An unusual cause of paraplegia

Abstract

A 40-year-old man was admitted to hospital with an acute onset of paraplegia of 5 days' duration, preceded by vague back pain in the interscapular region for 2 months. The pain was intermittent and was relieved by rest and analgesics. He had no significant past medical history. Physical examination revealed a gibbus at the level of the thoracic (T4–T6) vertebrae and signs of extramedullary cord compression at T7 level. Cardiovascular, respiratory, abdominal and ophthalmological examination was unremarkable and there were no Marfanoid features. Full blood count, biochemical and lipid profile, and electrocardiogram were within the normal range. Sputum examination was negative for acid-fast bacilli. Chest X-ray (Figure 1) showed mediastinal widening and X-ray of dorsolumbar spine showed scoliosis at T5–T8 with convexity to the right. Magnetic resonance imaging revealed gross dilatation of the arch of aorta and two large saccular aneurysms with size of 11.3 cm × 10.8 cm and 9.4 cm × 10.2 cm, causing destruction of T6–T9 vertebrae and spinal cord compression (Figure 2). A positive serum VDRL (venereal disease research laboratory test) and TPHA (Treponema pallidum haemaglutination assay) confirmed that the patient had syphilis. Enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) was negative. CSF analysis was normal and the CSF VDRL and TPHA were non-reactive. A diagnosis of cardiovascular syphilis was made and oral prednisolone was started followed by 2.4 million units of benzathine penicillin G. While awaiting surgery the patient's condition deteriorated rapidly as a result of a rupture of the aneurysm and he died despite aggressive resuscitation efforts. Autopsy confirmed syphilitic aortic aneurysm with destruction of vertebrae and direct spinal cord compression.