Syphilitic meningomyelitis presenting with visceral crisis: A case report

RATIONALE

We report a rare case of syphilitic meningomyelitis presenting with visceral crisis and possessing characteristic imaging findings.

PATIENT CONCERNS

The patient, a 50-year-old woman, complained of pain in the upper abdomen and back. She then developed numbness in both lower extremities and weakness in the left lower limb.

DIAGNOSIS

Magnetic resonance imaging (MRI) of the spinal cord revealed the candle guttering sign and irregular enhancement at the T6 level. Rapid plasma reagin test of the cerebrospinal fluid yielded a titer of 1:8. Thus, the patient was diagnosed with syphilitic meningomyelitis.

INTERVENTIONS

She was treated with ceftriaxone and dexamethasone after the failure of penicillin treatment.

OUTCOMES

She could perform the activities of daily living, and her pain completely disappeared.

LESSONS

A patient with syphilitic meningomyelitis can present with visceral crisis caused by the involvement of the posterior nerve roots or the posterior horn, which usually occurs in patients with tabes dorsalis. Considering the non-specific symptoms and MRI features, we should be aware that abdominal pain may be a symptom of myelopathy, and syphilitic meningomyelitis ought to be taken into account in a patient with longitudinally extensive myelitis.

DEVELOPMENT OF GANGLIONOPATHY AND TABETIC VISCERAL CRISES ON THE BACKGROUND OF POLYRADICULONEUROPATHY ASSOCIATED WITH MONOCLONAL GAMMOPATHY (CASE REPORT)

The article presents an analysis of the clinical occurrence of development of chronic polyradiculoneuropathy associated with monoclonal IgG/k (kappa) gammopathy of the undetermined significance. The peculiarity of this occurrence is the uniqueness of the development of the symptoms which are characteristic of tabes dorsalis in this pathology with episodic severe visceral crises and also with ganglionopathy. The example describes the clinical polymorphism of the course of visceral crises, the problems of their diagnosis and as a consequence of inadequate treatment with the development of severe social maladaptation. The importance of timely diagnosis and treatment of such conditions is discussed.

Longitudinally Extensive Transverse Myelitis and Optic Neuropathy Associated with Syphilitic Meningomyelitis and Human Immunodeficiency Virus Infection: A Case Report and Review of the Literature

The incidence of co-infection with Treponema pallidum and human immunodeficiency virus (HIV) is increasing in developing and developed countries. The neurological complications of both infections occasionally occur simultaneously during a clinical course. We herein report the case of an HIV carrier with syphilitic meningomyelitis and subclinical optic neuropathy. The patient presumably had latent syphilis and slowly developed longitudinally extensive transverse myelitis (LETM). A cerebrospinal fluid examination confirmed the diagnosis of active neurosyphilis based on an elevated T. pallidum hemagglutination assay index. A change in the patient's immune status, possibly due to HIV, might have converted the syphilis from latent to active, leading to LETM of the spinal cord.

[Chronic hydarthrosis of the knee in a Tunisian patient: tabetic arthropathy]

Tabetic arthropathy (TA) is a type of neuropathic arthropathy that has become rare. The purpose of this report is to describe a case of tabetic arthropathy involving the knee. A 53-year-old man was hospitalized for painless right knee arthropathy. Clinical examination demonstrated hydarthrosis of the right knee, peripheral neuropathic syndrome of the lower limbs, and paralysis of the IXth and Xth cranial pairs. Plain radiography showed the presence of lytic lesions in the internal femoral condyle and tibial plateau. Syphilitic serology tests were positive in the blood and cerebrospinal fluid.

Case report: Neuropathic arthropathy of the hip as a sequela of undiagnosed tertiary syphilis

BACKGROUND

Neuropathic arthropathy is characterized by rapidly progressive bone destruction in the setting of impaired nociceptive and proprioceptive innervation to the involved joint. It is seen most commonly in the foot and ankle, secondary to peripheral neuropathy in patients with diabetes mellitus. Other less common sites of involvement may include the knee, hip, shoulder, and spine, depending on the underlying etiology. Neuropathic arthropathy can be associated with tabes dorsalis, a unique manifestation of late, tertiary neurosyphilis that may arise in individuals with untreated syphilis many years after initial infection, and usually involves the knee, or less commonly, the hip.

CASE REPORT

We report the case of a 73-year-old man with neuropathic arthropathy of the hip and tabes dorsalis attributable to previously undiagnosed tertiary syphilis. There was considerable delay in the diagnosis and unnecessary diagnostic testing owing to failure to consider syphilis as the cause.

