CSF VDRL Research Articles

Bilateral Disc Edema Heralding Ocular Syphilis: A Case Series (P10-10.006)

<h3>Objective:</h3> To describe five patients presenting with visual symptoms and disc edema who were diagnosed with ocular syphilis. <h3>Background:</h3> The Centers for Disease Control and Prevention (CDC) reported that in 2017–2021, men accounted for 83% of syphilis cases. Gay, bisexual, and other men who have sex with men account for 53% of male cases. Human immunodeficiency virus (HIV) positivity increases a patient’s risk of developing neurosyphilis. <h3>Design/Methods:</h3> Case series <h3>Results:</h3> The mean age of patients was 49 years (range 42–57). All were male. Three patients were positive for HIV but had undetected viral loads at the time of ocular syphilis diagnosis. Patients presented with varying degrees of impaired visual acuity, and each had improvement of visual acuity with treatment. RPR titers were elevated at the time of diagnosis and improved with treatment. CSF VDRL was negative in each case. Each patient was diagnosed with ocular syphilis and treated with 18–24 million units of intravenous aqueous crystalline penicillin daily for 10–14 days. Response to treatment was recorded based on examination and rapid plasma reagin (RPR) titers at 3 months. <h3>Conclusions:</h3> Ocular syphilis and neurosyphilis can be seen even in immunocompetent patients. Isolated ocular syphilis is an uncommon presentation of neurosyphilis, and may be associated with normal CSF evaluation. In our patients, treatment had been initiated prior to sampling of CSF, which could contribute to nonreactive VDRL. It is important to consider ocular syphilis in middle-aged male patients who present with vision loss and disc edema as it is a treatable and potentially reversible cause of vision loss. <b>Disclosure:</b> Dr. Anderson has nothing to disclose. Ms. Hayse has nothing to disclose. Joseph Boss has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Unity Biotechnology . Joseph Boss has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Eyepoint pharmaceuticals . Dr. Antonio has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Cochrane. Dr. Antonio has received research support from AAN PALF. The institution of Dr. Antonio has received research support from Trinity Health Foundation. The institution of Dr. Antonio has received research support from AAN IDEAS Grant.

2348. Distinct cerebrospinal fluid immune proteins mark neurosyphilis

Abstract Background Neurosyphilis (NS) is increasing in prevalence in the U.S. but remains challenging to diagnose, particularly in asymptomatic cases. Uncovering central nervous system (CNS) specific immune pathways may shed light on disease pathogenesis and potential biomarkers. Methods Paired cerebrospinal fluid and blood were collected from participants with syphilis without neurological symptoms from 2013–2019. Participants were categorized as NS if CSF VDRL was positive and matched by RPR and date of enrollment to participants without neurosyphilis (non-NS), defined by VDRL negative and CSF WBC &amp;lt; 5/uL. Paired CSF and plasma were run on a 71-plex chemokine/cytokine array, high-sensitivity (SIMOA) ELISA for markers of neuronal and astrocyte injury, and ELISA for neopterin, a marker of intrathecal macrophage/microglial activation. Comparisons between NS and non-NS were made using T-tests and Wilcoxon rank-sum tests, with p-values adjusted (FDR) for multiple comparisons. Results 24 participants were enrolled with characteristics as in Table 1. HIV status, age, race/ethnicity, and plasma RPR values did not significantly differ by group. Six cytokines were significantly (p&amp;lt; 0.05, FDR &amp;lt; 0.10) different in the CSF in NS compared to non-NS, including MIG/CXCL9, IP-10/CXCL10, macrophage-derive-chemokine (MDC), IL-8/CXCL8 and BCA-1/CXCL13, which was previously recognized as elevated in NS (Figure 1B). Neopterin, but no neuronal or astrocyte markers, was elevated in the CSF of NS versus non-NS (p &amp;lt; 0.001) (Figure 1A). After adjusting for multiple comparisons, there were no significant differences between markers in plasma of NS vs non-NS. Differences between NS and non-NS groups were not affected by HIV status. Conclusion There is a distinct and compartmentalized CNS immune response occurring in individuals with NS, as indicated by elevated markers of CNS inflammation and of key chemoattractants, the CXC family of proteins. Elevation of neopterin, but not neuronal injury markers suggest asymptomatic disease elicits an immune response without incurring neuronal damage. These immune biomarkers can provide insight into neuroinflammatory processes during asymptomatic NS and should be explored as potential CSF biomarkers of NS. Disclosures Magnus Gisslen, MD, PhD, Amgen: Honoraria|AstraZeneca: Advisor/Consultant|AstraZeneca: DSMB membership|Biogen: Honoraria|Gilead Sciences: Advisor/Consultant|Gilead Sciences: Honoraria|GlaxoSmithKline/ViiV: Advisor/Consultant|GlaxoSmithKline/ViiV: Honoraria|MSD: Advisor/Consultant|MSD: Honoraria|Novo Nordic: Honoraria|Novocure: Honoraria|Pfizer: Advisor/Consultant|Pfizer: Honoraria|Sanofi: Honoraria.

