ACUTE STROKE DURING PENICILLIN DESENSITIZATION DUE TO JARISCH HERXHEIMER

Abstract

<h3>Introduction</h3> Jarisch Herxheimer reaction (JHR) is a transient episode seen within 24 hours of treatment with antibiotics in patients infected by spirochetes. Although seen in 95% of patients, it occurs rarely in late or latent syphilis. The severity depends on the spirochete load. <h3>Case Description</h3> A 21-year-old female, 23 weeks pregnant, presented for penicillin desensitization as treatment of late latent syphilis. She had developed a systemic cutaneous reaction at age 2 and anaphylaxis at age 14 after exposure to penicillin. During the last dose of desensitization, she developed acute left sided weakness (2/5 power) and numbness (absent distal sensation) of her arm and leg. The infusion was stopped and she was given tissue plasminogen activator. Her CT and MRI head were negative for stroke. Her symptoms resolved 5 hours later and were attributed to Jarisch Herximer reaction. Lumbar puncture was negative for neurosyphillis. She was subsequently re-desensitized and given 2.4 million IM Benzathine penicillin Qweek for 3 weeks. She had reduction in RPR and has delivered. <h3>Discussion</h3> We report a case of focal neurologic deficits with no known stroke risk factors, from JHR during IV penicillin desensitization. JHR presentation can vary in different stages of syphilis. It is rarely seen in late or latent syphilis infection. Neurologic manifestations include convulsions or focal deficits. During desensitization, JHR symptoms can be concerning for anaphylaxis with hypotension and rash. Although it is an acute, self-limiting condition, it is important to identify JHR and to distinguish it from allergic reactions for appropriate treatment.