The aim of this review is to summarize the published data and to allow earlier identification of populations at risk of hypopituitarism as optimal hormonal replacement may significantly improve their quality of life and life expectancy.