1169. Revenge of the Syph(ilis): Investigating Congenital Syphilis at a Tertiary Care Center Amidst a Rising Epidemic

BackgroundCongenital syphilis is a chronic infection acquired by the fetus in utero from a mother infected with Treponema palladium. It has a large spectrum of disease manifestations from asymptomatic infection to blindness, abnormal bone and teeth formation, deafness, or even death. Despite antenatal screening and the availability of effective treatment the incidence of congenital syphilis has risen since 2012, with 23.3 cases per 100,000 live births in 2017 according to the Centers for Disease Control. We sought to investigate the epidemiology, clinical manifestations, and treatment outcomes of congenital syphilis.MethodsWe undertook a retrospective review of individuals born at Texas Children’s Hospital from January 1, 2010 to May 15, 2021 to evaluate compliance with current diagnostic and treatment recommendations. Diagnostic and billing codes for congenital syphilis were used to generate a list of subjects. Patient demographics and clinical details were abstracted from the electronic medical record (EMR). Statistics were performed using Microsoft Excel. Results107 children (52% male, 48% female) were identified from diagnostic and billing codes in the EMR under the SNOMED-CT diagnosis of “congenital syphilis” and were less than two years of age at the time of diagnosis. All received penicillin within one month of diagnosis. 94 of these had a skeletal x-ray performed, with 11 (12%) having an abnormal skeletal x-ray consistent with congenital syphilis. 88 (82%) had a lumbar puncture done with a quantitative CSF VDRL obtained. 88 received aqueous penicillin G for proven/highly probable or possible syphilis. Four patients were deceased at the time of data inquiry. Of those with abnormal skeletal x-rays, “metaphyseal lucency” was the most common finding. ConclusionCongenital syphilis remains a significant concern in the United States and carries the risk of significant long-term morbidity for infants and children. Antenatal screening with appropriate treatment in pregnancy and adequate follow-up would decrease the need for neonatal evaluation and treatment.Disclosures C. Mary Healy, MD, Dexcom (Shareholder)Intuitive (Shareholder)Quidel Corporation (Shareholder)Up to Date (Other Financial or Material Support, Honorarium)Vapotherm (Shareholder)

Neurosyphilis: Still prevalent and overlooked in an at risk population

Neurosyphilis (NS) presents with a variety of clinical syndromes that can be attributed to other aetiologies due to difficulties in its diagnosis. We reviewed all cases of NS from the "Top End" of the Australian Northern Territory over a ten-year period to assess incidence, clinical and laboratory manifestations. Patient data (2007-2016) were extracted from hospital records, centralised laboratory data and Northern Territory Centre for Disease Control records. Clinical records of patients with clinically suspected NS were reviewed. A diagnosis of NS was made based on the 2014 US CDC criteria. Results were also recategorized based on the 2018 US CDC criteria. The population of the "Top End" is 185,570, of whom 26.2% are Indigenous. A positive TPPA was recorded in 3126 individuals. A total of 75 (2.4%) of TPPA positive patients had a lumbar puncture (LP), of whom 25 (35%) were diagnosed with NS (9 definite, 16 probable). Dementia was the most common manifestation (58.3%), followed by epilepsy (16.7%), psychosis (12.5%), tabes dorsalis (12.5%) and meningovascular syphilis (8.3%). 63% of probable NS cases were not treated appropriately due to a negative CSF VDRL. Despite increased specificity of the 2018 US CDC criteria, 70% of patient in the probable NS group were not treated appropriately. The overall annual incidence [95%CI] of NS was 2.47[1.28-4.31] per 100 000py in the Indigenous population and 0.95[0.50-1.62] in the non-Indigenous population (rate ratio = 2.60 [1.19-5.70];p = 0.017). Neurosyphilis is frequently reported in the NT, particularly in Indigenous populations. Disturbingly, 60% of probable neurosyphilis patients based on the 2014 criteria, and 70% based on the 2018 criteria with were not treated appropriately. It is critical that clinicians should be aware of the diagnosis of NS and treat patients appropriately.

