Meningovascular Neurosyphilis Research Articles

Clinical Spectrum of Neurosyphilis among HIV-Negative Patients in the Modern Era

Background: The clinical spectrum of neurosyphilis (NS) has changed over time. Objective: To describe the clinical spectrum and characteristics of NS in HIV-negative patients. Methods: A retrospective chart review was performed for 149 in patients with NS. Result: All patients were >25 years old, including 16.8% asymptomatic for NS, 15.4% with syphilitic meningitis, 24.2% with meningovascular NS, 38.9% with general paresis, 4.0% with tabes dorsalis and 0.7% with gummatous NS. The original misdiagnosis rate was 84.6%. All 149 patients had positive serum Treponema pallidum particle agglutination (TPPA) and rapid plasma reagin (RPR). The overall positive rates of cerebrospinal fluid RPR (CSF-RPR) and CSF-TPPA were 57.0 and 89.9%, respectively. CSF pleocytosis and elevated CSF protein were found in 40.3% of patients. Nonspecific abnormal brain magnetic resonance imaging and electroencephalography findings were present in 60.4 and 54.8% of NS patients, respectively. Conclusions: NS has various clinical manifestations, laboratory findings and magnetic resonance imaging and electroencephalography findings, but all studies lack specificity. Every patient with neurological or psychiatric symptoms that are without unambiguous causes should have blood tests for syphilis. When serology proves positive, patients should undergo CSF examination.

Laboratory findings in neurosyphilis patients with epileptic seizures alone as the initial presenting symptom

A retrospective chart review was performed to characterize the clinical presentation, the characteristic combination of serologic and cerebrospinal fluid (CSF) abnormalities, and the neuroimaging findings of neurosyphilis (NS) patients who had epileptic seizures alone as an initial presenting symptom. In a 6.75-year period, 169 inpatients with NS were identified at Zhongshan Hospital (from June 2005 to February 2012). We demonstrated that 13 (7.7%) of the 169 NS patients had epileptic seizures alone as an initial presenting feature. Epileptic seizures occurred in NS patients with syphilitic meningitis (2 cases), meningovascular NS (5 cases), and general paresis (6 cases). The types of epileptic seizures included simple partial, complex partial with secondary generalization (including status epilepticus), and generalized seizures (no focal onset reported). Nine of NS patients with only epileptic seizures as primary symptom were misdiagnosed, and the original misdiagnosis was 69.23% (9/13). Ten (10/13, 76.9%) patients had an abnormal magnetic resonance imaging, and 7 (7/13 53.8%) patients had abnormal electroencephalogram recordings. In addition, the sera rapid plasma reagin (RPR) and Treponema pallidum particle agglutination (TPPA) from all 13 patients were positive. The overall positive rates of the CSF-RPR and CSF-TPPA were 61.5% and 69.2%, respectively. Three patients demonstrated CSF pleocytosis, and 9 patients exhibited elevated CSF protein levels. Therefore, NS with only epileptic seizures at the initial presentation exhibits a lack of specificity. It is recommended that every patient with clinically evident symptoms of epileptic seizures should have a blood test performed for syphilis. When the serology results are positive, all of the patients should undergo a CSF examination to diagnose NS.

