An 80 year-old man with history of hypertension, remote cerebrovascular accidents (CVA), and multiple admissions for syncope and orthostatic hypotension presented with sudden syncope, hypotension, and acute respiratory failure requiring intubation. Vital signs were notable for hypotension that responded to intravenous fluids. Initial exam, laboratory evaluation, and radiology results were negative for any cardiopulmonary, metabolic, or infectious processes, but did show aneurysmal dilation of the ascending aorta. He was easily extubated the next day with normal vital capacities. Exam off sedation was pertinent for Argyll Robertson pupil, horizontal nystagmus, action tremor of the upper extremities, and Charcot joints. MRI/MRA showed patency of a once-occluded left anterior cerebral artery, multiple old lacunar strokes, and subacute complete occlusion of the vertebrobasilar system. Meningovascular (MV) syphilis was considered and rapid plasma reagin was reactive with a titer of 1:32 and confirmatory fluorescent treponemal antibody (Ab) was reactive, confirming a diagnosis of syphilis. The patient refused lumbar puncture and was empirically treated for neurosyphilis (NS) with penicillin (PCN) G and oral probenacid for 14 days.
Syphilis, a sexually transmitted disease caused by treponema pallidum, is known as the great imitator due to its variety of clinical presentations. Late symptomatic infection, or tertiary syphilis, can involve cardiovascular or neurologic systems. MV NS is the most prevalent form of NS and can cause acute ischemic stroke from cerebral arteritis, though is rarely considered as a possible etiology of CVA in older patients. Studies suggest young patients with CVA should be screened for NS, however the average age of patients admitted for CVA and found to have MV syphilis was 72 years. Given the increasing rates of syphilis infection, NS should be considered in all patients presenting with CVA, particularly those with risk factors for infection and other clinical findings suggestive of tertiary syphilis.
This case highlights the wide variety of presenting symptoms found in NS. The MV CVA phenotype was recurrent syncope and respiratory failure from vertebrobasilar insufficiency. Findings of tabes dorsalis and ascending aortic aneurysm led to the diagnosis of tertiary syphilis. NS is typically diagnosed by cerebrospinal fluid (CSF) pleocytosis, elevated protein and VRDL titers, however these findings are not highly sensitive or specific. NS may be presumed with positive serum treponemal antibody tests and clinical findings of tertiary syphilis. Given the low cost and risk associated with PCN, empiric treatment is a reasonable approach to patients with suspected NS without CSF analysis.
NS should be considered in all patients with CVA, particularly those with risk factors for infection or with findings of tertiary syphilis. Prompt diagnosis can allow for treatment and prevention of catastrophic neurovascular consequences.
To cite this abstract:Gonzales H, Karlen N. Neurosyphilis: Keep in Mind for Patients with Strokes. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 530. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/neurosyphilis-keep-in-mind-for-patients-with-strokes/. Accessed January 19, 2020.