Stroke after Initiating IV Penicillin for Neurosyphilis: A Possible Jarisch-Herxheimer Reaction.

Vineet Punia,Appaji Rayi,Adithya Sivaraju

doi:10.1155/2014/548179

Abstract

Introduction. Syphilis incidence has increased in the US in the last decade. Jarisch-Herxheimer reaction (JHR) is a well-documented adverse effect of penicillin treatment in syphilis. Stroke has not been reported as part of its phenomenology. Case Report. A 57-year-old man presented with worsening memory. His minimental status examination score was 14/30. Serum RPR test was positive and VDRL test in the CSF was reactive. Within six hours of first dose of IV crystalline penicillin G, he was found to have hemineglect and difficulty moving the left leg. MRI of the brain showed multiple acute ischemic strokes. Immediate MRA ruled out vascular occlusion. Penicillin treatment was stopped. Four hours later, he was found to be febrile and had two episodes of generalized tonic-clonic seizures. Conclusions. We report a case of confirmed neurosyphilis with no known modifiable stroke risk factors, who developed acute ischemic stroke and other constitutional symptoms consistent with JHR after IV penicillin. This is the first reported case in literature where an acute ischemic stroke can be attributed to Jarisch-Herxheimer reaction. Given an increase in incidence of syphilis in recent years, our case underlies the importance of keeping in mind potential catastrophic drug adverse reactions in neurosyphilis patients.

Highlights

Syphilis incidence has increased in the US in the last decade
It typically starts within 1-2 hours of the start of penicillin therapy but delayed onset up to 12–24 hours in patients with late neurosyphilis has been reported in literature [6]
We present the case of a patient who developed strokes in multiple vascular territories within hours of initiation of IV penicillin therapy for treatment of confirmed neurosyphilis

Summary

Introduction

Infectious diseases are relatively rare cause of stroke, but they may be a significant contributor in patients who lack conventional risk factors. In patients with dementia paralytica, it is associated with seizures, exacerbation of preexisting psychosis, or the development of focal neurological deficits [5] It typically starts within 1-2 hours of the start of penicillin therapy but delayed onset up to 12–24 hours in patients with late neurosyphilis has been reported in literature [6]. We present the case of a patient who developed strokes in multiple vascular territories within hours of initiation of IV penicillin therapy for treatment of confirmed neurosyphilis. We propose that JHR is the most likely cause of stroke in this patient

Case Presentation

Findings

Discussion