To highlight an interesting case of neurosyphilis presenting with spinal cord involvement, cerebral ischemia, and uveitis, emphasizing its mimicry of demyelinating/vascular disorders and the value of targeted history in reemerging infections.

A 56 year old man with no prior medical history presented with 5 days of progressive paraparesis, numbness, urinary retention, and fecal incontinence, preceded by months of blurry vision and 25-lb weight loss. Initial evaluation overlooked sexual history. On further discussion, he disclosed prior syphilis exposure and recent unprotected intercourse. 

Exam revealed asymmetric dilated pupils, 2/5 hip flexion, hyperreflexia with clonus, and sensory loss below the groin. RPR was 1:256 with positive treponemal antibody. CSF showed pleocytosis, high protein, low glucose, and reactive VDRL, confirming neurosyphilis. MRI spine demonstrated longitudinally extensive T2 hyperintensity with syrinx; brain MRI/CTA showed left MCA perivascular enhancement, acute infarct, and multifocal stenoses. Ophthalmology noted anterior/intermediate uveitis.

He was treated with IV penicillin G for 14 days followed by benzathine penicillin. For vasculitis and myelitis, he received 3 days of IV methylprednisolone followed by oral prednisone taper. Over two weeks, strength and sensation improved, though urinary retention persisted. He was discharged with improved mobility, ongoing physical therapy, and urology follow up. 

Neurosyphilis can present with a rare triad of transverse myelitis, vasculitic stroke, and uveitis. The differential included multiple sclerosis, neuromyelitis optica, infectious meningomyelitis, and systemic vasculitis, but diagnosis was confirmed with reactive CSF VDRL. This case emphasizes the importance of obtaining a thorough sexual history, recognizing CSF VDRL as the diagnostic gold standard, and initiating timely penicillin therapy, with adjunctive corticosteroids considered in cases of vasculitis or myelitis. This case highlights the evolving spectrum of neurosyphilis and reinforces the CDC’s call for greater clinician vigilance.