Syphilitic Gumma Research Articles

The imaging findings in intracranial syphilitic gumma

The imaging findings in intracranial syphilitic gumma

Left temporal cerebral syphilitic gumma: Case report and literature review

Syphilis is a systemic disease caused by the spirochaete Treponema pallidum that affects the central nervous system at any time and whose clinical presentation has undergone changes in recent decades, due to the emergence of the acquired immune deficiency virus. We present the case of a 50-year-old immunocompetent woman with no significant changes in sexual behaviour, who only presented with headache and speech disturbances (mixed aphasia). MRI and CT scans initially showed left parietal injury, and later left temporal recurrence. The patient was treated for neurosyphilis for 5 weeks and showed improvement at her one-month follow-up appointment, before once again manifesting speech disturbances with sensory aphasia six months after treatment onset. Another control MRI was performed, revealing a relapse of the tumour lesion in the left temporal region. Intravenous treatment was once again initiated with benzathine penicillin and new serological and imaging tests were conducted, revealing the absence of lesions. Gummatous neurosyphilis is a rare condition, which explains why it tends to be erroneously diagnosed and treated. It is for this reason that we have presented our case study and literature review.

The laryngeal disease of the German Emperor Friedrich III: treatment failure or fateful course.

Since the death of the Emperor Friedrich III in June 1888, there are still controversial discussions whether the Crown Prince could have been healed from his laryngeal cancer by a thyrotomy planned by his German physicians for May 21, 1887. In order to find an answer to this historical question, the Emperor's biographies, the literature on laryngology published in the late nineteenth and early twentieth century, German manuals on laryngology and ENT, the BMJ and Lancet were thoroughly studied where in particular not only Mackenzie but also Virchow had published several articles on the disease of Friedrich III. Prof. Gerhardt had decided not to perform biopsies of the tumor. Furthermore, he did not perform iodine potassium treatment ex juvantibus as it was common practice at that time in order to confirm the diagnosis of carcinoma by excluding syphilitic gumma. So Mackenzie was perfectly right when insisting on performing excisional biopsy before surgery. It is tragedy that Virchow by making the diagnosis of pachydermia laryngis provided the justification for canceling the surgical intervention that had already been decided. It was also mistake that Prof. Gerhardt did not accompany the Crown Prince during his stay in England in summer 1887. The authority of the delegated medical officer Dr. Landgraf did not suffice to persuade Mackenzie to discuss again the matter of performing surgery together with Gerhardt and von Bergmann. The drawings made by Dr. Landgraf show an impressive tumor growth. The refusal of new consultations with Gerhardt and von Bergmann by Mackenzie can only be explained by the fact that Mackenzie was generally against such a surgical intervention. Regarding the question of the chances of such a surgery it can be said that thyrotomy and laryngectomy had been refused by the majority of laryngologists since the Congress of London in 1881 and the publication of P. v. Bruns in 1878. In Berlin, however, the improvement of surgical and anesthetic techniques by E. Hahn led to a positive opinion. F. Semon, who had strictly refused thyrotomy until 1886, supported the indication of thyrotomy of the Crown Prince since Hahn had successfully operated one of his patients in London. So the chance of healing a limited carcinoma of the vocal folds by thyrotomy was given. However, it may be questioned if partial resection had the desired outcome. The limited mobility of the left vocal fold that had been diagnosed already in May 1887 indicates that probably laryngectomy would have been necessary. The prognosis of this procedure, however, was extremely poor at that time. It is irony of history that T. Gluck who performed the separation of the airways from the digestive pathways in an animal model already in 1880 under von Langenbeck could not further develop his technique under von Bergmann. The Crown Prince acquired his disease at a time when the acceptance of surgical treatment of laryngeal carcinomas had reached its lowest point. Ten years later, the technique of thyrotomy was successfully established by Hahn, Butlin, and Semon so that Morell Mackenzie would probably have agreed to the intervention. Ten years later, due to Gluck and Sörensen, even the technique of laryngectomy had reached the performance that is still valid today so that the Emperor could have been treated successfully even with an advanced laryngeal carcinoma.

Cerebral Syphilitic Gumma Mimicking Glioblastoma

A case of suspected glioblastoma accompanied by systemic syphilis was referred to our institute for surgery. She was a 47-year-old woman presenting with headache and vomiting. A frontal mass with ring enhancement and surrounding edema was revealed by MRI. Although neurosyphilis was considered a differential diagnosis, surgery was performed and cerebral syphilitic gumma was confirmed by histology. To reduce misdiagnosis, we reviewed the related literature and summarized pathogenesis, radiologic features, and treatment strategy of cerebral syphilitic gumma.

