Meningovascular syphilis causing recurrent stroke and diagnostic difficulties: a scourge from the past

Abstract

We describe a case of a 49-year-old man who presented with recurrent strokes in the left middle cerebral artery territory, manifesting with dysphasia, higher cognitive deficits, motor deficits and subsequent infarcts in the right middle cerebral and anterior cerebral artery territories, manifesting with seizures, behavioural and social issues. A key issue of the case was the diagnostic difficulty faced by the physicians. 'Meningovascular syphilis' was subsequently confirmed and appropriate treatment was given but there was subsequent relapse with worsening of the symptoms. Multiple specialists were involved in the management, namely stroke team, neurologists, psychiatrists, infectious disease and multidisciplinary therapy teams. This case highlights the need to be vigilant to the resurgence of syphilis, a scourge from the past, as a cause of stroke, especially in individuals who have had exposure to affected people. It is easy to miss the diagnosis and mistake it for other conditions unless a detailed history is taken and appropriate investigations are conducted, with a low threshold for diagnosis.

Progressive Stroke Caused by Neurosyphilis With Concentric Enhancement in the Internal Cerebral Artery on High-Resolution Magnetic Resonance Imaging: A Case Report

“…Most cases of meningovascular syphilis present with stroke (8) and many specialists use antiplatelet regimens (3,7). However, there are no recommendations (7,(14)(15)(16)(17). Intracerebral hemorrhage in neurosyphilis is rarely reported (18,19).…”

Infectious Myelopathies

“…Meningovascular syphilis can be seen after 1 month; however, it is more often encountered in the late stage. 7 Late neurologic manifestations typically occur more than 5 years after infection (tertiary syphilis). Tabes dorsalis affects the dorsal spinal cord tracts and dorsal root ganglion and is characterized by radicular or severe, lancinating abdominal pain along with sensory gait ataxia and bladder dysfunction.…”

Neurosyphilis

“…25 Although syphilis testing in cases of acute stroke may not be practical for every patient population, red flags that should raise the suspicion for meningovascular syphilis include stroke with concomitant or preceding symptoms of meningitis or encephalitis; stroke in young, sexually active individuals, especially in the absence of traditional cerebrovascular risk factors 32 ; and recurrent, unexplained strokes. 33 Obtaining a detailed social history, including sexual history, to uncover potential epidemiologic exposures is critically important and should not be shied away from by neurologists.…”

“…In a study from Thailand, also with a reported high local prevalence of syphilis, 2.5% of 284 patients presenting with an acute stroke were diagnosed with neurosyphilis based on serum and CSF testing; among people younger than 50 years of age presenting with stroke, 4.4% met the definition for having neurosyphilis 25 . Although syphilis testing in cases of acute stroke may not be practical for every patient population, red flags that should raise the suspicion for meningovascular syphilis include stroke with concomitant or preceding symptoms of meningitis or encephalitis; stroke in young, sexually active individuals, especially in the absence of traditional cerebrovascular risk factors 32 ; and recurrent, unexplained strokes 33 . Obtaining a detailed social history, including sexual history, to uncover potential epidemiologic exposures is critically important and should not be shied away from by neurologists.…”