Objective:

A rare case of syphilitic vasculitis presenting as spastic paraparesis in a patient with a history of untreated syphilis.

Background:

Neurosyphilis is a late complication of untreated syphilis and involves the infection of the central nervous system. It can manifest as meningitis, general paresis, tabes dorsalis, and syphilitic vasculitis. Syphilitic vasculitis can lead to ischemic strokes and other vascular complications. This rare presentation can cause significant diagnostic challenges, especially when it mimics other neurodegenerative or vascular disorders. Spastic paraparesis, resulting from vascular damage to the spinal cord, is an uncommon presentation of neurosyphilis and is often under recognized.

Design/Methods:

N/A

Results:

A 66-year-old male with a complex medical history including hypertension, diabetes mellitus, stroke, and untreated syphilis, presented with progressive worsening of bilateral lower extremity weakness and frequent falls over several years, now associated with urinary incontinence. Neurological examination revealed spastic paraparesis with increased muscle tone and hyperreflexia in lower extremities. Brain MRI demonstrated a subacute small left parietal cortical infarct, while spinal imaging including MRI cervical, thoracic and lumbar spine showed multilevel degenerative changes without evidence of cord compression.

Serology was positive for syphilis, and syphilitic vasculitis was suspected as the underlying cause of both the ischemic stroke and spastic paraparesis. Extensive work-up excluded other etiologies. CSF analysis revealed positive VDRL, confirming the diagnosis of neurosyphilis. Digital subtraction angiogram was consistent with cerebral vasculitis. The patient was promptly started on intravenous penicillin G. After stabilization and initiation of treatment, he was discharged with plans for continued antibiotic therapy and outpatient follow-up to monitor neurological recovery.

Conclusions:

This case highlights the importance of considering syphilitic vasculitis as a potential cause of spastic paraparesis, especially in patients with a history of untreated syphilis. Prompt diagnosis through serologic testing and early initiation of appropriate therapy are critical to prevent long-term complications and improve functional outcomes.