Neurosyphilis Presenting with Multiple Cranial Neuropathy

Neurosyphilis can present with various clinical symptoms. We report a patient with multiple cranial neuropathy that, mimicked tuberculosis, but was finally diagnosed as neurosyphilis. A 38-year-old man was admitted due to subacutely progressive hearing loss. Brain MRI revealed multiple dural enhanced masses on contrast-enhanced T1 weighted images. Brain biopsy of the dural enhanced lesion revealed chronic granulomatous inflammation with coagulation necrosis, compatible with syphilitic gumma. Serum venereal disease research laboratory and fluorescent treponemal antibody absorption test results were positive. Treatment with penicillin resolved the patient’s symptom. Key Words: Neurosyphilis, Multiple cranial neuropathy

Syphilitic Gumma Lesion in Meckel's Cave and Infratemporal Fossa Presenting with Cranial Nerve Deficit

We describe the case of a 54-year-old man presenting with symptoms of left otalgia with irradiation to the jaw. Initial investigation revealed an isointense T1, hypointense T2, and homogenously enhancing nodular lesion invading the left Meckel’s cave, spreading into rotundum and ovale foramina toward the infratemporal fossa. There was also infiltration of the pterygoid muscles. Biopsy was done through an endoscopic transmaxillary approach directed at this lesion in the pterygomaxillary and infratemporal fossa. The initial diagnosis was hemangioma.

Cerebral syphilitic gumma misdiagnosed as glioma: A case report and literature review

Cerebral syphilitic gumma misdiagnosed as glioma: A case report and literature review

Cerebral Gumma Mimicking a Brain Tumor in a Human Immunodeficiency Virus-Negative Patient: A Case Report

Syphilis has a broad spectrum of clinical manifestations, and the cerebral gumma is a kind of neurosyphilis which is rare and can be cured by appropriate antibiotic treatments. However, in clinical practices, diagnosis of cerebral syphilitic gumma is often difficult because imaging and laboratory findings revealed elusive results. Herein, we present a rare case of neurosyphilis presenting as cerebral gumma confirmed by histopathological examination, and positive serologic and cerebrospinal fluid analyses. This case report suggests that cerebral gumma should be considered as possible diagnosis for human immunodeficiency virus-negative patients with space-occupying lesion of the brain. And this case also provides importance of clinical suspicions in diagnosing neurosyphilis because syphilis serology is not routinely tested on patients with neurologic symptoms.

Cerebral Syphilitic Gumma Mimicking a Brain Tumor in the Relapse of Secondary Syphilis in a Human Immunodeficiency Virus-Negative Patient

Diagnosis of cerebral syphilitic gumma is frequently determined at the time of surgery, because imaging and laboratory findings demonstrate the elusive results. A 59-year-old woman presenting dysarthria showed a mass on her brain computed tomography. She was first suspected of brain tumor, but histological results from surgical resection revealed cerebral gumma due to neurosyphilis. After operation, she presented fever and rash with an infiltration on a chest X-ray. Histological assessment of skin was consistent with syphilis. Fluorescent treponemal antibody absorbed test IgG in cerebrospinal fluid was positive. She was successfully treated with ceftriaxone for 14 days.

Cerebral syphilitic gumma: a case report and review of the literature

A 45-year-old male presented with subacute onset of a right-sided hemiparesis, right homonymous hemianopsia, and slurred speech. The brain imaging revealed two separate intraparenchymal enhancing lesions. The cerebrospinal fluid rapid plasma reagin and venereal disease research laboratory test were positive and consistent with syphilitic gumma, and the patient responded dramatically to penicillin G. Despite, currently low incidence of syphilis; CNS gummas should be in the differential of mass lesions as they are eminently treatable.

