Neurosyphilis Presenting Research Articles

A peculiar case of neurosyphilis presenting with general paresis of the insane with concurrent untreated HIV infection

A peculiar case of neurosyphilis presenting with general paresis of the insane with concurrent untreated HIV infection

Late-onset mania as a manifestation of neurosyphilis: A Case Report

IntroductionThe evaluation of manic behavior with later onset is crucial, as various organic factors such as medications, infections, metabolic disturbances, tumors, and epilepsy can serve as potential etiological causes. While not universally observed, most studies indicate a connection between late-onset mania and neurological disorders like neurosyphilis.ObjectivesOur study aims to investigate the relationship between late-onset mania and neurosyphilis.MethodsIn this paper, we present a case of neurosyphilis presenting exclusively with symptoms of mania.ResultsA 72-year-old Tunisian woman with no prior medical or psychiatric history was referred to the psychiatric emergency room due to alterations in her mental state and behavior over the past ten days. During the psychiatric assessment, she displayed increased motor activity, fluctuating emotions, and rapid flow of ideas. The general physical examination yielded no notable findings. The serum Venereal Disease Research Laboratory (VDRL) test returned a strongly positive result (+++), and the TPHA examination confirmed a positive result at a titer of 1/60. In the serologic analysis of cerebrospinal fluid, VDRL was also positive, thereby confirming the diagnosis of neurosyphilis (NS). The diagnosis of mania secondary to a medical condition was established. The patient was treated with ceftriaxone and antimanic medications, resulting in a significant improvement in her psychiatric symptoms within a few days.ConclusionsThis case underscores the importance of conducting serologic testing for syphilis in patients who present with manic symptoms, experience a late-onset mental disorder, and have no prior history or family history of affective disorders.Disclosure of InterestNone Declared

A Case of Neurosyphilis Presenting with Isolated Abducens Nerve Palsy.

We herein report a case of neurosyphilis that presented with isolated bilateral abducens nerve palsy. A 39-year-old man was referred to our department with diplopia. He had a history of homosexual relationships and showed only bilateral abducens nerve palsy upon a neurological examination. Positive syphilis tests in the serum and cerebrospinal fluid and a contrasting effect on the abducens nerve on magnetic resonance imaging (MRI) confirmed the diagnosis of active neurosyphilis. When a patient manifests isolated abducens nerve palsy, neurosyphilis can be a differential diagnosis, although rare, and contrast-enhanced MRI may help diagnose the disease.

Neurosyphilis presenting with Guillain–Barre syndrome: a case report

BackgroundSyphilis is associated with a wide variety of systemic presentations, earning it the moniker “The great mimicker”. Neurosyphilis is classically associated with meningovasculitis in the acute-subacute stage and tabes dorsalis and dementia paralytica in later stages. However, one of the less well described presentations include Guillain–Barre Syndrome. This case presents a patient with an ascending polyneuropathy suspicious for Guillain–Barre Syndrome who also had other atypical findings including a truncal sensory loss, optic disc swelling, and rash ultimately found to have neurosyphilis. Electrodiagnostic testing was consistent with demyelination, supporting a diagnosis of neurosyphilis associated Guillain–Barre Syndrome.Case presentationA 37-year-old female presented to the emergency department with a weakness and difficulty swallowing. She described a three-month history of symptoms, initially starting with a persistent headache followed by one month of a pruritic rash on her chest, palms, and soles. Two weeks prior to presentation, she developed progressive weakness in her arms, numbness in her arms and chest, and difficulty swallowing. Neurological exam was notable for multiple cranial neuropathies, distal predominant weakness in all extremities, length-dependent sensory loss, and hyporeflexia. Investigation revealed a positive Venereal Disease Research Laboratory in her cerebrospinal fluid without significant pleocytosis, contrast enhancement in cranial nerves V, VII, and VIII on MRI, and a demyelinating polyneuropathy on electrodiagnostic testing. She was diagnosed with Guillain–Barre syndrome, secondary to neurosyphilis. The patient acutely declined and required intubation, and ultimately made a full recovery after treatment with plasmapheresis and penicillin.ConclusionsThis case describes a clinical entity of syphilitic Guillain–Barre Syndrome and highlights the importance of including syphilis in the differential of any patient presenting with ascending polyradiculopathy, especially given the resurgence of syphilis.

