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The great imitator: syphilis with predominant meningoencephalitic features

Abstract number: 1134_02_28

Manfredi R., Sabbatani S., Pocaterra D., Chiodo F.

Introduction:

A significant recrudescence of syphilis was observed in recent years, not contained by prophylactic measures against HIV and other STDs. Meningeal and meningoencephalitic involvement may occur also in early stages of syphilis, thus posing problems of differential diagnosis.

Case reports:

A young woman and an HIV-infected male developed a syphilis with predominant meningoencephalitis expression. In the first p, based on an isolated positive Borrelia burgdorferi serology (later deemed as a cross-reaction), early ceftriaxone was started, due to a suspected neurological Lyme disease. Also after the diagnosis of neurosyphilis (on the ground of positive CSF serology), antimicrobial therapy was left unchanged for 3 weeks at our Day-Hospital facilities, until complete clinical-microbiological cure. A second, HIV-infected p was hospitalized owing to mild fever lasting 2 weeks, associated with cephalalgia and anxiety.The favorable virological-immunological status (CD4 + count 439 cells/mL and undetectable HIV viraemia, under an effective HAART regimen), did not exclude all searchs for possible HIV-related disorders.Although serum examination detected a potential latent syphilis (isolated positive serum Treponema pallidum IgG, TPHA 1:640,IgG-positive RPR, and mute history for syphilis), only CSF examination disclosed an increased cell content (50/mL), altered brain-blood barrier indexes with increased intrathecal Ig synthesis, and frank VDRL,TPHA (1:1520), and borderline T. pallidum IgM serology.Penicillin G at 24 MU/day for 14 days led to a slow resolution of neurological signs and symptoms, and a tendency to improvement of specific CSF-serum syphilis serology during subsequent controls.

Discussion:

Focusing on differential diagnosis, a luetic etiology should not be underestimated, when facing young p suffering from a meningoencephalitis of unclear origin.Our cases were characterized by a young age (34 and 44 years, respectively), when compared with usual mean age of tertiary neurosyphilis. In absence of suggestive history and other syphilis signs, the diagnosis was achieved only after the retrieval of elevated syphilis serology positivity on both CSF and serum, together with some clinical signs, such as seizures, altered mentation, cognitive abnormalities, and anisochoria in the first p, and persisting headache and anxiety in the second p. Our experience with ceftriaxone (started in the first p when neuroborreliosis was suspected), was favorable like that with high-dose i.v. penicillin G.

Session Details

Date: 01/08/2007
Time: 00:00-00:00
Session name: XXIst ISTH Congress
Subject:
Location: Oxford, UK
Presentation type:
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