An unusual presentation of neurosyphilis with complicated pulmonary involvement in a patient without HIV infection

Abstract

Background: Neurosyphilis could develop at any time in the course of syphilis; with an annual incidence of 0.7 per 100,000 men. Homosexual and HIV were risk factors. Here we report an unusual case of neurosyphilis in non-HIV patient with complicated pulmonary involvement. Case description: A fifty-six-year-old promiscuity, heterosexual man, active smoker presented with a three-month history of pruritic maculopapular rashes on his body associated with low-grade fever, and a two-week history of productive cough with dyspnea. On physical examination, he was tachypnea, with crackles on the base of the right lung. There was plaque hyperpigmentation on his malar area and multiple maculopapular, erythematous lesions on his trunk, extremities including palms of the hands, and scrotal area. No ulcer was found on his penis. Laboratory results revealed leukocytosis (19.9 × 103/μl), non-reactive HIV test, with high titer of serum VDRL (1/8) and TPHA (1/1280). Chest X-ray showed infiltrate on right perihilar area. Patient was diagnosed as pneumonia with secondary syphilis. The patient was treated with a single dose of benzathine penicillin G 2.4 million units intramuscular and azithromycin 500 mg tablet OD. During observation, he had altered mental status, generalized tonic seizure, high-grade fever with respiratory distress. He had Argyll Robertson pupil, left central facial and hypoglossal nerve paralysis, and positive meningeal signs, with normal brain CT scan result, non-reactive CSF-VDRL and TPHA, with high leucocyte (17 cells/μl) and protein (54 mg/dl). He was diagnosed neurosyphilis with hospital-acquired pneumonia and treated with ceftriaxone and vancomycin, 2 g OD and 750 mg OD intravenous, respectively. The patient showed no significant improvement and unfortunately, he progressed to death caused by multiple organ dysfunctions due to septic shock. Discussion: There is no single, highly sensitive and specific diagnostic test exists for neurosyphilis. The diagnosis of neurosyphilis is based on clinical findings and the results of serologic tests and CSF examination. The CSF-VDRL has sensitivity 30–70%, non-reactive test does not exclude neurosyphilis. Neurosyphilis in a patient without HIV infection could be diagnosed by a high WBC or protein in CSF with symptoms or signs of neurosyphilis even with non-reactive CSF-VDRL. Conclusion: Neurosyphilis could be considered even with a non-reactive CSF-VDRL result in non-HIV patient.