Neurological manifestations of syphilis-HIV coinfection in South Africa

ObjectiveSyphilis and HIV coinfection is highly prevalent in South Africa, and both can cause neurological complications. We describe the clinical presentation and outcome of neurosyphilis in patients with and without HIV coinfection diagnosed at a tertiary facility, Groote Schuur Hospital (GSH), in South Africa. MethodsWe retrospectively analyzed folders of adults with positive cerebrospinal fluid (CSF) fluorescent treponemal antibody absorption test in 2018 and 2019, with follow-up data collected until 2022. ResultsHIV-coinfection was identified in 35% of the 69 included patients. Patients with HIV-coinfection were more likely to be female (58% vs 25% female, p < 0.01), and present earlier (median age = 31 years vs. 40 years, p < 0.001). Neuropsychiatric manifestations (confusion, dementia, psychosis), and strokes were the commonest clinical presentations in both groups. Those with HIV-coinfection were significantly less likely to be diagnosed with neurosyphilis by the treating clinician (71% vs. 91%, p < 0.05), as were those with a negative CSF Venereal Disease Research Laboratory (74% vs. 94%, p < 0.05). Accurate diagnosis of neurosyphilis was associated with an increased 12-month survival (alive: N = 36 [63%]) relative to those who did not receive an accurate diagnosis (alive: N = 2 [17%], p < 0.05). Those who were optimally treated with antibiotics had significantly higher 12-month survival (alive: N = 33, 63%) compared to those with suboptimal treatment (alive: N = 5, 29%), p < 0.01. ConclusionNeurosyphilis presented similarly in those with and without HIV-coinfection. Accurate identification and optimal antibiotic treatment of neurosyphilis, particularly in CSF VDRL negative patients and those with HIV-coinfection, is necessary to improve patient survival.

Neurosyphilis Presenting as Longitudinally Extensive Transverse Myelitis

Neurosyphilis Presenting as Longitudinally Extensive Transverse Myelitis

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.

MRI of neurosyphilis with mesiotemporal lobe lesions of "knife-cut sign” on MRI: A case report and literature review

Neurosyphilis with mesiotemporal lobe lesions remains a difficult entity to diagnose, especially when it mimics herpes simplex encephalitis (HSE). Here, we report what appeared to be the first case of mesiotemporal imaging of neurosyphilis presenting as a “knife-cut” sign and mimicking HSE pathological hallmarks on imaging. The magnetic resonance imaging (MRI) changes in neurosyphilis and HSE were indistinguishable in the initial diagnosis because of the common involvement of the mesiotemporal lobe. Neurosyphilis was diagnostically confirmed by positive readings in the treponema pallidum hemagglutination assay (TPHA), rapid plasma reagin (RPR) and cerebrospinal fluid-polymerase chain reaction (CSF-PCR) tests for Treponema pallidum infection. Neurosyphilis and HSE had similar clinical features and signs on MRI, except the knife-cut sign which is a common diagnosis in HSE. Therefore, neurosyphilis with mesiotemporal changes and knife-cut signs on MRI should be evaluated in the differential diagnosis in all patients, as similar changes may also occur in HSE patients. The literature review of published articles between 1997 and 2020 was conducted to further validate our clinical observations and discuss diagnostic and treatment options for neurosyphilis with mesiotemporal lobe lesions.

Neurosyphilis among people with and without HIV infection: A Danish nationwide prospective, population-based cohort study 2015–2021

Comparative data on clinical presentation, laboratory characteristics, treatment, and outcome of neurosyphilis (NS) in people living with HIV (PLWH) and NS patients without HIV are scarce. Nationwide, population-based, prospective cohort study on all adults with NS diagnosed between 2015 and 2021 at departments of infectious diseases in Denmark. We identified 108 patients with NS, which equals a yearly incidence of 0.3/100,000 adults. The median age was 49 years, 85 (79%) were male, 43 (40%) were men having sex with men and 20 (22%) were PLWH. Ninety-five (88%) had early NS, 37 (34%) had ocular or ocular and otogenic NS, and 27 (25%) had symptomatic meningitis. Most common symptoms were visual disturbance (44%), skin rash (40%), fatigue (26%) and chancre (17%). Median CSF leukocyte count was 27×106 cells/L. PLWH less often had neurological deficits (p=0.02). Unfavorable outcome was observed in 23 (21%) at discharge of whom 0 were PLWH (p=0.01). Among the 88 NS patients without HIV a CSF leukocyte count of ≥30×106 cells/L was associated with unfavorable outcome (OR=3.3 (95% confidence interval: 1.1-10.4)). PLWH with NS have better outcomes than NS patients without HIV infection.