LITERATURE REVIEW

With the advent of effective antimicrobial therapy and public health campaigns, the relationship between untreated syphilis and neuropathic arthropathy has been primarily a historic point of interest. However, current epidemiologic research suggests a resurgence of syphilis in the United States, with an increased incidence of patients presenting with manifestations of tertiary syphilis from unidentified and untreated primary infections. Treatment options for neuropathic arthropathy of the hip are limited. Arthrodesis has had poor success and treatment with THA has had high complication rates.

CONCLUSIONS

Syphilis is not merely a historic cause of neuropathic arthropathy. Neurosyphilis and tabes dorsalis should be considered in the differential diagnosis for patients presenting with rapid joint destruction consistent with Charcot arthropathy and no other apparent cause.

[Indications for lumbar puncture in patients with early active syphilis and human immunodeficiency virus coinfection: experience in a tertiary level hospital in La Coruña, Spain, 2003-2006]

INTRODUCTION

In the last years, the incidence of syphilis has incremented in Spain and coinfection with HIV occurs in a high percentage. In HIV-infected patients with syphilis, neurological complications, treatment failure and relapse appear to be slightly raised. Therefore, careful follow-up must be carried out because of the risk of developing neurosyphilis. According to the guidelines, lumbar puncture (LP) is indicated in HIV-infected patients with late latent syphilis or syphilis of unknown duration, but it is discussed in HIV-infected patients with early active syphilis. Recent research has been developed in order to determine clinical and analytical findings for identification of patients with high neurosyphilis risk. We review different opinions about this topic and report our experience.

METHODS

We have performed LP in all HIV-infected patients with early active syphilis during 2003-2006.

RESULTS

Of the eight studied patients, none met criteria for neurosyphilis. Three of eight (38 %) had a peripheral blood CD4 cell count CD4 + <or= 350 cells/microL. Seven of eight (875 %) had RPR >or= 1:32.

CONCLUSION

In these patients, performance of LP could be over indicated because of lack of well-established criterion. Our results are in agreement over to recent studies which restrict indication of LP to specific groups.

Charcot's arthropathy of the hip joints: a late manifestation of tabes dorsalis successfully treated by total joint arthroplasty. report of 2 cases

This article describes 2 cases of Charcot's arthropathy of the hip joints successfully treated with cemented total hip arthroplasty. Follow-up at 10 and 9.5 years confirmed the success of the treatment. This article also includes a review of current publications on the topic.

Tabetic arthropathy. A report of 43 cases

Destructive tabetic arthropathy (TA) has become rare in the course of syphilis because of early diagnosis and treatment. TA is difficult to manage because of the severity of the handicap and the absence of a specific treatment. We describe the clinical, biological, and radiological characteristics of TA. In this paper, we performed a retrospective study of 24 patients with TA from 1983 to 2003. Inclusion criteria were typical radiological findings and positive syphilitic serology in blood and/or synovial fluid and/or cerebrospinal fluid. Included in the study were 15 men and 9 women, their mean age was 53.71+/-12.25 years, and the delay of diagnosis was 36.83+/-53.03 months. Thirteen patients (54.2%) had a known primary syphilitis. In the studied cases, 43 of the patients' joints were involved, which concerned knees, hips, the spine, and ankles in 91.66, 8.33, 8.33, and 4.16% of cases, respectively. TA was bilateral in 62.5% and multifocal in 8.3%. The neurological exam found signs suggesting tabes dorsalis in seven cases. The osteoarticular exam showed an abnormal range of mobility (n=25), hydarthrosis, and articular deformation (n=17). Syphilitic serology tests were positive in synovial fluid, cerebrospinal fluid, and blood in 12 (50%), 8 (33.33%), and 24 (100%) cases, respectively. Radiological exam showed atrophic and hypertrophic forms. The frequency and severity of TA in our study may be explained by the frequency of atypical forms of syphilitis and the absence of penicillin in Morocco in the 1950s.

Functional recovery from paraplegia caused by syphilitic meningomyelitis

BACKGROUND

Syphilitic involvement of the nervous system can present in many different ways. We report a patient who presented with rapidly evolving paraparesis secondary to syphilitic meningomyelitis.

METHODS

Case report.

