Clinical and imaging findings in patients with neurosyphilis: a study of a cohort and review of the literature

Khamaysi, Ziad; Bergman, Reuven; Telman, Gregory; Goldsher, Dorith

doi:10.1111/ijd.12095

Cited by 28 publications

(19 citation statements)

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“…For NS to be recognized as subacute or chronic CNS inflammation, the organism first needs to break through the blood-brain barrier, and the pathology of diffuse inflammatory activity may include meningitis, vasculitis, and even vasculitis-related infarct or hemorrhage, mainly involving the medium to large vessels and their perforating arteries. Consequently, NS patients frequently show abnormal neuroimaging findings of infarcts in the basal ganglia, brainstem, and cortical and subcortical regions, as in our patients [15][16][17]. Brain atrophy reflects a decrease in the volume of brain parenchymal tissue and usually affects the limbic lobe, temporal lobe, and hippocampus.…”

Section: Discussionsupporting

confidence: 53%

Neuroimaging Features, Follow-Up Analyses, and Comparisons Between Asymptomatic and Symptomatic Neurosyphilis

Shang

Tang

et al. 2020

Dermatol Ther (Heidelb)

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Introduction: Many studies have explored the imaging characteristics of patients with neurosyphilis, but no systematic study has been made on the neuroimaging changes after antisyphilitic treatment. The purpose of this study was to examine neuroimaging differences before and after treatment, comparing patients with asymptomatic and symptomatic neurosyphilis. Methods: A total of 102 patients with neurosyphilis, including 60 cases of symptomatic neurosyphilis and 42 cases of asymptomatic neurosyphilis, were identified between December 2012 and June 2019. Their demographics, medical histories, serological tests of peripheral blood and cerebrospinal fluid, and especially neuroimaging features before and after antisyphilitic treatment were collected and analyzed. Results: The patients presented with variable clinical and neuroimaging features, including cerebral infarction or hemorrhage, atrophy, demyelination, arteritis, encephalitis, and hippocampal sclerosis. A total of 29 neuroradiological re-examinations were performed in 19 patients treated with anti-syphilitic medicine. The results indicated that some patients still presented neuroradiological progression after treatment, including 42.1% showing infarction lesions, 47.4% mild to severe brain atrophy, and 15.8% white matter demyelination. Conclusion: The clinical and neuroimaging features of neurosyphilis patients are diverse, and their follow-up neuroimaging continued to show progression even with standardized treatment.

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Section: Discussionsupporting

confidence: 53%

Neuroimaging Features, Follow-Up Analyses, and Comparisons Between Asymptomatic and Symptomatic Neurosyphilis

Shang

Tang

et al. 2020

Dermatol Ther (Heidelb)

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“…I read with great interest the recent paper by Khamaysi et al . on tertiary syphilis with invasion of the central nervous system.…”

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confidence: 99%

Neurosyphilis and brain magnetic resonance imaging

Czarnowska-Cubała

2015

Int J Dermatology

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I read with great interest the recent paper by Khamaysi et al. 1 on tertiary syphilis with invasion of the central nervous system. The diagnostic process included brain magnetic resonance imaging (MRI), which revealed abnormalities with hyperintense signal changes that were misinterpreted as infarcts, mild atrophy, and mild enlargement of the celebral sulci.Neuropsychiatric symptomatology is now recognized as representing the most common clinical manifestations of neurosyphilis. 2 The diagnosis of neurosyphilis is complex, and no reference standard exists. Given that standard laboratory findings are unremarkable, serum analysis for syphilis with nonspecific lipoidal tests (rapid plasma reagin [RPR] and Venereal Disease Research Laboratory [VDRL] tests) and treponemal-specific tests (fluorescent treponemal antibody absorption [FTA-Abs] test) should be considered routine in patients presenting with or hospitalized for psychiatric disorders. However, it should be noted that an ultimate serology test with cerebrospinal fluid analysis for venereal disease is found to be non-reactive in 43% of cases. 2 Brain MRI findings in neurosyphilis are not specific, and no radiologic pathognomonic findings have been identified to date. 2,3 However, generalized cerebral atrophy and foci of increased signal intensity are commonly seen in populations of patients with neurosyphilis. Moreover, the identification of the most common radiologic manifestations of cerebral infectious vasculitis can be helpful. In neurosyphilis, the most frequently reported abnormalities refer to the middle cerebral artery and branches of the basilar artery. There is also some evidence that ischemic changes in MRI on medium contrast enhancement, and atrophy, white matter lesions, and edema are indicative of neurosyphilis. In addition, multiple areas of infarction in different vascular territories and of different ages in young patients seem to be indicative of cerebral vasculitis. However, normal findings are also frequently seen. 3 The complexity of the diagnostic process in neurosyphilis, which is associated with a range of false negative tests, points to brain MRI as an auxiliary tool in the differential diagnosis of the insidious disease of neurosyphilis. References 1 Khamaysi Z, Bergman R, Telman G, et al. Clinical and imaging findings in patients with neurosyphilis: a study of a cohort and review of the literature. Int J Dermatol 2014; 53: 812-819. 2 Patel MV, Shelby J, Yekkirala L. Neurosyphilis in patients with psychotic symptoms: clinical presentation in the modern era. Carle Selected Papers 2011; 54: 33-36. 3 Czarnowska-Cubała M, Wiglusz MS, Cubała WJ, et al. MR findings in neurosyphilis -a literature review with a focus on a practical approach to neuroimaging. Psychiatr Danub 2013; 25(Suppl.): 153-157.