Neurosyphilis prevalence at a Portuguese stroke unit care.

Syphilis is a systemic human disease which is caused by infection with the spirochete Treponema pallidum. It is spread worldwide, and there has recently been an increase in its incidence. Neurosyphilis (NS) can have a variety of presentations; meningovascular NS is a specific affection of the Treponema which occurs in an early stage after the primary infection, causing an inflammatory arteriopathy which may result in an ischemic stroke. As a rare manifestation of syphilis, there are few prevalence and epidemiological studies, and data are almost non-existent. The objective of this study is to analyse the prevalence of meningovascular NS in a stroke unit in a tertiary hospital. A descriptive retrospective study was carried out over a period of 44 months in a stroke unit. All patients admitted had neurological symptoms compatible with a vascular event, and routine blood tests including infectious screening were performed. Those with positive test results for syphilis were identified and proceeded to lumbar puncture to CSF cytochemical analysis and VDRL. NS was categorized as confirmed or probable (using CDC criteria). A total of 525 patients were admitted, and 62.53% were submitted to a routine screening for syphilis. A total of 309 patients (95.67%) revealed a negative screening; 12 patients (3.72%) had a positive syphilis serology. Among the 12 patients with positive screening, a single case of NS (0.31%) was identified. We observed a low prevalence of NS (0.31%), but this result was surprisingly higher than what was expected in an elderly population.

Stroke and syphilis: A retrospective study of 53 patients

ObjectiveThe aim of this study was to describe the clinical, biological and radiological characteristics of patients with syphilitic vasculitis, and to assess the outcome after treatment. MethodologyA retrospective review was carried out based on the records of patients with ischemic stroke, and reactive CSF TPHA and VDRL results. None of these patients showed symptoms of any other diseases or had received high doses of penicillin. ResultsA total of 53 patients with stroke met the diagnostic criteria for syphilitic arteritis. Their average age was 41±12 years. Nine patients had a history of genital ulcer (17%), and the median duration of illness after presenting a chancre was 8 [range: 1–14] years. A prodromal syndrome was seen in 27 patients (50.9%) and included changes in mental status in 14 patients (26.4%), seizures in 10 cases (18.9%), headache in eight (15.1%) and memory loss in seven (13.2%). Neurological events included focal motor deficits in 29 cases (54.7%), ataxia in 11 (20.8%) and movement disorders in 15 (28.3%). HIV serology was performed in 31 patients and proved negative in every case. Disease evolution was generally favorable: 12 patients (22.6%) were autonomous at the time of hospital discharge; 29 (54.7%) had partially recovered; and only seven (13.2%) still had signs of severe sequelae. ConclusionA diagnosis of syphilitic stroke should be suspected in young patients as a manifestation of syphilis, and tests for neurosyphilis should be routine in neurology departments to make a prompt diagnosis, thereby preventing psychological sequelae.

Clinical Characteristics and Outcomes of Patients with Otosyphilis and HIV Infection