Cavernous sinus syndrome, an atypical presentation of tertiary syphilis: Case report and review of the literature

Cavernous sinus syndrome is rarely caused by tertiary syphilitic infection. To our knowledge only two other cases of cavernous sinus syndrome caused by syphilis have been reported in the literature. We report a case of a 62-year-old female who presented with a mass in the cavernous sinus, which was initially diagnosed as a meningioma radiologically, necessitating a biopsy for diagnostic confirmation. Clinical features of syphilitic aortitis and subsequent positive neurosyphilis laboratory results lead to the suspicion of a gumma infiltrating the cavernous sinus. Empirical treatment with penicillin in an attempt to defer the need for biopsy led to both significant clinical improvement and radiological resolution. This confirmed the diagnosis of a syphilitic gumma in the cavernous sinus. In this paper we emphasize the rarity of cavernous sinus syndrome as a result of syphilitic infection, highlight the diagnostic difficulties using current serological and radiological measures, and propose treating intracerebral mass lesions in serum positive cases empirically prior to more invasive measures.

Solitary frontal ulcer: A syphilitic gumma

We report the case of a 30-year-old woman presenting with a single, deep, asymptomatic frontal ulcer that had developed in the previous two months without preceding trauma. Blood tests revealed reactive Rapid Plasma Reagin and Treponema pallidum hemagglutination assays. The diagnosis of syphilitic gumma was confirmed after histological analysis of the ulcer border. No other manifestations of late syphilis were detected. Ulcer healing was observed after treatment with benzathine penicillin and there was progressive reduction of follow-up serum RPR titers. The relevance of this case arises from its unusual presentation in a previously healthy immunocompetent individual.

CEREBRAL SYPHILITIC GUMMATA

Cerebral syphilitic gummata are rare manifestations of tertiary, meningovascular syphilis. No extensive characterization of these lesions has been published recently, and only a few small reviews containing imaging findings have been published to date. To better characterize cerebral gummata, we present a case seen at Tulane University, followed by an extensive review of the literature. A 56-year-old man with a history of treated syphilis presented with seizures and confusion. A rapid plasma reagin titer was reactive in serum but Venereal Disease Research Laboratory results were negative in cerebrospinal fluid. Neuroimaging demonstrated an occipital lesion and the patient underwent subtotal resection. The pathological examination demonstrated a syphilitic gumma containing Treponema pallidum visualized by fluorescence immunostaining. An extensive literature search was performed for published case reports of cerebral gummata. One hundred fifty-six cases containing 185 lesions were located. Patients presented with signs and symptoms based on location. Lesions are more common in men (64%) and those aged 18 to 39 years. Cerebrospinal fluid syphilis tests were positive in 64%. Lesions are located everywhere but are most common on the convexities (66%). Computed tomography usually reveals a hypodense lesion that enhances. Magnetic resonance imaging usually demonstrates hypointensity on T1, hyperintensity on T2, and enhancement with gadolinium. Most patients are responsive to antiluetic therapy, with the majority demonstrating complete or near-complete imaging and symptom resolution. Cerebral gummata are rare lesions. Intravenous penicillin G with imaging follow-up is recommended for most patients. Surgery should be reserved for those unresponsive to antibiotics or those with acutely elevated intracranial pressure.

Neurosyphilis révélée par une atteinte multiple des nerfs crâniens : apport de l’imagerie par résonance magnétique nucléaire

Introduction We report the magnetic resonance imaging (MRI) findings in a case of neurosyphilis revealed by the involvement of two cranial nerves. Case report A 41-year-old man developed a right cochleovestibular and left trigeminal neuropathy, associated with high serum titers of VDRL and TPHA, high titers of TPHA in the cerebrospinal fluid (CSF) and several CSF oligoclonal IgG bands. On MRI, hypertrophy and gadolinium contrast enhancement of these cranial nerves were associated with several supratentorial cortical nodules surrounded by marked cerebral edema, corresponding to syphilitic gummas. One of these cortical nodules was biopsied. Microscopic examination showed lesions of meningoencephalitis with necrosis and granulomatous vasculitis. After penicillin therapy, the serum VDRL titers and the MRI abnormalities disappeared, a partial clinical recovery was observed and a significant reduction of the serum TPHA titers was found. Discussion Such MRI abnormalities are not specific and can be observed in various tumoral, auto-immune and infectious diseases. They can also mimic neurofibromatosis type II. Cranial nerve involvements in neurosyphilis can result from nerve inflammation in basal meningitis, nerve ischemia in meningovasculitis or from compression by an adjacent gumma. In our case, the cranial neuropathy was related to a mixed meningovascular and parenchymatous form of neurosyphilis.

Intracranial syphilitic gumma resembling malignant brain tumour

We report a patient with a temporal lobe syphilitic gumma mimicking a malignant brain tumour in a 43-year-old immunocompetent man. The diagnosis was confirmed histologically and using polymerase chain reaction. Syphilitic gummatous involvement of the central nervous system is rare, with only a few cases having been reported. The unique feature of this case was the extensive oedema surrounding the lesion, suggestive of an active process.

