Objective:

To present a rare case of multifocal bilateral cerebral infarcts caused by meningovascular neurosyphilis in a young adult with a new diagnosis of HIV/AIDS.

Background:

Meningovascular neurosyphilis is an uncommon but important cause of ischemic stroke, accounting for approximately 10–15% of neurosyphilis cases and is more likely in younger adults. HIV infection increases susceptibility and severity of neurosyphilis, with neurosyphilis reported in up to 25% of HIV-positive, potentially leading to multifocal and bilateral infarcts in atypical distributions. Early recognition is essential to reduce neurologic morbidity.

Design/Methods:

N/A

Results:

A 36-year-old right-handed male with cannabis use disorder presented with acute confusion, selective mutism, and right lower extremity weakness. Neurological exam revealed a somnolent, intermittently confused patient who followed simple commands, had right lower extremity weakness (3/5), intact language, and exhibited restlessness with punding behaviors. Initial CT and CTA were unremarkable, but brain MRI showed acute bilateral basal ganglia and left-greater-than-right frontal watershed infarcts. CSF analysis revealed lymphocytic pleocytosis (47 cells/µL), elevated protein (398 mg/dL), low glucose (32 mg/dL), and reactive VDRL, confirming meningovascular neurosyphilis. He was concurrently diagnosed with HIV with advanced immunosuppression (CD4 71, viral load 318,000). Empiric treatment was initiated with intravenous penicillin G on day 5; ART (bictegravir, emtricitabine, tenofovir alafenamide) started on day 8. Neurological status gradually improved with combined therapy. Stroke etiology was attributed to meningovascular syphilis compounded by HIV vasculopathy.

Conclusions:

This case highlights meningovascular neurosyphilis as a rare but important etiology of multifocal bilateral cerebral infarcts in young adults with HIV/AIDS. Clinicians should maintain high suspicion for neurosyphilis in patients with unexplained strokes, especially with atypical imaging and HIV risk factors. Early CSF analysis, serologic testing, and prompt antimicrobial therapy are essential to limit neurological morbidity. Interaction between HIV-induced immunosuppression and syphilitic vasculitis may predispose to bilateral infarcts, emphasizing the need for comprehensive infectious and vascular workup.