BackgroundThe increased rates of syphilis in HIV infected individuals has provided information on ocular and neurological complications, but data on cochleovestibular dysfunction is limited. Otosyphilis is a potentially reversible cause of hearing loss in HIV infected individuals.MethodsWe performed a retrospective chart review from 2007 through 2016 and identified six patients who met inclusion criteria of a diagnosis of otosyphilis and HIV infection. We collected the following data: demographics, clinical characteristics, laboratory findings, treatment courses, and outcomes.ResultsWe identified a total of six patients with HIV and otosyphilis. All patients were male with a mean age of 36 (range 23–51) without known predisposing factors for hearing loss. The mean CD4 count was 323 (range 17–547) with all but two patients having a viral load of less than 50 copies. Four of the patients were receiving combination antiretroviral therapy at the time of diagnosis of otosyphilis. All patients had a rapid plasma reagin (RPR) titer of at least 1:16 (range 1:16–1:128). Three patients presented with unilateral hearing loss and two with bilateral; with one patient having just vestibular dysfunction. The mean duration of symptoms prior to presentation was about seven weeks (range one week to 16 weeks). Three of six patients had objective hearing loss on audiometric testing, one had no detectable hearing loss, and two did not have formal audiometric testing. All had lumbar puncture performed at diagnosis with a CSF mean white blood cell count of 23 (range 0–129) and a mean total protein level of 38 (range 28–57). Only one patient had a positive CSF VDRL test. Five patients were treated with intravenous penicillin for 14 days and one with ceftriaxone for 14 days due to a penicillin allergy. Five patients received a corticosteroid taper. Three out of the six patients noted subjective hearing improvement with treatment in six months.ConclusionHIV infected patients with a diagnosis of syphilis should be asked screening questions to identify hearing symptoms or vestibular dysfunction, as otosyphilis is an important cause of reversible hearing loss.Disclosures All authors: No reported disclosures.

Optic Neuritis in Acute Neuroborreliosis (Lyme Disease) in the U.S.-Mexican Border: Case Report

Objective: We describe a patient diagnosed with acute neuroborreliosis presenting with anterior optic neuritis (papillitis) in a non-endemic region. Case Presentation: A 43-year-old previously healthy right handed man admitted due to an insidious onset of severe headache and spells of ascending paresthesias from his right foot into his right arm and face followed by speech arrest and clumsiness of his right hand. His neurologic exam was significant for somnolence, nuchal rigidity and Kernig and Brudzinski signs were present. MRI of the brain with gadolinium showed diffuse hyperintense signal involving the supra and infratentorial cortical sulci, with associated faint diffuse leptomeningeal enhancement, consistent most likely with diffuse leptomeningoencephalitis. EEG: normal. CSF VDRL was negative. Dilated fundus exam revealed mild optic nerve edema more significant to the left than to the right eye, confirmed and measured by spectral domain OCT (Optical Coherence Tomography). There was an evidence of posterior uveitis with an early vitreous hemorrhage superficial to the left optic nerve. Lyme disease serum antibody (IgM) Immunoblotting was positive in 2 bands confirming the diagnosis of neuroborreliosis. Conclusion: Optic nerve involvement in Lyme disease is an uncommon complication that should be confirmed by specific diagnostic criteria to establish its causal relation.

An Old Flame Reignites: Vagal Neuropathy Secondary to Neurosyphilis

This report describes neurosyphilis presenting as vocal fold paresis and velopharyngeal incompetence. This represents the first reported case of neurosyphilis presenting as a vagal neuropathy since1963. Case report. Review of medical records and literature search. The patient presented with voice changes and nasopharyngeal reflux of liquids. Examination showed a left vocal fold paresis and moderate velopharyngeal incompetence. Laryngeal electromyography revealed evidence of denervation, and neurologic evaluation showed bilateral Adie's pupils and a positive CSF VDRL. A remote history of syphilis treated with one intramuscular injection was obtained. The patient was treated with 6 weeks of penicillin and regained normal vocal function with minimal residual intermittent hypernasality. Given the recent increase in the incidence of syphilis in the United States, this case serves as a reminder of the importance of including syphilis in the differential diagnosis of cranial neuropathies and the increasing likelihood of syphilis presenting to otolaryngology and speech pathology practices. Syphilis, a disease whose incidence had declined progressively for 60 years in the United States, is now resurgent and must be considered in the evaluation of patients presenting with unexplained cranial neuropathies.