A case of neurosyphilis presenting as sudden onset of limbic encephalitis

A 52-year-old male was carried to hospital by ambulance, because of an abrupt abnormal behavior and impaired consciousness. Soon after the arrival, the patient started a generalized seizure. Although the seizure was stopped by Midazolam, amnesia were observed. With meningeal irritation signs, in addition to the clinical course, the patient was thought to develop limbic encephalitis. The cause of the encephalitis was diagnosed as neurosyphilis because of the positive serum and CSF syphilis reactions, and the patient was treated with penicillin G from the first admission day on. Steroid pulse therapy was also conducted, followed by acyclovir since herpes encephalitis could not be ruled out; the brain MRI showed left-side dominant T2/FLAIR high intensity lesions in the bilateral temporal lobes and left hippocampus. With the treatment progression, the amnestic syndrome improved and the patient returned to work. Although neurosyphilis is a rare cause of acute onset limbic encephalitis, it is important to keep the possibility of this disease in mind in making a treatment plan.

Dysphagia as a presentation of neurosyphilis: The great imitator

Infectious esophagitis, including candida and HSV, often presents in the backdrop of systemic illness and an immunocompromised state

A rare case of neurosyphilis presenting as generalized dystonia with bilateral cerebellar infarctions.

The Article Abstract is not available.

Neurosyphilis Presenting as Mimicker of Giant Cell Arteritis with Bilateral Papilledema (P1-1.Virtual)

Neurosyphilis Presenting as Mimicker of Giant Cell Arteritis with Bilateral Papilledema (P1-1.Virtual)

Neurosyphilis presenting as encephalitis: Two case reports

Neurosyphilis can present with wide variability of central nervous system manifestations making difficult reaching a correct diagnosis. In addition, features of neurosyphilis that mimic herpetic or autoimmune encephalitis have been described. We present two patients whose clinical manifestations were suggestive of encephalitis.

Neurosyphilis.

This article focuses on the epidemiology, clinical presentation, diagnosis, and management of neurosyphilis, with an emphasis on clinically relevant issues faced by the practicing neurologist. The incidence of primary and secondary syphilis, the sexually transmissible stages of infection, has been on the rise for the past 2 decades. A concerning recent trend is the surge in cases of syphilis in women and of congenital syphilis. Neurosyphilis remains a relatively common complication that can occur at any stage of syphilis. Along with meningitis, meningovascular syphilis, which has been historically described as a late presentation of neurosyphilis, now frequently occurs as a manifestation of early infection. Late forms of neurosyphilis, including tabes dorsalis and general paresis, are less prevalent in the era of widespread penicillin use. As more laboratories adopt the reverse-sequence algorithm for syphilis testing, patients with serodiscordant results (ie, a reactive serum treponemal test with a nonreactive nontreponemal test) may present an increasingly encountered diagnostic challenge for neurologists. Although the CSF Venereal Disease Research Laboratory (VDRL) remains a mainstay of diagnostic testing for neurosyphilis, using a higher titer cutoff (greater than 1:320) for the Treponema pallidum particle agglutination assay (TPPA) from the CSF may improve the utility of the TPPA as a supporting criterion for the diagnosis of neurosyphilis. Penicillin G is the treatment of choice for neurosyphilis, although ceftriaxone may be a reasonable alternative therapy. A high index of suspicion and awareness of the variable clinical presentations of neurosyphilis are essential to the approach to this treatable infection. Neurologists should be mindful of the limitations of serologic testing in the diagnosis of neurosyphilis and exercise clinical judgment to determine the likelihood of the diagnosis.