FINDINGS

Cerebrospinal fluid (CSF) studies confirmed the diagnosis of neurosyphilis. Spinal magnetic resonance imaging (MRI) studies were indicative of leptomeningeal and thoracic spinal cord disease. Treatment with IV penicillin resulted in marked clinical, radiologic, and CSF improvement. MRI imaging provided documentation of spinal cord involvement and was useful in monitoring recovery. This patient's progressive neurologic improvement was monitored for 2 years and documented by periodic Functional Independence Measure scores.

CONCLUSION

Recognition of this unusual complication of secondary neurosyphilis is important, because it is a treatable cause of paraparesis with potential for good recovery.

Rapidly progressive tabes dorsalis associated with selective IgA deficiency

Tabes dorsalis is uncommon and progresses slowly from infection to clinical manifestation. We report a rare case of rapidly progressive tabes dorsalis associated with selective IgA deficiency (sIgAD). A 28-year-old man was hospitalized with lightning back pain, nausea, and bladder bowel dysfunction. Serum and cerebrospinal fluid (CSF) revealed high titers of Treponema pallidum antibody, and the serum IgA level was less than 5 mg/dl. Thl-dominant cytokine expression was observed, as is usually seen in neurosyphilis. He was treated with Ceftriaxone and CSF pleocytosis disappeared. We postulate sIgAD influenced the atypical rapid clinical course of tabes dorsalis in this patient.

Pachymeningitis luetica: a case report

Pachymeningitis luetica is extremely rare in developed countries. We describe a 41-year-old male patient with pachymeningitis luetica, multiple ischaemic infarctions, and severe hydrocephalus. The delay in making the diagnosis contributed to patient's death. Rapid diagnosis is essential on the slightest suspicion of an infection by Treponema pallidum, because timely treatment with antibiotics is effective.

Syringomyelia complicating syphilitic spinal meningitis: a case report

An association between syringomyelia and spinal syphilis was described in the early literature but has not been the subject of reports subsequently. We give details of a contemporary case, affirmed by magnetic resonance imaging. The patient showed significant clinical recovery following penicillin treatment, while the imaging appearances became less pronounced.

[A case of tabes dorsalis observed in an HTLV-1 carrier]

We report a case of a 53-year-old female HTLV-1 carrier with tabes dorsalis. In addition to typical symptoms of tabes dorsalis, she presented HTLV-1 associated myelopathy (HAM) like clinical features such as sensory disturbance with thoracic sensory levels and bladder disturbance (pollakiuria). Although penicillin treatment did not improve in her neurological symptoms, steroid therapy was effective especially in HAM like symptoms. The CSF neopterin level was markedly decreased after steroid therapy, indicating that inflammation in the spinal cord was settled down after treatment. Our case suggests that CNS infection like tabes dorsalis may be modified by HTLV-1 infection and then present some atypical clinical features based upon altered immunological aspects of HTLV-1 carriers.

A new case of insufficiency fracture in a patient with tabes dorsalis

A new case of insufficiency fracture in a patient with tabes dorsalis is reported. Whereas the osteoarthropathies and bone lesions due to tabes dorsalis are well known, only one other case responsible for bone loss has been reported in the medical literature.

[Neuro-arthropathy, a painless but very destructive disorder of frequently one joint]

In a 38-year-old man who suffered from recurrent painless swelling of the right knee, neuroarthropathy was diagnosed, associated with tabes dorsalis. The patient was treated with a knee brace to stabilise the joint. Neuroarthropathy is a progressive degenerative joint disease caused by a central or a peripheral neurological disorder and causing denervation of the joint.

Neurosyphilis presenting as tabes dorsalis in a HIV carrier

Tabes dorsalis associated with human immunodeficiency virus (HIV) infection is extremely rare. This is a report of a 36-year-old male who had developed unsteady gait for 4 months. Tabes dorsalis was diagnosed by clinical manifestation and CSF examination. HIV antibody was proved by Western blotting. HIV accelerates and alters the natural course of treponemal infection by changing the immunological response of the lues.

[A case of severe rarefaction osteopathy associated with tabes dorsalis]

The authors report the case of a 63 years old man who presented 13 years after a diagnosis of a tabes dorsalis, stress fractures of the lower limbs and Charcot's joints (knees). 7 years later, he had multiple stress fractures of the sacrum and pelvis and of the ribs following a minor trauma. Laboratory investigations revealed a major osteoporosis probably related to the neurochirurgical complications of the tabes dorsalis.

