MRI in patients with general paresis

Clinical and Laboratory Characteristics, Neuroimaging Alternations and Treatment Response of 25 HIV-Negative General Paresis Patients

Purpose

General paresis is a common type of neurosyphilis featuring progressive cognitive deterioration. The lack of a golden standard of diagnosis and its nonspecific clinical manifestations resulted in a high rate of misdiagnoses. This study aims to investigate the clinical, laboratory and radiological presentations of general paresis and enrich its knowledge for timely diagnoses.

Patients and methods

The study collected hospitalized patients admitted for general paresis from September 2002 to November 2022. Their socio-demographical and medical status, clinical presentations, cognitive assessments, laboratory and radiographical manifestations and treatment information were collected retrospectively.

Results

A total of 20 males and 5 females were included. Patients' ages ranged from 30 to 66 years (average 50.3 years). The average and median time for diagnosing general paresis was 14.1 months and 10.0 months respectively. The most frequent initial symptom is memory deterioration (68.0%). Impaired calculative ability and memory deterioration were the most frequent cognitive anomalies, as found in 50% and 45.4% of subjects during examination. The mean and median scores of MoCA was 16.7 and 17 respectively. Serological tests revealed positive TPPA for all patients and a median RPR titer at 1:64 positive. All CSF samples with TPPA and FTA-ABS results reported positivity. The MRI manifestations of general paresis include patchy or speckled hyperintensities (70.8%) and cerebral atrophy (45.8%). The most common lesioned sites in MRI were the ventricular and paraventricular area (50.0%) and temporal lobes (45.8%). For treatment, penicillin-based anti-syphilitic plans were adopted in 17 patients (68.0%).

Conclusion

The clinical features and radiological alternations of general paresis patients often exhibited diverse and nonspecific alternations. However, some specific clinical manifestations and auxiliary examinations can provide meaningful clues for the identification and differential diagnosis of this disease.

Alzheimer's Disease and Neurosyphilis: Meaningful Commonalities and Differences of Clinical Phenotype and Pathophysiological Biomarkers

BACKGROUND

Neurosyphilis-associated cognitive and behavioral impairment- historically coined as "general paralysis of the insane"- share clinical and neuroradiological features with the neurodegenerative disease spectrum, in particular Alzheimer's disease (AD). Anatomopathological similarities have been extensively documented, i.e., neuronal loss, fibrillary alterations, and local amyloid-β deposition. Consequently, accurate classification and timely differential diagnosis may be challenging.

OBJECTIVE

To describe clinical, bio-humoral, brain MRI, FDG-PET, and amyloid-PET features in cases of neurosyphilis with an AD-like phenotypical presentation, as well as clinical outcome in terms of response to antibiotic therapy.

METHODS

We selected the studies comparing patients with AD and with neurosyphilis associated cognitive impairment, to investigate candidate biomarkers classifying the two neurological diseases.

RESULTS

The neuropsychological phenotype of general paralysis, characterized by episodic memory impairment and executive disfunction, substantially mimics clinical AD features. Neuroimaging often shows diffuse or medial temporal cortical atrophy, thus contributing to a high rate of misdiagnosis. Cerebrospinal fluid (CSF)-based analysis may provide supportive diagnostic value, since increased proteins or cells are often found in neurosyphilis, while published data on pathophysiological AD candidate biomarkers are controversial. Finally, psychometric testing using cross-domain cognitive tests, may highlight a wider range of compromised functions in neurosyphilis, involving language, attention, executive function, and spatial ability, which are atypical for AD.

CONCLUSION

Neurosyphilis should be considered a potential etiological differential diagnosis of cognitive impairment whenever imaging, neuropsychological or CSF features are atypical for AD, in order to promptly start antibiotic therapy and delay or halt cognitive decline and disease progression.

Clinical and laboratory features in patients with positive syphilis serology presenting with acute ischemic stroke or transient ischemic attack: a prospective cohort study

Background

Neurosyphilis (NS) can lead to acute ischemic stroke (AIS) or transient ischemic attack (TIA). We compared the clinical characteristics and laboratory features among AIS and TIA patients who were syphilis-seronegative (control group) or had latent syphilis (LS) or NS to evaluate their stroke outcome.

Methods

This prospective cohort study was conducted on patients who had recently suffered AIS or TIA. After serological syphilis screening, clinical and laboratory data were collected, and brain imaging and spinal tap (serologically syphilis-positive patients only) were performed. Stroke outcome was re-evaluated approximately three months later.

Results

The 344 enrolled patients were divided into three groups: control group (83.7%), LS (13.1%), and NS (3.2%). A multivariate analysis revealed: 1) age of ≥ 70 years, generalized brain atrophy via imaging, and alopecia (adjusted odds ratio [AOR] = 2.635, 2.415, and 13.264, respectively) were significantly associated with LS vs controls; 2) age of ≥ 70 years (AOR = 14.633) was significantly associated with NS vs controls; and 3) the proportion of patients with dysarthria was significantly lower (AOR = 0.154) in the NS group than in the LS group. Regarding the NS patient cerebrospinal fluid (CSF) profile, only 2/11 cases had positive CSF-Venereal Disease Research Laboratory (VDRL) test results; the other nine cases were diagnosed from elevated white blood cell counts or protein levels combined with positive CSF fluorescent treponemal antibody absorption (FTA-ABS) test results. Regarding disability, the initial modified Rankin scale (mRS) score was lower in the control group than in the NS group (p = 0.022). At 3 months post-stroke, the mRS score had significantly decreased in the control (p < 0.001) and LS (p = 0.001) groups. Regarding activities of daily living, the 3-month Barthel Index (BI) score was significantly higher in control patients than in LS (p = 0.030) or NS (p = 0.002) patients. Additionally, the 3-month BI score was significantly increased in the control (p < 0.001) and LS (p = 0.001) groups.