Association of CSF glucose concentration with neurosyphilis diagnosis

Abstract The most specific criterion for diagnosing neurosyphilis is a reactive CSF VDRL. Unfortunately, there are in Europe, including Poland small number of specialized laboratories for serological diagnosis of syphilis. Thus, CSF serology results are obtained with delay. Therefore, the decision on recommended therapy for neurosyphilis is taken on the basis of CSF basic tests. In this paper we attempt to determine the utility of CSF glucose concentration and its cut-off values in prediction of asymptomatic neurosyphilis. CSF and blood were collected from 55 HIV-uninfected patients with syphilis of unknown duration. Patients with neurosyphilis (14.5%) were characterized by higher CSF pleocytosis (p&lt;0.0001), elevated CSF protein concentration (p&lt;0.05) and lower CSF glucose concentration (p&lt;0.0001). Multivariate regression analysis identified CSF pleocytosis and CSF glucose concentration as the two independent predictors of reactive CSF VDRL (p&lt;0.0001). In the selected group of patients with CSF pleocytosis ≥5/µL (n=25) CSF glucose concentration ≤2.72 mmol/L was associated with 100% sensitivity (95%CI: 63–100%) and 100% specificity (95%CI: 75.3–100%) for reactive CSF VDRL. CSF glucose concentration may be particularly useful as a predictive marker of neurosyphilis in HIV uninfected patients with syphilis of unknown duration with CSF plecytosis ≥5/µL.

Stroke Secondary to Neurosyphilitic Vasculitis in an HIV/AIDS Patient (P01.251)

Objective: To describe a case of CNS Syphilis as a cause of large-vessel stroke in a newly-diagnosed HIV/AIDS patient. Background Occlusive vessel disease in young patients is usually secondary to hypercoagulability risk factors. However, CNS infections (including viral, bacterial, fungal, spirochete) can also present with similar findings. If not correctly identified and treated, such infections lead to significant morbidity and mortality. CNS syphilis has been associated with perivascular inflammation, cerebrovascular thrombosis, vessel occlusion, ischemia and infarction. Here we report the successful and timely treatment of a young patient who presented with a large vessel stroke, with eventual diagnosis of CNS syphilis. Design/Methods: Case Report. Results: A 33-year old man with recent diagnosis of HIV/AIDS presented to the emergency department with a 2-month history of personality change, depression, and new-onset syncope. Examination revealed fluctuating mental state, left-sided weakness, left hemi-neglect and right-gaze deviation. MRI brain revealed a right MCA distribution infarct. MRA revealed complete occlusion of the right MCA, and stenosis of the right proximal ICA. Laboratory examination revealed a low CD4 count of 42, HIV viral load of ∼1 million copies, positive serum RPR, elevated ESR (141 mm/hr) and CRP (3.4). CSF studies revealed 2 WBC, 10 RBC, normal glucose, and elevated protein. CSF VDRL and FTA tests were positive. A diagnosis of neurosyphilitic vasculitis was made. Upon treatment with Penicillin G for 14 days, the patient9s symptoms improved significantly. Conclusions: Here we present a case of a young man without any hypercoagulability risk factors, with HIV/AIDS, with occlusive large vessel infarcts secondary to syphilitic infection. Our case highlights the need for detailed evaluation of etiologies underlying large vessel strokes (including CSF), when such unusual stroke findings are present, so that appropriate and early treatment can be initiated. Disclosure: Dr. Rickard has nothing to disclose. Dr. Iyadurai has nothing to disclose.

Why did we perform a lumbar puncture in a young patient with ischemic stroke?