Spectrum and characterization of movement disorders secondary to neurosyphilis

There have been frequent reports of Neurosyphilis with atypical features. Syphilitic infection of the central nervous system can result in various movement disorders (MD). The few reports of MD patients with neurosyphilis have been mainly of single patient. Between June 2005 and February 2012 we identified, 169 in-patients with neurosyphilis at Zhongshan Hospital. We performed a retrospective chart review to characterize MD findings, clinical signs and symptoms, misdiagnosis rate, laboratory findings, and brain magnetic resonance imaging results. We found that seven of the 169 neurosyphilis patients presenting with MD, had originally been misdiagnosed with Parkinsonism (4), laryngeal dystonia (1), corticobasal syndrome (1), and sensory ataxia (1). None of these patients were initially suspected of having neurosyphilis. The correct diagnosis was syphilitic meningitis (1), meningovascular neurosyphilis (2), general paresis (3), and tabes dorsalis (1). Among them, six patients had abnormal imaging studies, and sera rapid plasma reagin (RPR) and Treponema pallidum particle agglutination (TPPA) from all seven patients were positive. The cerebrospinal fluid (CSF) examinations showed that four patients were CSF-RPR positive (titers ≤1:16) by CSF syphilitic serologic testing, but all seven patients were CSF-TPPA reactive. Moreover, two patients had CSF pleocytosis and four patients had elevated CSF protein expression. Our findings reinforced the importance of routine serologic testing for syphilis should be a part of the evaluation of patients with atypical MD presentations or in whom alternative diagnoses are not forthcoming. When serology is positive, all patients should be examined more thoroughly for neurosyphilis by lumbar puncture.

Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients

BackgroundNeurosyphilis is known as “the great imitator” or “the great impostor” because of its wide range of clinical symptoms. A high misdiagnosis rate of ischemic stroke was observed among neurosyphilis patients in clinical practice, which prevents patients from receiving the most appropriate treatment, and often results in more severe neurologic damage. MethodsA total of 149 neurosyphilis patients were retrospectively reviewed. The control group comprised 1570 non-neurosyphilitic ischemic stroke patients. The proportion of patients with ischemic stroke as the primary symptom of the different types of neurosyphilis and the misdiagnosis rate of neurosyphilitic ischemic stroke were analyzed, including the risk factors for cardiovascular disease. ResultsAmong the 149 neurosyphilis patients, 21 (14.09%) developed ischemic stroke as a primary symptom, including three cases of syphilitic meningitis and 18 cases of meningovascular neurosyphilis. Only four of the neurosyphilis patients had histories of ischemic stroke and recurrence. The other 17 cases were treated for the first time in the emergency department; however, none of the patients were initially suspected of neurosyphilitic ischemic stroke. All of the patients were only diagnosed with neurosyphilis during their follow-up treatment. The misdiagnosis rate of neurosyphilitic ischemic stroke was as high as 80.95% (17/21). Furthermore, except for hypertension, no significant differences in cardiovascular risk factors were observed between the groups (P>0.05). ConclusionsIn clinical practice, particularly during emergencies, any ischemic stroke patient should be screened for neurosyphilis.

Up-to-date immunology methods for examination of the cerebrospinal fluid in patients sufferingfrom neurosyphilis

The authors conducted a comparative study of the diagnostic value (sensitivity, specificity, efficiency and predictive value of positive and negative results) of immunology methods (microprecipitation test, RPR, complement-fixation test, immunofluorescence test with whole spinal fluid, ELISA, passive hemagglutination test, Treponema pallidum immobilization test, immunoblotting) for studying the cerebrospinal fluid in 37 neurosyphilitic patients and 31 patients with syphilis in the anamnesis but without any clinical and laboratory data confirming the syphilitic affection of the nervous system. The highest diagnostic efficiency indices for neurosyphilis were noted for such methods as microprecipitation test (80.9%), passive hemagglutination test (98.5%) and immunoblotting (97.0%), which enables the authors to recommend the methods as standard neurosyphilis diagnostics methods in the territory of the Russian Federation. It was revealed that antibodies for pale treponema antigens Tr17 and Tr47 were detected in the course of immunoblotting most often regardless of any clinical manifestations and duration of the syphilitic infection. The authors set the priorities for individual examination methods when diagnosing asymptomatic, early and late meningovascular neurosyphilis. They also developed a diagnostic algorithm for detecting neurosyphilis based on the sequential application of ELISA/immunoblotting, microprecipitation test and passive hemagglutination test.

