A Blurry Disguise for the

Great Imitator!

By, Dr Kamaljit Kaur Khalsa

(ST2 Medical Microbiology)

Greater Glasgow & Clyde

The story…

• 61 year old man

– 3m before diagnosis:

• Left sided hearing loss, tinnitus

• Gait disturbance: needing a walking stick

• MRI normal ?labrynthitis

– 2m before diagnosis

• Admitted for 2 days; malaise, sweats and eye symptoms

• Non-contrast spiral CT brain & MRI

‘small vessel change’

• Diagnosed ?acoustic neuroma ?labyrinthitis

• High dose steroids & home with O/P ENT review

• 61 year old man

– O/P Ophthalmology review

• Swollen left optic disc

• VA 6/9 right, 6/5 left, enlarged blind spot

• CRP 41, ESR 16

• Colour vision declining

• CT orbit NAD

• Finally admitted as an emergency:

• Nystagmus on left lateral gaze, reduced

visual acuity, declining colour vision,

presence of ‘zig-zag’ lines obstructing

vision.

• Gait ataxic and generalised

maculopapular rash noted on chest.

A diagnostic test was performed..

What is the next most appropriate

investigation?

A autoantibodies

B CSF PCR for multiple viruses

C HIV testing

D serum B12

E syphilis serology

Results

Syphilis EIA positive HIV test-negative

• VDRL 1:128

• TPPA> 1:280

• IgM Positive

CSF

• Normal opening pressure

• Pleocytosis with 17 WBC/ cu mm

• CSF +ve VDRL at neat, protein 0.69 g/L (0.10-0.50

g/L), glucose 3.0 mmol/L (2.5-4.5 mmol/L)

Final diagnosis

Acute Meningovascular

Neurosyphilis

Management

• Treatment with procaine penicillin 2.4 mega

units I/M daily for 21 days with oral

probenecid 500mgs qds and a tapering

course of high dose prednisolone.

• He has a made a reasonable recovery and

responded serologically although has residual

tinnitus.

• Arrange three monthly VDRL serum tests for

a year and repeat LP after one year to ensure

clearance of CSF VDRL reactivity.

CNS Invasion with Treponema pallidum

Clearance/Resolution Transient Meningitis

Persistent/asymptomatic meningitis (early onset disease)

Clearance/Resolution

Early symptomatic neurosyphilis

(Weeks-Months)

Late symptomatic neurosyphilis

(Years)

Symptomatic Meningitis

•Headache, meningism, nausea,vomiting

Cranial neuropathies

Ocular involvement

Meningovascular stroke + meninigits

General paresis Dementia

Personality change

Tabes dorsalis Spinal cord involvement Sensory ataxia

Incontinence

Number of syphilis diagnosis in the

UK by sex and sexual orientation:

1997-2007

Key Learning Points

• Cases of syphilis are on the rise;

clinicians should be aware of its many

‘disguises’

• Clinical presentation of neurosyphilis

changed in recent years so difficult to

categorise

• Routine testing for syphilis in adults

presenting with unexplained visual or

auditory disturbance should be

considered.

Special Thanks…

• Dr Andrew Winter, Consultant in GUM

• Dr Krishna Dani, SpR in Neurology

• West of Scotland Regional Virus

Laboratory

• Patient

Any Questions?