The European Stroke Organization recommends performing lumbar puncture (LP) in the etiological investigation of an ischemic stroke ‘‘when indicated’’ [1]. This recommendation leaves the decision to the clinician. Cerebrospinal fluid analysis may yield essential information in cases of pediatric ischemic stroke [2]. In adults it is generally accepted that a LP should be performed in case of suspicion of central nervous system (CNS) infection and vasculitis [1, 3], but its role in the etiological investigation of an ischemic stroke is unclear. We aimed to determine the frequency of LP performed in the investigation of ischemic stroke of young patients, the reasons that lead to its performance, CSF results and their contribution to the etiological diagnosis. We analyzed a retrospective cohort of consecutive patients with ischemic stroke, aged 18–55 years, admitted to Santa Maria Hospital Stroke Unit from May 2007 to December 2009. Patients were investigated according to a standardized protocol that includes brain CT and/or MRI, electrocardiogram, laboratory evaluation with vasculitis and infection screening (HIV, hepatitis, VDRL), cervical arteries and transcranial ultrasound, transthoracic/transesophagic echocardiogram and 24-h ECG Holter monitoring. The decision to perform digital subtraction angiography and LP was individually discussed. CSF analysis always included: gross characteristics, hemoglobin, total cell count, total protein, glucose, chloride and immunoglobulins; specific antibody indices were integrated when appropriate. Clinical files from patients who were submitted to a LP were retrospectively reviewed. Demographic, clinical, analytical and imagiological features and stroke etiology according to the TOAST classification were analyzed. From the 143 young stroke patients admitted during the study period, a lumbar puncture was performed in 36 (25.2%). Four patients were excluded because the LP was done for the differential diagnosis (stroke vs. other condition) at the emergency department. Reasons that led to LP were: (1) suspicion of infection (one HIV?, two VDRL? and one endocarditis), (2) suspicion of CNS vasculitis (four ANAs?, one antiphospholipid?, six with intracranial arterial stenosis), and (3) cryptogenic stroke (nine) or with a PFO as the only identified cause (eight). Twenty-nine out of 32 analyzed patients had completely normal CSF. Three patients showed [5 cells/ml, three had CSF proteins [50 mg/dl, and matched CSF oligoclonal bands were present in one patient; CSF VDRL was positive in one patient. Post LP headache occurred in nine patients, but there were no other complications related to the procedure. LP contributed to a change in the etiological ischemic stroke classification in one patient (3%, 95% CI 1–16) from undetermined cause to other determined cause (syphilis). Variation in the proportion of etiological subgroups found in young adult stroke studies reflects different ancillary investigations [4]. Regarding LP in ischemic stroke etiological investigations, apart from studies before the era of brain or cardiac imaging [5–7], there is little information in the literature. However, though inflammatory causes of stroke such as Lyme neuroborreliosis [8] among others are rare, correct diagnosis and treatment of these rare causes R. Geraldes A. C. Fonseca P. Canhao T. P. Melo J. M. Ferro Stroke Unit, Department of Neurosciences, Santa Maria Hospital, Av. Prof. Egas Moniz, 1649-035 Lisbon, Portugal

P-760 - Neurosyphilis: four case reports of immunocompetent patients presenting initially to psychiatry

Introduction Symptomatic neurosyphilis in immunocompetent patients is nowadays a rare diagnosis. Yet, if not properly diagnosed and treated, consequences for the patient's health are severe. Known as “the great imitator”, its detection involves both a high degree of suspicion and adequate diagnostic tests. Psychiatric symptoms are often the presenting symptoms of this illness. Objectives The authors report four cases of neurosyphilis with psychiatric symptoms (general paresis) in immunocompetent patients. All four patients were initially referred for observation by a psychiatrist in the emergency room. Special diagnostic features of each case and potential diagnostic pitfalls are highlighted. Aims To raise awareness to the importance of this rare but highly disabling disease. Methods Review of clinical records and complementary exams. Results All patients were male, two Caucasian and two African Black, with ages ranging from 41–56 years old. Clinical presentations were quite distinct, showing the symptomatic heterogeneity of paretic neurosyphilis. Blood VDRL test was negative in one case, CSF VDRL was negative in another case. TPHA was always positive in blood and CSF. White cell count and protein quantification in the CSF remains important to confirm diagnosis. Conclusions Current prevalence of symptomatic neurosyphilis in Western Europe is unknown. Atypical cases presenting with heterogeneous psychiatric and neurologic symptoms, with no previous history of mental illness, should undergo blood VDRL testing, and specific blood treponemal testing should be considered in specific situations. A high index of clinical suspicion is needed. Confirmation of diagnosis is only possible through further CSF analysis.

The Silence of Neurosyphilis

Case A 54-year-old African-American male presented with bilateral pedal frostbite after a snow storm. He demonstrated loss of sensation in his lower extremities. He was confused and dysphasic and was unable to articulate his history coherently but did endorse abdominal pain, nausea and vomiting. Initial CT scanning of the head could not rule out a subacute infarct versus abscess in the left posterolateral temporal lobe. A comprehensive workup was unrevealing except for positive serum and CSF VDRL. Tabes dorsalis was suspected.