Meningovascular neurosyphilis with basilar artery thrombosis, a case report and literature review

Herein a case is described of a 54-years old patient, HIV negative, with cerebro-vascular disease by basilar artery thrombosis secondary to meningovascular neurosyphilis. Neurosyphilis is the impairment at any stage of the central nervous system by Treponema pallidum subspecies pallidum and includes asymptomatic and symptomatic forms of infection. The presentation can take many forms, depending on the location and extent of tissue damage. The currently recommended treatment is crystalline penicillin, 4 million units every 4 hours for 14 days.

Meningovascular neurosyphilis with basilar artery thrombosis, a case report and literature review

Se presenta el caso clinico de un paciente de 54 anos, negativo para VIH, con enfermedad cerebrovascular por trombosis de la arteria basilar, secundaria a neurosifilis meningovascular. La neurosifilis es el compromiso del sistema nervioso central por Treponema pallidum subespecie pallidum en cualquier estadio de la entidad e incluye las formas asintomaticas y sintomaticas de la infeccion; sus formas de presentacion son diversas y dependen de la localizacion y la extension de las lesiones. La recomendacion actual es el tratamiento con 4 millones de unidades de penicilina cristalina cada 4 horas por 14 dias. doi: http://dx.doi.org/10.7705/biomedica.v32i1.586

Meningovascular neurosyphilis as the cause of ischemic cerebrovascular disease in a young man

Authors report a case of a 35-year-old male with right-sided mild paresis, incontinence, dysexecutive syndrome, short-term memory loss and behavioral changes. Bilateral cerebral infarcts in the region of the caudate nuclei and the adjacent white matter were proved by brain MRI and multiple stenoses of the branches of Willis-circle were confirmed by MR angiography. Elevated protein level and pleocytosis were found in the cerebrospinal fluid with intrathecal IgG synthesis. Serum rapid plasma reagin, Treponema pallidum Particle Agglutination test, Treponema pallidum ELISA, liquor Venereal Disease Research Laboratory tests were positive. Meningovascular neurosyphilis was diagnosed. 24M U/day intravenous penicillin-G treatment was given for 14 days. The patient has vascular dementia due to the bilateral strategic infarcts disconnecting the prefrontal circuits; his symptoms are similar to general paresis. Laboratory and radiologic improvement was observed. Still, the patient have severe residual cognitive decline.

Meningovascular neurosyphilis: a report of stroke in a young adult

A young adult patient with meningovascular neurosyphilis in the form of acute ischemic stroke with right hemiparesis and speech disturbance is reported. CT scan showed features of ischemic infarct and extensive laboratory studies were made before the diagnosis ultimately was revealed. Such cases could result in confusion for the clinician, and high index of clinical suspicion of this condition is required since syphilis is not routinely tested, as routine screening is seen to be of low diagnostic yield. As clinical practice indicates, it remains a difficult problem approaching diagnosis of neurosyphilis, and this is achieved through exclusion of neurosyphilis as a clinical possibility.

Amnestic syndrome due to meningovascular neurosyphilis

Amnestic syndrome due to meningovascular neurosyphilis

Myelin basic protein in cerebrospinal fluid in neurosyphilis (author's transl)

Myelin basic protein (MBP) was demonstrated in the CSF of 15 out of 41 patients with assumed or ascertained neurosyphilis using a radio-immunoassay. In parenchymatous syphilis (progressive paralysis, tabes dorsalis) more than 50% of patients had MBP-positive CSF independent of immunological findings and previous treatment. CSF of patients with meningovascular neurosyphilis was mostly negative, only in 2 cases with acute symptoms was MBP demonstrable. In one of these patients MBP was no longer demonstrable in the CSF 6 months after treatment. The frequent occurrence of MBP in CSF in parenchymatous neurosyphilis can be taken as evidence of persistence of demyelinising activity even in cases where immunological finding point to "syphilis satis curata" (sufficiently treated syphilis).

