2024 American Academy of Neurology Abstract Website

Objective:

Neurosyphilis can mimic different diseases, not only in its clinical presentation but also on imaging. Treponema Pallidum is also known as the “great imitator”. Having an ultimate diagnosis of neurosyphilis is quite critical as this can affect management drastically. Herein, we discuss the case of a 69-year-old female who was treated for neurosyphilis, while having an atypical imaging finding of anterior temporal lobe enhancement that simulated an infection with HSV.

Background:

A 69-year-old female with untreated syphilis infection (diagnosed almost 20 years prior presentation), was brought in with progressive decline in memory and confusion over one month. According to the family, the patient was unable to recall the name of her children or attend to her daily activities. On initial examination, she was alert but not oriented to herself, family members, location nor time, she had perseveration while answering questions, was able to only mimic commands. The rest of her examination was otherwise unremarkable.

MRI of the brain with contrast showed anterior temporal lobes, insular cortex and pons T2 and FLAIR hyper-intensities, that were all enhancing. Syphilis serology was positive and reactive for IgG/IgM. Treponema pallidum hemagglutination test was positive, and HIV was negative. CSF studies showed protein of 94.6 mg/dL, WBC of 15 cells/mm3 with lymphocytic predominance, RBC of 35 cu/mm, VDRL in the CSF was negative. Viral studies in the CSF were all negative. Benzathine penicillin G 24 million units was given for the total of 14 days with improvement in her mental status on follow up at one and two months.

Design/Methods:

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Results:

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Conclusions:

This unusual imaging finding of anterior temporal lobe hyperintensities with enhancement, plus the clinical presentation make it worth listing neurosyphilis next to many disease processes including HSV on the differential list.