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The Eleventh Hour: Neurosyphilis, Still Fashionable but a Controversial Diagnosis Rodica Bălaşa* University of Medicine and Pharmacy of Tirgu Mures, Romania

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The Eleventh Hour: Neurosyphilis, Still Fashionable but a Controversial Diagnosis Rodica Bălaşa* University of Medicine and Pharmacy of Tirgu Mures, Romania The Journal of Critical Care Medicine 2017;3(2):53-55 EDITORIAL DOI: 10.1515/jccm-2017-0015 The Eleventh Hour: Neurosyphilis, Still Fashionable but a Controversial Diagnosis Rodica Bălaşa* University of Medicine and Pharmacy of Tirgu Mures, Romania Syphilis is a consequence of a symbiotic relationship organism in vitro; the infestation is marked by impres- between Treponema pallidum and humankind. sive painless (probably secondary to poor host immune The spirochete is nowadays well characterized in response) cutaneous involvement; a good motility and shape and in length, and its entire genome is sequenced. adherence to cell-surface molecules allows spirochetes Despite all these, confirmation of infection is based on to penetrate the blood-brain barrier and disseminate serologic tests. The diagnosis of nervous system disease into the CNS; a various but atypical CNS pathology is heavily depends on examination of the cerebrospinal produced (an approach based on phenomenology in- fluid [1-4]. stead of pathophysiology) but fortunately only a small Neurologic involvement is generally dichotomized number of patients become clinically manifest; a di- into early/secondary (acute meningitis, cranial nerves agnosis of later CNS disease demand advanced tech- involvement) or late/tertiary (all the rest of the mani- niques for cerebrospinal fluid assay; luckily, both spi- festations) [1]. rochetes are sensitive to the same family of antibiotics [1,3,6]. In the current issue of Journal of Critical Care Medi- cine, Bologa et al. present the utility of having menin- An interesting discussion is that cranial syphilitic govascular syphilis in mind as a possible diagnosis, vasculitis differs from other cerebrovascular disease in an apparent average case of an 84-year-old patient through the site of damage and not the mechanism. diagnosed with stroke [5]. The obliterative endarteri- Prodromal manifestations are more frequently found tis that involves the intracranial arteries causes stroke. in meningovascular syphilis (headaches, mental status Symptomatic involvement of the central nervous sys- change, meningismus) compared with classical stroke tem (CNS) is scarce, found in 4-6% of neglected pa- cases. The percentages of the symptoms as described tients. Among neurosyphilis cases, this type of CNS in- in specialized literature are: headache 10%, dizziness volvement occurs in approximately a forth of untreated 10%. The arterial territory most frequently affected is patients [1,2]. the middle cerebral artery territory. It is still unknown which factors lead to the development and evolution of The spirochetal infections of the nervous system this chronic tertiary syphilis. The vascular lesions are have two main actors: Treponema Pallidum and Borre- due to an endarteritis with perivascular inflammation lia Burgdorferi sensu lato. There are numerous similari- that obliterates vasa vasorum. The endarteritis consists ties between these 2 infections, due to biologic charac- in an intimal fibroblastic proliferation, decreasing the teristics of spirochetes: a wide mythology, both being media thickness, and in the periphery plasma cells and called the great imitator ; after 1950 the types of central lymphocytes infiltrate the adventitia [1-3]. nervous system (CNS) involvement were described in a scientific manner; both are chronic; the immune reac- The old tertiary syphilis classification comprised 3 tion can be demonstrated by the presence of antibodies types: cardiovascular syphilis, neurosyphilis, and late against major epitopes (a small number of surface an- benign also known as gummatous syphilis. Lately, re- tigens are expressed on the spirochete’s surface but the searchers have gathered clinical and laboratory data expressed epitopes might be changed during the infes- from neurosyphilis cases and compiled them into 6 dif- tation); a close contact with a vector is required for spi- ferent diagnostic types: first category – neuropsychiat- rochetal spreading, demonstrating the lability of this ric (most frequently found) disorders such as dementia, * Correspondence to: Rodica Balasa, University of Medicine and Pharmacy of Tirgu Mures, 38 Gheorghe Marinescu Street, Tirgu Mures, Romania. E-mail: [email protected] 54 • The Journal of Critical Care Medicine 2017;3(2) Available online at: www.jccm.ro