A Case of Neurosyphilis With Penicillin Failure

Abstract

Neurosyphilis is any involvement of the central nervous system (CNS) by Treponema pallidum. The CNS may be involved at any stage of infection.A 54-year-old previously healthy African American male was hospitalized due to a two-year history of progressive cognitive decline. One year after symptoms began, he developed, over a four-month period, gait disturbance resulting in frequent falls, speech impairment, worsening memory loss, psychosis, and an inability to perform activities of daily living.A diagnosis of neurosyphilis was established upon cerebrospinal fluid (CSF) positive results and new changes in his mental status. The CSF showed predominant lymphocytic pleocytosis (17), elevated protein (111), and IgG index (4.25). Other viral and bacterial panels were negative. Intravenous penicillin G, 24 million units daily for 14 days, was given. Two months later, the patient was transferred to the hospital for altered behavior and mental status changes from the cognitive baseline. The repeat CSF rapid plasma reagin (RPR) titer (1:4) was the same as at initial diagnosis, despite appropriate treatment. Brain MRI showed progressive volume loss in both temporal lobes, thalamus, and cerebellum, consistent with evolving encephalitis. Treatment with intravenous penicillin G, 24 million units, was repeated. The patient improved clinically.Hence, in emerging cases of syphilis, this patient has been diagnosed with a neurosyphilis flare, unresponsive to the usual dose and duration of penicillin. We recommended a repeat CSF examination every six months and having a lower threshold for CSF examination for possible flare or resistance. Our case showed a failure to respond to the usual course of penicillin, requiring a second course of IV Penicillin G, although no resistance to penicillin has been reported.

Common postbariatric surgery emergencies for the acute care surgeon: What you need to know

“…The other critical point in the workup of this patient population is that postbariatric surgery patients have the same risk of common abdominal surgical issues like appendicitis or diverticulitis and, in fact, have an increased risk of acute biliary disease. 21,22 The differential and initial evaluation should include these considerations and not focus purely on the assumption that the presenting complaint is directly related to the bariatric surgical procedure.…”

“…For example, while internal hernias or small bowel anastomotic leaks would be of concern in a patient who underwent an RYGB, those should not even be in the differential for the patient who underwent one of the purely restrictive operations such as the SG. The other critical point in the workup of this patient population is that postbariatric surgery patients have the same risk of common abdominal surgical issues like appendicitis or diverticulitis and, in fact, have an increased risk of acute biliary disease 21,22 . The differential and initial evaluation should include these considerations and not focus purely on the assumption that the presenting complaint is directly related to the bariatric surgical procedure.…”