Dementia due to neurosyphilis with persistently negative CSF VDRL

A 44-year-old right-handed homosexual man was referred for gradual deterioration of skills as a chef, impairment of memory, and decreased fluency and comprehension of speech. He had prominent personality change from an easygoing nature to irritability and anxiety. Over a year, his mental abilities deteriorated such that he was unable to drive a car, maintain a job, or live independently. He had no prior neurologic, psychiatric, or systemic illness. Episodes of agitation, confusion, and body tremors appeared 1.5 years after onset. Evaluation by a neurologist at that time at another hospital revealed disorientation, disinhibition, poor attention and recall, tremors during handwriting, and motor impersistence. Mini-Mental State Examination score was 23 out of 30. There was diffuse cerebral atrophy on MRI (figure, A), and the EEG was normal. CSF had protein of 97 mg/dL, 1 WBC/mm3, and many oligoclonal bands. CSF Venereal Disease Research Laboratory test (VDRL), CSF 14-3-3 level, serum HIV and Lyme antibody, toxicology screen, thyroid and liver functions, …

Modern neuropsychiatric presentation of neurosyphilis.

As a cause of neuropsychiatric disease, non-HIV related neurosyphilis became uncommon enough for the American Academy of Neurology to drop lumbar puncture from its suggested list of tests for dementia. We reviewed 17 inpatient charts with Centers for Disease Control (CDC) guidelines with definite or probable neurosyphilis. Sixteen presented with neuropsychiatric symptoms, four with overt psychosis. An intensive workup, including lumbar puncture, should be considered in middle-aged patients with new onset neuropsychiatric symptoms. Syphilis, “the great imitator,” used to be part of the standard differential diagnosis of neuropsychiatric disease. With the advent of modern treatment, the incidence of tertiary syphilis has greatly declined. The disease is now considered unusual, except in the context of HIV infection. After anecdotally noting a number of cases, we wished to quantify the number and presentation of cases at our institution. We requested charts of all patients with discharge diagnosis International Classification of Disease-9 (ICD-9) 94.9 from August 1998 to October 2001. The charts were systematically screened for CDC criteria for definite (positive CSF VDRL) or probable (elevated CSF protein or leukocytosis with a history of syphilis exposure and no better explanation) neurosyphilis. Infants and patients with a documented positive HIV serology or an AIDS-defining illness were excluded. L.L. reviewed the charts and abstracted each patient’s age, complaints, symptoms, serum serologies, neurologic exam, CSF blood counts and glucose, CSF serologies, and treatment. The protocol was approved by the Institutional Review Boards of the Tulane University Health Sciences Center and the Medical …

Early onset syphilitic meningoencephalitis presenting as abnormal behaviour in a case of HIV infection

He developed a painless ulcer over shaft of penis followed by painful swelling in the left inguinal region in the first week of March 98. The bubo ruptured two weeks later. He improved following some treatment by a private practitioner. In the last week of March 98, he was admitted and treated for HBsAg positive viral hepatitis. Patient was a married individual with a 13 year old son and a healthy wife, who did not have any bad obstetric history. Examination revealed bilateral, discrete, firm and nontender axillary lymphadenopathy, mild nontender hepato- splenomegaly and tachycardia of 114/min. Central nervous system (CNS) examination was essentially normal and there was no neck rigidity. Dermatovenereological examination revealed large atrophic scars over dorsal aspect of shaft of penis and over left inguinal fold. Repeat CSF examination again showed increased cell count and protein with normal sugar levels. It stained negative for Cryptococcus. Blood VDRL was found to be reactor 1:16 dilution, with positive TPHA test. HIV infection was confirmed by Western Blot test. CSF examination was repeated on dermatologist's request to look for CSF VDRL, which was found to be reactor, with positive TPHA test. Patient was diagnosed as a case of syphilitic meningoencephalitis with HIV infection and treated with crystalline penicillin, 3 MU 4 hourly IV for 10 days, followed by benzathine penicillin 2.4 MU IM weekly for three weeks. Discussion