Loosening of a hip prosthesis in a patient affected with tabetic disease

The authors present a case of hip Charcot joint treated with cemented arthroplasty. Although there was only weak serological positiveness for lues and no neurological changes associated with the disease, three months after surgery there was dislocation and loosening of the prosthesis.

Disorders of micturition in tabes dorsalis

The aim of this study was to determine whether the disorders of micturition that occur in patients with tabes dorsalis can be attributed exclusively to disturbed bladder sensation, as has been previously suggested. Urodynamic studies were performed in 8 patients with tabes dorsalis who had no obvious organic obstructive urological disease. The results indicated that not only disturbed bladder sensation but also suprasacral and/or sacral lesions innervating the detrusor could be responsible for voiding dysfunction in such patients.

Meningovascular syphilis of the spinal cord presenting with incomplete Brown-Séquard syndrome: case report

A man aged 31 presented to hospital with acute onset of weakness in the legs, sensory loss, and disturbance of bladder and bowel function. Incomplete Brown-Séquard syndrome secondary to meningovascular syphilis of the spinal cord was diagnosed after serological tests for syphilis gave positive results. His condition was probably caused by endarteritis of the arteria radicularis magna of Adamkiewicz. He was treated with procaine penicillin 1.8 MIU intramuscularly once a day and probenecid 0.5 g by mouth three times a day for 21 days followed by physiotherapy and rehabilitation. Considerable neurological recovery was expected. To our knowledge this association has not been reported previously in detail in an English publication.

[Changes in the femoral neck in tabes dorsalis. Case report]

The authors analyze diagnostic and therapeutic problems in fractures associated with tabes dorsalis. In the foreground of the clinical picture are in the majority neurological symptoms. The first symptoms develop 15 years after the primary infection. The laboratory results are not decisive for the diagnosis. Previously treatment of these fractures was conservative in rare instances arthrodesis of the affected joint was performed. In the case-history the authors submit new therapeutic possibilities in fractures of the neck of the femur associated with tabes dorsalis, using total endoprostheses of the hip joint. The authors mention also possible complications. The subjective evaluation by the patient is, however, very favourable.

[Endoprosthetic management of tabes dorsalis arthropathy]

Three special cases of tabic arthropathy are reported. The disease is displayed in detail. One case showed an aneurysma of the arteria ulnaris. After resection of the aneurysma conservative treatment was performed. In a second case with active not yet diagnosed tabic hip a cemented total hip was implanted, which failed only 9 weeks later. The third case was an inactive tabic hip joint. The implantation of a cementless Autophor hip proved well. Total joint replacement has not to be performed in an active state of the disease, but can be done after consolidation. The significance of the VDRL-test for justing the activity of the disease is displayed.

Voiding dysfunction in tertiary syphilis

After years of decline to near disappearance, there recently has been an increasing incidence of syphilis in America. New cases of tertiary neurosyphilis are being reported which often have associated significant urologic sequelae. For the first time in the English literature, the uro-dynamic findings of a patient with tabes dorsalis are presented. Our findings indicate that treatment of urinary retention associated with tabes dorsalis is better managed by intermittent catheterization than by prostate surgery because of the impaired detrusor activity. A review of neurosyphilis and its urologic implications and urodynamic findings are presented. Prompt recognition of this entity should encourage a full urodynamic evaluation prior to a commitment to prostatic surgery.

Multiple neuropathic arthropathy in a patient with syphilis

An unusual case of neuropathic arthropathy in a patient with tabes dorsalis is presented. The special feature consisted of multiple joint involvement in the upper limbs and spine. This uncommon location of Charcot joints can probably be attributed to the patient's occupation which involved heavy strains on his upper limbs.

Total prosthetic replacement in tabetic arthropathy of the hip joint

The treatment of tabetic arthropathy of the hip by prosthetic replacement has been recorded in the literature in 5 cases, of which only 4 were followed up. The authors present 4 more cases in which follow-up showed that the operation was definitely contraindicated in this condition. All the cases developed recurrent subluxation and/or loosening of the prosthesis.

Pathogenesis of the neurotrophic joint: neurotraumatic vs. neurovascular

The most widely accepted and propagated theory of neurotrophic joint pathogenesis is the neurotraumatic one. Seldom published and little known is the neurovascular theory. To gain better understanding of the pathogenesis, we reviewed radiographs of 91 neurotrophic joints with attention to the particular joint affected, the type of changes present (resorptive vs. productive), and the time sequence involved. The pathological findings, when available, were also reviewed. While many joint changes could not be explained on a traumatic basis alone, all could be explained by a vascular mechanism.