Syphilitic Myelitis: Rapid Clinical and Radiological Improvement Following Antibiotic and Steroid Therapy
Frederick Crow1, Alec Phelps1, Christopher Burrell1, Jamil Numan1, Briana Bodner1
1Department of Neurology, Marshall University/ MUSOM
Background:
Neurosyphilis is a CNS infection caused by Treponema pallidum that typically occurs in late syphilis and can cause meningitis, meningovascular stroke, dementia, and spinal pathology. Syphilitic myelitis is a rare manifestation of late neuro-syphilis with a paucity of documented cases. In the US, prevalence may be as high as 1.5% of cases. It can mimic inflammatory conditions that cause transverse myelitis, potentially delaying appropriate and timely treatment. The standard therapy for neurosyphilis is IV penicillin 18 to 24 million units per day for 10-14 days, but no clear guidelines exist for concomitant steroids in cases with spinal cord enhancement.
Results:
A 47-year-old female presented 3 weeks after onset of vitiligo, weakness, imbalance, and urinary incontinence. Her exam revealed ataxic gait, loss of vibration sense at T6, 3+ DTRs in the lower extremities, and bilateral Babinski signs. Serology was positive for RPR and T.pallidum antibodies, with CSF showing a VDRL Titer of 1:4, elevated WBC, and lymphocytic pleocytosis. MRI showed long-segment T2 flare changes involving the posterior columns and enhancement from T6-T10. IV penicillin (25 million units/day) was initiated. After 3 days her neuropathy progressed into the cervical dermatome, prompting initiation of IV methylprednisolone (1000mg). A follow-up MRI after one dose of steroids showed remarkable improvement of enhancement. The patient’s upper extremity symptoms resolved, and lower extremity symptoms improved significantly. She continued IV steroids for 5 days, followed by oral prednisone taper while completing her penicillin course.
Conclusions:
This case highlights the benefit of combining penicillin with steroids in treating neurosyphilis complicated by syphilitic myelitis. Early source control for 2-3 days followed by high dose IV steroids resulted in rapid radiological and clinical improvement. We postulate this approach may yield quicker recovery than antibiotics alone or possibly when both antibiotics and steroids are initiated simultaneously on the same day.
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