Intrathecal IgA synthesis in neurosyphilis

Neurosyphilis can develop during any stage of syphilis. It has recently been reported that cerebrospinal fluid (CSF) data from patients with parenchymal or meningovascular neurosyphilis all show the absence of IgA synthesis and occasionally a concomitant IgM synthesis. In this context, it has been stated that intrathecal IgA synthesis contradicts the diagnosis of neurosyphilis. In our CSF analysis of four patients with definite neurosyphilis we observed an intrathecal synthesis of IgA, IgG and IgM in two patients. Our data are consistent with data of other studies suggesting that about 50% of patients with neurosyphilis show intrathecal synthesis of IgA. Therefore, intrathecal synthesis of IgA does not necessarily contradict the diagnosis of neurosyphilis. We hypothesize that intrathecal synthesis of IgA does not necessarily serve as a discriminating feature between neurosyphilis and other inflammatory central nervous system (CNS) disorders and that other laboratory parameters and the clinical picture have to be taken into account as well.

Neurosífilis: formas de presentación y manejo clínico

Neurosyphilis results from the infection of the central nervous system by Treponema pallidum. It causes diverse clinical pictures which are occasionally similar to other, better known neurological diseases. In this paper our aim is to offer a global clinical vision of this entity by reviewing the different forms it can take and its diagnostic and therapeutic management.The forms of presentation of neurosyphilis can be grouped in two categories: early (asymptomatic, meningeal and meningovascular neurosyphilis) and late (progressive general paralysis and tabes dorsalis). Other less important forms, such as gummas, ocular forms, syphilitic amyotrophy or hypoacusis, have also been described. Diagnosis is complex and is based on the study of the cerebrospinal fluid. Given the difficulty involved in performing an accurate diagnosis, different criteria have been developed in which T. pallidum serology plays a key role. The most effective treatment is penicillin, although on occasions it may have no effect and we therefore recommend clinical and fluid analysis follow ups. Lastly, we describe the changes in incidence and clinical presentation, and the complications that may arise in diagnosis when HIV carrying patients also suffer from this disease.Neurosyphilis is a disease that still occurs nowadays and, due to its clinical polymorphism, must be borne in mind as a differential diagnosis in a number of neurological and psychiatric illnesses. This, together with the fact the serological tests are difficult to interpret and its irregular response to the usual treatment, makes it difficult to manage and means that the neurologist must have a thorough knowledge of the disorder.

Magnetic resonance angiography in meningovascular syphilis

Meningovascular neurosyphilis (MN) is an unusual cause of stroke in young adults. The clinical manifestations include prodromal symptoms weeks or months before definitive stroke. The diagnosis is based on clinical findings and examination of the serum and cerebrospinal fluid. We report a case of MN with basilar artery irregularities demonstrated by magnetic resonance angiography.

Meningovascular neurosyphilis in human immunodeficiency virus infection as a differential diagnosis of focal CNS lesions: a clinicopathological study

The acquired immunodeficiency syndrome (AIDS) appears to alter the course of syphilis and particularly neurosyphilis. We report the case of an HIV-positive patient with two CNS lesions due to vascular complications of neurosyphilis of the meningovascular type, 18 months after he had developed a penile chancre. On admission, CT scans were inconsistent with cerebral toxoplasmosis or CNS lymphoma. At necropsy, histopathological examination showed typical Heubner's endarteritis of the basilar and posterior cerebral arteries. In AIDS patients, superadded meningovascular syphilis must be suspected, especially when CT scanning reveals the presence of multi-focal, low density lesions with the particular characteristics of infarction.

Reactivity of locally produced CSF antibodies in patients with neurosyphilis against antigens of Treponema pallidum.