The great imitator: neurosyphilis presenting as subacute confusion.

The great imitator: neurosyphilis presenting as subacute confusion.

The associations of increased cerebral small vessel disease with cognitive impairment in neurosyphilis presenting with ischemic stroke.

Background and PurposeIschemic stroke is a common clinical feature of neurosyphilis, but its accompanying cognitive decline is often overlooked. The mechanisms of cognitive impairment in neurosyphilis presenting with ischemic stroke are not fully understood. Cerebral small vessel disease (CSVD) was recently shown to predict post‐stroke cognitive decline. Therefore, this study aims to validate the correlation between CSVD and cognitive impairment in neurosyphilis presenting with ischemic stroke.MethodsWe enrolled 179 neurosyphilis patients diagnosed as acute ischemic stroke and performed a 12‐month cognitive assessment follow‐up. CSVD burden was evaluated by neuroimaging markers, including white matter hyperintensities (WMHs), lacunes, cerebral microbleeds (CMBs), and perivascular spaces (PVS). We performed multivariate logistic regression analysis to determine the association between cognitive decline and total CSVD burden score in neurosyphilis patients.ResultsThe neurosyphilis participants had a significantly higher total CSVD score and lower cognitive function score compared with the syphilis‐uninfected patients. Acute cognitive impairment was associated with total CSVD score, extensive microbleeds, and Grade 3 WMHs. After 12‐month follow‐up, the poor prognosis of post‐stroke cognitive impairment was associated with a higher burden of CSVD and extensive microbleeds.ConclusionsCerebral small vessel disease loads in neurosyphilis patients presenting with ischemic stroke are independently associated with acute cognitive impairment and have a prospective value for post‐stroke cognitive outcomes.

An Early Presentation of Neurosyphilis Manifesting as Cranial Polyneuropathies: A Case Report

Neurosyphilis (NS) is a rarely reported disease, with neurological manifestations occurring in the late stages of the infection. The incidence of NS has steadily increased, particularly with increased cases of human immunodeficiency virus (HIV) infection among homosexual partners, and can occur at any stage of the disease. In this case report, we present a 53-year-old homosexual man with HIV who presented with a gradual onset of vertigo over a course of 2 weeks, followed by gradual onset of multiple cranial neuropathies. Magnetic resonance imaging of the brain revealed pathological enhancement of multiple cranial nerves. Laboratory workup revealed reactive Venereal Disease Research Laboratory dilutional titer in the cerebrospinal fluid, supporting the diagnoses of NS. He was treated with intravenous penicillin with gradual resolution of symptoms. Our case illustrates that NS can occur with no known prior evidence or manifestation of the infection. The diagnosis of NS should be entertained in individuals with a known history of HIV and unexplained multiple cranial neuropathies. J Neurol Res. 2021;11(1-2):27-31 doi: https://doi.org/10.14740/jnr650

Neurosyphilis Presenting as Acute Ischemic Stroke and Improvement with Thrombolytics (2859)

Neurosyphilis Presenting as Acute Ischemic Stroke and Improvement with Thrombolytics (2859)

An Early Presentation of Neurosyphilis Manifesting as Cranial Polyneuropathies: A Case Report

Neurosyphilis (NS) is a rarely reported disease, with neurological manifestations occurring in the late stages of the infection. The incidence of NS has steadily increased, particularly with increased cases of human immunodeficiency virus (HIV) infection among homosexual partners, and can occur at any stage of the disease. In this case report, we present a 53-year-old homosexual man with HIV who presented with a gradual onset of vertigo over a course of 2 weeks, followed by gradual onset of multiple cranial neuropathies. Magnetic resonance imaging of the brain revealed pathological enhancement of multiple cranial nerves. Laboratory workup revealed reactive Venereal Disease Research Laboratory dilutional titer in the cerebrospinal fluid, supporting the diagnoses of NS. He was treated with intravenous penicillin with gradual resolution of symptoms. Our case illustrates that NS can occur with no known prior evidence or manifestation of the infection. The diagnosis of NS should be entertained in individuals with a known history of HIV and unexplained multiple cranial neuropathies. J Neurol Res. 2021;11(1-2):27-31 doi: https://doi.org/10.14740/jnr650