Prevalence of neurosyphilis in human immunodeficiency virus-infected patients with latent syphilis

purpose: A prospective study was done to determine the prevalence of confirmed neurosyphilis (cerebrospinal fluid [CSF] Venereal Disease Research Laboratory [VDRL]-reactive) in human immunodeficiency virus (HIV)-infected patients with latent syphilis (reactive serum rapid plasma reagin [RPR] and microhemagglutination- Treponema pallidum [MHA-TP]). patients and methods: All HIV-infected patients seen for their first visit at the Los Angeles County/University of Southern California Medical Center AIDS Clinic from June through December 1990 were screened for latent syphilis. Those with reactive serum RPRs and MHA-TPs who had not received recent (within 6 months) therapy for syphilis were offered diagnostic CSF sampling. results: A total of 312 patients were screened, of whom 71 (22.8%) had reactive serum RPRs and MHA-TPs. Thirty-three of these patients (47%) had diagnostic CSF sampling (26 refused lumbar puncture or were lost to follow-up; 12 had had recent therapy for syphilis and thus did not have CSF sampling). Among the 33 patients who had CSF sampling, 20 (60.6%) had normal CSF profiles (white blood cell count less than 8/mm 3, protein less than 0.60 g/L; glucose greater than 2.8 mmol/L) and nonreactive CSF VDRIs. Ten of the 33 patients (303%) had abnormal CSF profiles and nonreactive CSF VDRLs, and three of 33 (9.1%) had reactive CSF VDRLs. conclusions: Asymptomatic neurosyphilis was found in 9.1% of our patient population undergoing CSF sampling, giving a 1.0% prevalence of CSF VDRL-reactive neurosyphilis in the population we screened. The abnormal CSF findings may have been due to either nonreactive CSF VDRL neurosyphilis, central nervous system infection with HIV, or infection with some unrecognized agent.

Neurosyphilis in HIV carriers: MR findings in six patients.

Neurosyphilis, a sexually transmitted disease that can cause neurologic damage, has become increasingly prevalent in the AIDS era. HIV carriers can contract neurosyphilis without the presence of other concurrent opportunistic infections. Because MR findings of neurosyphilis are seldom reported, we retrospectively reviewed and evaluated contrast-enhanced MR images of six young (average age, 33 years) HIV-positive men with high serum and CSF VDRL titers indicative of neurosyphilis. All six patients tested negative for concurrent opportunistic infections. Five patients had acute or subacute strokelike symptoms involving the basal ganglia or middle cerebral arteries; one had a parietal convexity mass mimicking meningioma with headache and ataxia. Contrast-enhanced MR images showed patchy enhancement involving the basal ganglia and middle cerebral artery territories in the first five patients and the convexity mass in the sixth patient. On the basis of brain biopsy, a convexity mass was diagnosed in the patient with syphilitic gumma. The imaging findings of the remaining five patients represented ischemic infarct caused by meningovascular syphilis. After penicillin treatment, serum and CSF VDRL titers decreased, and neurologic signs and symptoms improved in all six patients. A follow-up MR study in the patient with the gumma showed that the lesion resolved almost completely. In young HIV patients with stroke symptoms or a convexity mass, neurosyphilis should be considered. Contrast-enhanced MR can reveal the extent of involvement by neurosyphilis and should be used to facilitate diagnosis and proper treatment.

An Evaluation of Oligoclonal Banding and CSF IgG Index in the Diagnosis of Neurosyphilis

It can be difficult to determine which patients would benefit from therapy to control central nervous system infection with Treponema pallidum. The authors have followed patients prospectively to evaluate two new diagnostic tests available. They performed lumbar punctures on 107 consecutive patients with syphilis of unknown duration, untreated (n = 19) or with serology that did not decrease sufficiently during follow-up (n = 88). The mean age was 47 years, with 91 males and 16 females. Twelve had neurologic symptoms. In order to establish a gold standard, the authors required the cerebrospinal fluid Venereal Disease Research Laboratory (CSF VDRL) test to be reactive (n = 25). They then examined oligoclonal banding and CSF IgG index as diagnostic tests by comparing them to the gold standard. Oligoclonal banding, abnormal in 20, had a sensitivity of 52% and a specificity of 91%. The CSF IgG index, abnormal in 56, had a sensitivity of 92% and a specificity of 60%. The posttest likelihoods of a positive test result were low, and hence neither test ruled in the diagnosis. With a post-test likelihood (PTL) negative of 4%, a negative CSF IgG index assisted in ruling out the diagnosis. Oligoclonal banding was not a satisfactory test for neurosyphilis. The CSF IgG index appears to help only in ruling out infection. Further effort is needed in developing diagnostic tests to assist the clinician in the diagnosis of neurosyphilis.