The reactivity and specificity of locally produced cerebrospinal fluid (CSF) antibodies against antigens of Treponema pallidum were assessed by Western blotting in patients with clinical signs of parenchymal or meningovascular neurosyphilis. All nine patients showed local production of treponeme-specific antibodies in the central nervous system (CNS). In most of the patients serum and CSF antibodies were bound to the same antigens: the common treponemal 48/45 kDa protein and the putative specific T. pallidum protein in the range of 12-14 kDa. In some patients the intensity of staining obtained by CSF antibodies was higher than that derived from serum, indicating locally produced antibodies. In contrast to other more acute inflammatory CNS diseases, no expanded or different antigen binding of the CSF antibodies compared with serum antibodies was found in neurosyphilic patients. The results presented are discussed with regard to the role of the blood-brain barrier in antibody concentrations of CSF and serum.

Ischemic cerebrovascular disease in the young. Two common causes in India.

Mandurai City is a composite of many villages with a total population not exceeding one million. Undoubtedly more than 95% of the hospital patients come from the rural areas. Our Government Hospital is the largest and reflects the medical assistance provided for people of average and low income. In our experience, 15% of cerebrovascular strokes occur in those below 40 years of age. Meningovascular neurosyphilis in men (10-15%) and puerperal cerebral venous thrombosis in women (20%) were the two commonly proved causes. Haemorrhagic stroke was uncommon. Embolic strokes from rheumatic heart disease formed 10%. In over 50%, the cause of stroke was not clear. Among 150 patients with neurosyphilis, mostly men, 25 had cerebral arterial thrombosis with stroke syndrome. This study reports on 138 patients with cerebral venous thrombosis and 7 patients with arterial thrombosis in puerperium. Mortality was 20% and quality of survival was good. The incidence, clinical picture, and diagnostic investigations are discussed with a review of literature.

Symptomatic neurosyphilis.

We observed 24 patients with symptomatic neurosyphilis. Of these 24 patients, nine had clinical manifestations of general paresis, seven tabetic neurosyphilis, five meningovascular neurosyphilis, one taboparetic, one tabomeningovascular, and one spinal neurosyphilis. Confusion, disorientation, lancinating pain, impaired memory, and bizarre behavior were the most prevalent symptoms. Sensitivity of the CSF FTA-ABS test was higher (96%) than that of the CSF VDRL test (79%). CSF cell count and total protein determination may be inadequate for assessing activity of neurosyphilis.

Angiographic findings in a case of brain syphilis.

The clinical difficulties of differentiating neurosyphilis from other brain diseases have long been accepted. Indeed, many patients with this disease have been subjected to fruitless craniotomy in the mistaken belief that a tumor or some other disease lay at the basis of their symptoms (6). The fact that neurosyphilis may also be associated with angiographic abnormalities which can simulate brain tumor, however, is not generally recognized, though of growing importance with the increasing use of angiography. Since no reports of angiographic changes in paretic meningovascular neurosyphilis were found in angiographic texts (4, 8) or in the literature of the past twelve years, the following case is reported. Case Report B. D., a 46-year-old Negro factory worker, suffered an abrupt onset of aphasia and right-sided weakness and sensory loss a few hours prior to admission. Over the preceding months there had been a gradual personality change, loss of recent memory, wandering of speech, and increasingly short-te...

NEUROSYPHILIS

THIS REPORT includes data relating to 15 patients treated with vaccine (typhoid) fever and penicillin and 17 patients treated with malarial fever and penicillin. About 80 per cent of the patients in each group had dementia paralytica or the tabetic form of dementia paralytica, the remaining 20 per cent having asymptomatic neurosyphilis, tabes dorsalis or meningovascular neurosyphilis. The technic used in administering vaccine fever is similar to the continuous intravenous infusion method as used by Heyman. 1 TECHNIC OF VACCINE FEVER THERAPY The temperature is held above 103 F. (axillary) from five to ten hours, depending on the condition of the patient. The temperature is usually maintained around 104.5 F. (axillary) if possible, as this is the optimum temperature. The temperature, pulse rate and rate of respirations are recorded at fifteen minute intervals while the temperature is above 102 F. (axillary) or whenever there is any doubt