CRANIAL NERVE SYNDROME DUE TO NEUROSYPHILIS: A CASE REPORT
Introduction: Neurosyphilis, characterized by the invasion of the central or peripheral nervous system by Treponema Pallidum, occurs in 10 to 30% of untreated patients with syphilis, 5 to 35 years after the initial infection. Clinical manifestations are variable, affecting different topographies and comprising a diversity of neurological syndromes. Case report: A 32-year-old male patient, with a history of progressive bilateral hearing loss, presented occipital headache in tightness, of moderate daily intensity, loss of vision and cutaneous exanthema of the trunk and upper limbs. A magnetic resonance showed cranial nerve enhancement and lesion in the temporoparietal region. The analysis of CSF showed FTA-ABS IgG reagent; in blood, VDRL 1:64 and FTA-ABS IgG and IgM reagent. The patient started treatment with antibiotics. Discussion: Neurosyphilis may present signs and symptoms that may lead us to suspect another somatic disease, making diagnosis difficult. Cranial nerves are those most commonly affected, as determined in pre-antibiotic era studies, leading to possible alterations in vision and hearing, headaches and hemiparesis.
Neurosyphilis designates all the adverse effects on the central nervous system (CNS) caused by Treponema pallidum. It can occur at any time during the course of syphilitic disease, but usually it develops in the tertiary stage.
Despite a significant decrease in the incidence of neurosyphilis during the last three decades, the invasion of the human nervous system still takes place and the clinical presentation does not follow the traditional evolution of the pre-antibiotic era. The clinical diagnosis can be divided into asymptomatic and symptomatic, comprising a diversity of neurological syndromes with varying degrees of involvement, including eyes, meninges, cerebral parenchyma, spinal cord and peripheral nerves
A 32-year-old male patient started follow-up with neurology on May 20, 2017, with a history of progressive bilateral hearing loss in 10 days at the beginning of April 2017. After consultation with otolaryngology, he obtained improvement treatment with prednisone 60 mg (for 15 days), but mild tinnitus appeared. In May, he presented occipital headache in tightness, of moderate daily intensity, lasting until the date of the first neurological consultation. Twelve years ago, the patient had presented hemihipoesthesia and appendicular ataxia on the left side, with no defined etiology.
In the neurological examination was observed a loss of vision (left homonymous hemianopsia). The clinical examination showed cutaneous exanthema of the trunk and upper limbs. The analysis of the magnetic resonance showed thickening with contrast enhancement in cranial nerves V and III, contrast enhancement in cranial nerves VII and VIII, and lesion in right temporoparietal region (possibly responsible for the patient's previous history).
The analysis of CSF showed FTA-ABS IgG reagent; in blood, VDRL 1:64 and FTA-ABS IgG and IgM reagent; serum test also showed IgM and IgG reagent for Lyme disease (cross reactivity?). Serology was non-reactive for hepatitis B and C and HIV.
DISCUSSION AND CONCLUSION
Syphilis continues to be a challenge today and not only a disease with historical importance. Neurosyphilis have re-emerged in the last years, and presents several clinical manifestations, such as hemiparesis, quadriparesis, paresthesia, sensory deficits, headache, ataxia, reflex changes, peripheral neuropathy and cranial nerve palsy. Symptomatic neurosyphilis may be acute (acute syphilitic meningitis) or late/chronic, which includes both meningovascular syphilis and parenchymal neurosyphilis (general paresis and/or tabes dorsalis).
Early/acute neurosyphilis is often associated with cranial nerve palsies, and cranial nerves II, III, VI, and VII are those most commonly affected.
In our case, the diagnosis was done with a combination of clinical manifestations and results of magnetic resonance, CSF and serology. The patient was treated with crystalline penicillin and had a good outcome.
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