Neurosyphilis: mighty imitator forays with benign presentation and unique neuroimaging findings
Harmanpreet Tiwana A B and Aiesha Ahmed AA MD Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania-17033, USA.
B Corresponding author. Email: htiwana@pennstatehealth.psu.edu
Sexual Health 15(4) 358-360 https://doi.org/10.1071/SH17088
Submitted: 27 April 2017 Accepted: 19 December 2017 Published: 30 April 2018
Abstract
Background: Common causes of temporal lobe hyper intensities are central nervous system infections like herpes simplex encephalitis, Lyme disease, limbic encephalitis and vascular pathology like Cerebral Autosomal Dominant Arteriopathy with Subcortical infarcts and Leukoencephalopathy. Methods: Personal assessment, laboratory data analysis and neuroimaging for the patient who was admitted to a central Pennsylvania tertiary care referral centre were conducted. Results: A 52-year-old male presented with a 1-year history of diffuse dysesthesia in upper and lower extremities with associated intermittent headaches and neck stiffness. Evaluation with lumbar puncture revealed increased nucleated cells (50 ul) with lymphocytic predominance (96%) and an elevated protein level of 109 mg/dl. Magnetic resonance imaging (MRI) of the brain showed T2/FLAIR hyper intensity in bilateral subcortical temporal white matter, left-greater-than-right and associated volume loss in cerebral parenchyma. Additional abnormal work up included reactive serum reactive plasma regain and Treponema pallidum antibody particle agglutination. Diagnosis of neurosyphilis was made and the patient was treated with intramuscular (IM) penicillin for 3 weeks. At the time of discharge, his headache and neck stiffness resolved and dysesthesias were decreased in intensity. Conclusions: The diagnosis of neurosyphilis is intricate, and no reference standard exists. Neuroimaging findings of neurosyphilis commonly are cerebral infarctions, leptomeningeal enhancement or non-specific white matter lesions. Less common features on fluid-attenuated inversion recovery (FLAIR) sequences are cortical atrophy and mesial temporal parenchymal signal changes. It is prudent to keep neurosyphilis in differential of mesial temporal lobe white matter changes, as early diagnosis and treatment results in better prognosis.
Additional keywords: Mesial temporal white matter changes, Neurosyphilis, IM Penicillin.
References
[1] Jay CA. Treatment of neurosyphilis. Curr Treat Options Neurol 2006; 8 185–92.| Treatment of neurosyphilis.Crossref | GoogleScholarGoogle Scholar |
[2] Merritt HH, Adams RD, Solomon HC. Neurosyphilis. Oxford, New York: Oxford University Press; 1946.
[3] Chahine LM, Khoriaty RN, Tomford WJ, Hussain MS. The changing face of neurosyphilis. Int J Stroke 2011; 6 136–43.
| The changing face of neurosyphilis.Crossref | GoogleScholarGoogle Scholar |
[4] Larsen S, Kraus S, Whittington W. Diagnostic tests. In: Larsen SA, Hunter E, Kraus S, editors. A manual of tests for syphilis. Washington, DC: American Public Health Association; 1990. pp. 2–26.
[5] Stoner B. Current controversies in the management of adult syphilis. Clinical Infectious Diseases 2007; 44 S130–S146.
| 1:CAS:528:DC%2BD2sXksVOrtL0%3D&md5=8ab9634f85898f73c7fdc98b62eb7df1CAS |
[6] Morshed MG, Singh AE. Recent trends in the serologic diagnosis of syphilis. Clin Vaccine Immunol 2015; 22 137–47.
| Recent trends in the serologic diagnosis of syphilis.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC2MXit1Omsbs%3D&md5=1f855d206dac393ce16eaacf7ae420b2CAS |
[7] Harding AS, Ghanem KG. The performance of cerebrospinal fluid treponemal-specific antibody tests in neurosyphilis: a systematic review. Sex Transm Dis 2012; 39 291–7.
| The performance of cerebrospinal fluid treponemal-specific antibody tests in neurosyphilis: a systematic review.Crossref | GoogleScholarGoogle Scholar |
[8] Jeong YM, Hwang HY, Kim HS. MRI of neurosyphilis presenting as mesiotemporal abnormalities: a case report. Korean J Radiol 2009; 10 310–2.
| MRI of neurosyphilis presenting as mesiotemporal abnormalities: a case report.Crossref | GoogleScholarGoogle Scholar |
[9] Sureka J, Jakkani RK. Clinico-radiological spectrum of bilateral temporal lobe hyperintensity: a retrospective review. Br J Radiol 2012; 85 e782–92.
| Clinico-radiological spectrum of bilateral temporal lobe hyperintensity: a retrospective review.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC38vntValsg%3D%3D&md5=81d3132a49627c7001fb7ac8c224619cCAS |
[10] Bash S, Hathout GM, Cohen S. Mesiotemporal T2-weighted hyperintensity: neurosyphilis mimicking herpes encephalitis. AJNR Am J Neuroradiol 2001; 22 314–6.
| 1:STN:280:DC%2BD3M7ntFCntA%3D%3D&md5=e6d6709c272b35f40b46c766acaf0fb2CAS |
[11] Adamo MA, Abraham L, Pollack IF. Chronic granulomatous herpes encephalitis: a rare entity posing a diagnostic challenge. Journal of Neurosurgery: Pediatrics 2011; 8 402–406.
[12] Auer DP, Putz B, Gossl C, Elbel G, Gasser T, Dichgans M. Differential lesion patterns in CADASIL and sporadic subcortical arteriosclerotic encephalopathy: MR imaging study with statistical parametric group comparison. Radiology 2001; 218 443–51.
| Differential lesion patterns in CADASIL and sporadic subcortical arteriosclerotic encephalopathy: MR imaging study with statistical parametric group comparison.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3M3lvVejsQ%3D%3D&md5=8d3ba7b7649a69d20337400fba9fb58eCAS |
[13] Agarwal R, Sze G. Neuro-lyme disease: MR imaging findings. Radiology 2009; 253 167–73.
| Neuro-lyme disease: MR imaging findings.Crossref | GoogleScholarGoogle Scholar |