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“…Diffuse cortical atrophy is one of the major findings in NS. 1,4,6,7 In particular, atrophy of the bilateral medial temporal lobes (MTL) and hippocampus are more pronounced. [1][2][3]5 If patients with NS show bilateral MTL atrophy and cognitive impairments like AD, they might in the MTL with psychiatric symptoms, these can be confused with the typical radiologic manifestations of viral or limbic encephalitis.…”

Section: Discussionmentioning

confidence: 99%

Radiographic Features in a Patient Diagnosed with Neurosyphilis

Park

Ann

Jeon

et al. 2019

J Neurosonol Neuroimag

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Neurosyphilis (NS) is an infection of the central nervous system, caused by the invasion of Treponema pallidum, which can occur in any stage of syphilis, particularly in the late stages of the disease. 1 NS presents with various clinical features, such as mimicking early onset Alzheimer's disease (AD), mild frontotemporal dementia (FTD) or primary psychiatric disease (PPD). 1-3 Brain magnetic resonance imaging (B-MRI) features seen in NS vary, and are usually presented as cerebral infarction, sulci widening, global/hippocampal predominant atrophy, white matter lesions, or meningitis. 4-7 Recently, diffuse temporoparietal hypometabolism and spared thalamic metabolism, in fluorodeoxy-glucose-positron emission tomography (FDG-PET), have been reported as new findings in NS. 3 In the current case report, the authors describe a patient with NS, who exhibited varied and complex clinical symptoms. B-MRI showed severe atrophy, involving bilateral medial temporal lobes (MTL), and abnormalities were detected in FDG-PET scan. CASE REPORTA 49-year-old male patient was hospitalized with a history of psychiatric manifestations since 10 months, personality changes, and progressive cognitive impairments. The patient had a history of exhibiting depressive behavior and at times anger, for about 10 months before admission. He also displayed the habit of repeating words and frequently mentioning past episodes. Sometimes, during conversations, the patient interrupted inappropriately or spoke on irrelevant subjects.Approximately 7-month before hospitalization, the patient experienced delusion and insomnia. He believed he was a genius with an IQ of 190. Occasionally,The clinical features and brain magnetic resonance image (B-MRI) findings in neurosyphilis (NS) are highly varied. Cortical atrophy, especially involving the medial temporal lobes (MTL), is a remarkable radiographic feature, reported in B-MRI scans, in cases of NS presenting with severe cognitive impairments. The observed MTL atrophy is similar to the atrophy seen in neurodegenerative disorders such as Alzheimer's disease (AD) or frontotemporal dementia (FTD). A fluorodeoxy-glucose-positron emission tomography (FDG-PET), used for the diagnosis of AD, commonly reveals global cortical hypometabolism, sparing basal ganglia and thalamus, in NS. We report a case of NS, with complex symptoms and bilateral MTL atrophy. FDG-PET imaging showed bilateral thalamic and right visual cortical glucose reduction, as well as diffuse cortical hypometabolism. This type of FDG-PET pattern is a new finding in the field of NS. FIG. 2. Fluorodeoxy-glucose-positron emission tomography. (A) Hypometabolism observed in bilateral frontal, parietal, and temporal lobes (more prominent on the right) (black arrows), and thalamus (white arrows). (B) Statistical parametric mapping analysis showing the hypometabolism in bilateral frontal, parietal, and temporal lobes, compared with age-matched controls. A B 176 http://www.j-nn.org

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Clinical and imaging findings in patients with neurosyphilis: a study of a cohort and review of the literature

Abstract: Vascular insult was the most common neuroimaging finding in our patients with neurosyphilis, probably due to meningovascular endarteritis. Neurosyphilis should always be considered in young patients with unexplained brain infarcts.

Cited by 28 publications

References 11 publications

Neuroimaging Features, Follow-Up Analyses, and Comparisons Between Asymptomatic and Symptomatic Neurosyphilis

Neuroimaging Features, Follow-Up Analyses, and Comparisons Between Asymptomatic and Symptomatic Neurosyphilis

Neurosyphilis and brain magnetic resonance imaging

Radiographic Features in a Patient Diagnosed with Neurosyphilis

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