Cerebral syphilitic gumma in HIV-infected patients: case report and review

Neurosyphilis presenting as a cerebral gumma is an uncommon event. To date there are seven cases of cerebral gumma reported in human immunodeficiency virus (HIV)-infected patients. We describe a HIV-infected patient with neurosyphilis presenting as an expanding central nervous system lesion and unremarkable cerebrospinal fluid analysis. This case report illustrates the clinical and therapeutic aspects of syphilitic gumma in HIV-infected patients.

Syphilis and Spinal Disability

Syphilis is an important sexual related infection. The recent rises of syphilis have been among men having sex with men, but the incidence among heterosexuals has also risen. Syphilis has a medical correlation to disability. Syphilis can lead to spinal disability. Syphilitic thoracic aortic aneurysm and spinal gumma are the two important conditions. Syphilis can also superimpose the paraplegic case to additional neuroarthropathy.

Unsuspected Central Nervous System Gummas in a Case of “Cerebral Infarct” Associated With Cocaine Use

A 54-year-old African-American male was hospitalized with a left "cerebrovascular accident," altered mental status, agitation, rhabdomyolysis, and hypernatremia. Laboratory tests found cocaine in his system and a positive RPR (rapid plasmin reagin test). A CAT (computed axial tomography) scan without contrast taken 8 days prior to his death showed a left middle cerebral artery infarct, with edema and mass effect, and a 1-cm midline shift to the right. He underwent symptomatic treatment, eventually suffered cardiopulmonary arrest and multiorgan failure, and expired 8 days after admission. The left cerebral lesion diagnosed clinically as a cerebral infarct was actually determined to be a syphilitic gumma on postmortem neuropathologic examination. Neurosyphilis, although rare, should be considered in the differential diagnosis of space-occupying lesions in the brain because cases of syphilis continue to occur both sporadically and as an opportunistic infection associated with acquired immunodeficiency syndrome (AIDS) and because neurosyphilis is treatable.

Diffusion-Weighted Magnetic Resonance Imaging Findings in a Patient With Cerebral Syphilitic Gumma

Cerebral syphilitic gummas are rare entities, consisting of masses of granulation tissue that result from an exacerbated cell-mediated inflammatory response to Treponema pallidum, usually arising from the meninges of the convexity. Conventional magnetic resonance imaging and computed tomography findings of cerebral gummas have been reported, but diffusion-weighted imaging findings have not been previously described. In our patient, magnetic resonance imaging revealed a juxtacortical lesion with nodular enhancement, moderately restricted diffusion, a dural tail, and surrounding vasogenic edema. The role of diffusion-weighted imaging findings in the diagnosis of this condition is underscored.

Síndrome de restauración inmune asociado a tratamiento antirretroviral y criptococosis meníngea: Caso clínico

The objective of high activity antiretroviral therapy (HAART) in patients with AIDS, is to obtain immune restoration. This means a reduction of the viral load and restitution of the CD4 cell count. A decreased rate of HIV replication improves both the number and function of CD4 cells. Nevertheless, this treatment sometimes results in the reappearance of previous symptoms from treated conditions due to opportunistic infections (ie: tuberculosis, criptococcosis, hepatitis, Pneumocystis jirovesi, toxoplasmosis, etc) or non infectious condition such as sarcoidosis, Graves disease or Kaposi sarcoma. This is known as Inflammatory Reconstitution Immune Syndrome (IRIS). We report a 37 year-old woman in stage C3-AIDS with a previous criptococcal meningitis. She was treated, achieving a marked improvement with treatment and subsequent suppressive therapy with fluconazole 200 mg/day. IRIS appeared after 8 months of ongoing antiretroviral therapy with immune restoration with the development of aseptic meningitis and intracranial hypertension. The opportunistic agent could not be identified by cultures. Additional laboratory tests excluded toxoplasmosis, tuberculosis, bacterial cerebral abscesses, syphilitic cerebral gummas, and lymphoma. Brain CT and magnetic resonance studies were compatible with brain vasculitis and leptomeningitis. The patient condition improved with general measures, such as a repeated lumbar punctures and non steroidal anti-inflammatory drugs. We conclude that this patient had an IRIS due to a Cryptococcus neoformans antigen.