Neurosyphilis: the shape of a rising threat
Published in the International Journal of Infectious Diseases, the authors report a case of neurosyphilis presenting with memory disturbances, attention deficit and an acute psychotic decompensation in an immunocompetent man. Despite the known connection of neurosyphilis with psychiatric symptoms, this cause often remains unrecognized.

A 47-year-old man presented with five months history of progression on neurologic symptoms which started as memory disturbances, especially short-term memory and attention deficit. A month after onset of symptoms the patient has experienced an acute psychotic decompensation and hallucinatory-paranoid experiences. The patient was initially misdiagnosed as schizoaffective disorder and treated with antipsychotic drugs.

Psychological tests revealed deviations in terms of short-term memory and graphomotoric skill. Cognitive impairment was without daily fluctuations and was slightly more evident while treated with antipsychotic therapy. Speech was not affected and he successfully performed daily activities. Occasionally he was depressed without anxiety and aggression.

8 months after symptom onset, brain MRI (magnetic resonance imaging) and CT (computerized tomography) revealed age inadequate and premature atrophic changes of the brain parenchyma with wide CSF spaces infra and supratentorially. MRI images also showed thickening of dura and bilateral subdural hygromas (figure 1). Neurocognitive testing indicated cognitive impairment in verbal and nonverbal domains of nonassociative memory, and less severe disturbances of attention and executive functions. Values of thyroid hormones, vitamin B12 and folic acid were within normal range.

Ten months after symptom onset analysis of CSF showed an increased number of lymphocytes (67/3x106 /L; normal range 15/3x106 /L) and elevated protein values (68mg/dL; normal range 17-37mg/dL). The value of Tau protein in CSF was 257pg/mL, and pTau 18pg/mL. Beta-amiloids were 762pg/mL. Creatin kinase in blood was also increased (1014U/L, normal range 0-177U/L). Because of increased lymphocyte number and elevated protein values in CSF with present dura thickening, serological and neuroimmunological evaluation was performed revealing neurosyphilis. VDRL/RPR (serum: 1:128, CSF:1:4), TPHA (serum: 1:20480, CSF:1:2560), IgG-FTA-ABS (serum 1:40, CSF poor reactive), tests were reactive.

A HIV infection was also suspected but he was seronegative. Therapy was started with a course of intravenous procaine benzylpenicillin. The diagnosis was established 10 months after onset of symptoms. The patient was again hospitalized after three and eleven months. CSF analysis after eleven months revealed decrease of lymphocyte count (2/3x106 /L) and protein values (40mg/dL). A repeated MRI examination after three months did not show previously visible subdural hygroma and dural thickening was less prominent but atrophy of the brain parenchyma was more evident, particularly in the hippocampus.

Cognitive impairment is still present, but there is a significant improvement after antibiotic therapy. There was an evident RPR titer reduction (initial: serum 1:128, CSF 1:4, after three month: serum 1:32, CSF 1:2, after eleven months: serum 1:8, L0) as a sign of a good therapy response.

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