delirium, psychosis; second category – ischemic stroke Lately, due to the increase of syphilis infection even with an acute onset of a focal neurological deficit; third in the most unlikely patients, screening for spirochetal category, with ocular involvement which amounts to infection is advisable, although interpreting the tests optic nerve dysfunction followed sometimes by visual might be a source of problematic false-positive or false- loss or uveitis; fourth category, where tabes dorsalis is negative results [4,6]. The diagnosis is equally impor- included, with myelopathy of various types of onset i.e. tant since neurosyphilis has a curative treatment which acute, subacute, or chronic spinal cord syndromes; fifth is easy to administer, generally without any adverse category – the epileptic type, presenting partial sei- events or significant costs [7]. This is also the case of zures or myoclonus; sixth category, involving the brain the reported 84-year-old patient. stem and the cranial nerves. The 84-year-old patient re- ported in the article under discussion can be classified At first glance, stroke pathology in an 84-year-old in the second category. All the prodromal symptoms woman is a common occurrence, as well as syphilis of the patient were of CNS origin (dizziness, memory vascular involvement of the CNS. The importance of loss, insomnia, headache). In a previous publication case reports resembling the one currently under dis- from 2014, we reported the case of a 64 year-old pa- cussion consists of the different final image compared tient that presented hints of meningovascular syphilis, to each trivial scattered piece. The discussion of the syphilitic amyotrophy and general paralysis maybe a pathophysiology mechanism of CNS involvement by seventh category of tertiary syphilis [1-4]. an infection first described in 1530 remains still open Regarding the risk of neurosyphilis, Caucasians are in 2017. 2-3 times more predisposed than the rest of popula- tions, and it is more frequent in males than in females. Disclosure The case presented was a female that, like other re- ferred-to cases, contracted the infection most probably The author reports no disclosure relevant for this man- long before the disease expressed clinically, placing this uscript. pathology among progressive chronic infections. Spirochetal infection diagnosis in the tertiary stage References is exclusively done by serologic tests. We must not for- get that patients infected with spirochetes frequently 1. Halperin JJ: Spirochetal infection of the nervous system. In have elevated titers of anticardiolipin antibodies (a Aminoff M, Josephson SA (eds): Aminoff’s Neurology and General Medicine, Fifth Edition. London: Elsevier. 2014, pp.817- possible explanation would be the putative interaction 31 of the host’s lipoproteins with the spirochete). Diag- 2. Centers for Disease Control and prevention (CDC) Summary of nostic tests (that are very sensitive but lack specificity) Notifiable Diseases-United States, 2010. MMWR Morb Mortal from this group of “reaginic” antibodies are: Venereal Wkly Rep. 2012;59:25 Disease Research Laboratory (VDRL), rapid plasma 3. Park UI, Chow JM, Bolan G, et al. Screening for syphilis with reagin, Wassermann test, Hinton tests. A further test the treponemal immunoassay: analysis of discordant serology in positive patients to these reaginic tests is needed: results and implications for clinical management. J Infect Dis. microhemagglutination for Treponema Pallidum, Flu- 2011;204:1297-2004 orescent treponemal antibody. The importance of the 4. Balasa R, Bajko Z, Motataianu A, Maier S. Pitfalls in the diagnosis VDRL test remains when evaluating the response to a of neurosyphilis - case report and literature review. Acta Medica certain antibiotic. An infection of the CNS requires the Transilvanica. 2014;4:201-3 thorough examination of the CSF: CSF VDRL is reli- 5. Bologa C, Lionte C, Halit D, Luca C. Neurosyphilis Masquerading able (a positive result is perceived as part of the diag- as Stroke in an 84-year-old. J Crit Care Med. 2017;3(2):70-72. nosis). A slight increase of CSF leukocytes was found 6. Mattei PL, Beachkofsky TM, Gilson RT, Wisco OJ. Syphilis: a in the case reported by Bologa et al., similar to the ones reemerging infection. Am Fam Physician. 2012;86(5):433-40 found in the specialized literature. From the theoreti- 7. Ghanem KG, Workowski KA. Management of adult syphilis. Clin cal point of view, it is still highly debatable whether the Infect Dis. 2011;53(Suppl 3):S110-28 antibodies against Treponema pallidum are generated 8. Sparling PF. Diagnosis of neurosyphilis: new tools. Sex Transm inside the CNS [3,7,8]. Dis. 2010;37(5):288-9.
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