Case Report
Despite the drastic decline in syphilis infections worldwide since the discovery of penicillin, the prevalence of syphilis is rising. We report a case study of a patient with neurosyphilis and HIV with unique neuroimaging findings.
A 38-year-old gentleman with a 20-year history of HIV presented with weakness, incontinence, abdominal pain, and clouded thinking. Examination revealed upper extremity weakness, distal decreased sensation to pinprick and vibration, lower extremity hyperreflexia, positive Babinski, ataxia, wide-based unsteady gait, and positive Romberg.
MRI brain and spine revealed numerous round, contrast enhancing lesions with surrounding vasogenic edema in the bilateral cerebral hemispheres, midbrain, cervical cord, and thoracic cord. Laboratory studies were significant for CD4 342 cells/mm3, HIV viral load 71,800 copies/mL, cerebrospinal fluid with reactive VDRL quant 1:4, 450 WBCs/mL (2% polys), 17 RBCs/mL, glucose 32 mg/dL, and protein 540 mg/dL.
The patient was treated with IV Penicillin G for presumptive neurosyphilis with atypical imaging findings. After 11 days of antibiotic therapy, repeat MRI showed marked decrease in size and enhancement of all prior lesions, and at 10-month follow up, near complete resolution of all lesions. The patient’s only persistent deficit at 20 months was urinary retention.
This patient’s diffuse contrast enhancing lesions are unique in the setting of neurosyphilis. Neurosyphilitic gummas, a local inflammatory response at the meninges, are contrast enhancing but are generally limited to one or two locations. Case reports of syphilitic meningomyelitis describe edematous enhancing lesions of the spinal cord, but there are no reports of concurrent syphilitic lesions in the brain. Tabes dorsalis rarely has abnormal neuroimaging findings, and its associated neurologic deficits are permanent. It is typical for neurosyphilis in the setting of HIV to defy traditional disease progression manifested in immunocompetent hosts, but our patient’s imaging findings are unprecedented in the literature.
N/A