Conclusions

Because syphilis was detected in many AIS and TIA patients, especially those aged ≥ 70 years, routine serological syphilis screening may be warranted in this population. Patients with syphilitic infection had worse stroke outcomes compared with NS patients.

A case of neurosyphilis with psychosis and hippocampal atrophy

Neurosyphilis can mimic many neurological and psychiatric disorders. Though several of its varied central nervous system manifestations can be measured clinically and by neuroimaging, they are non-specific. Thus, this mimicry and the relative rarity of the illness in the present era make the diagnosis elusive. However, neurosyphilis is readily treatable; therefore, it must be considered a diagnostic possibility in the routine workup of early-onset dementia. This case report is of a young man presenting with psychosis and cognitive impairment. His brain scan showed hippocampal atrophy, a finding not often seen in neurosyphilis but more common in Alzheimer’s disease. Without awareness of the various causes of mesiotemporal atrophy, clinicians may erroneously diagnose cases such as this one as a neurodegenerative disorder.

T2/FLAIR hyperintensity in the mesial temporal lobe: challenging differential diagnosis

T2/FLAIR hyperintensity in the mesial temporal lobe is the most common MR finding of herpes simplex encephalitis but may be observed in other infectious and non-infectious diseases. The former includes herpes human virus 6 encephalitis, Japanese encephalitis, and neurosyphilis, and the latter autoimmune encephalitis, gliomatosis cerebri, bilateral or paradoxical posterior cerebral artery infarction, status epilepticus, and hippocampal sclerosis. Thus, T2/FLAIR hyperintensity in the mesial temporal lobe is not a disease-specific magnetic resonance imaging finding, and these conditions must be differentiated to ensure proper treatment. We review diseases that are presented with T2/FLAIR hyperintensity in the mesial temporal lobe and provide a helpful flow chart based on clinical and radiologic features.

Prevalence and association of syphilis reactivity in an Asian memory clinic population

Data on the association between syphilis reactivity and dementia in memory clinic patients are scarce. We studied the prevalence of syphilis reactivity and investigated its association with dementia and markers of cerebrovascular disease (CeVD) and neurodegeneration. Data on age, gender, education, brain computed tomography scan findings and syphilis reactivity were obtained from patients who attended the National University Hospital memory clinics (February 2006-February 2016) and subjects from the community. Binary logistic regression models were used to investigate associations between syphilis reactivity and dementia, CeVD and neurodegeneration, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Of 1271 memory clinic patients eligible for the study, 57 (4.5%) were syphilis reactive, with the rate of syphilis reactivity higher in demented (44/745; 5.9%) compared to non-demented (13/526; 2.5%) patients ( p = 0.004) and non-demented community-based (21/872; 2.4%) subjects ( p < 0.001). Binary logistic regression showed a significant association between syphilis reactivity and dementia in memory clinic patients independent of demographic factors (odds ratio: 2.06; 95% CI: 1.02-4.17, p = 0.044). A significant association between syphilis reactivity and dementia was found in memory clinic patients. The mechanism of this association requires further research and may involve neuroinflammation.

Clinical and laboratory characteristics in patients suffering from general paresis in the modern era

BACKGROUND

No gold standard currently exists for the diagnosis of general paresis (GP), thus often resulting in unnecessarily delayed therapeutic decision.

METHODS

A retrospective chart review was performed for 85 inpatients with GP in Zhongshan Hospital, Medical College of Xiamen University, and the characteristics of their clinical profiles, serum and cerebrospinal fluid (CSF) examinations, neuroimaging examination, and electroencephalogram (EEG) data were analyzed.

RESULTS

Among the 85 GP patients, the clinical symptoms that were frequently observed upon admission included a variety of psychiatric-behavioral symptoms and varying degrees of cognitive impairment. All of the patients had positive serum Treponema pallidum particle agglutination (TPPA) assays, 96.47% of the patients had positive CSF TPPA assays, and 41.18% of the patients had both CSF pleocytosis and elevated CSF protein levels. Focal atrophy in one cerebral region or in multiple regions was evident in neuroimages. The EEG data primarily showed slightly abnormal EEG activity.

CONCLUSION

These results demonstrate the complexity of the clinical characteristics of GP and highlight the importance of early diagnosis.

Neurosyphilis

No portion of the central nervous system is immune to the ravages of syphilis. Infection by Treponema pallidum can affect the meninges, brain, brainstem, spinal cord, nerve roots, and cerebral and spinal blood vessels. As a consequence, the disease may present in diverse and, at times, diagnostically challenging fashions. Neurologic manifestations of syphilis may develop within months of the initial infection or, alternatively, take decades to appear. Although approximately one-third of individuals infected by T. pallidum display cerebrospinal fluid abnormalities suggestive of invasion of the central nervous system by the organism, only a fraction of these develop clinically significant neurologic manifestations. The features of neurosyphilis may be modified by the concomitant presence of immunosuppressive agents or conditions such as HIV/AIDS. The epidemiology of neurosyphilis has largely paralleled that of syphilis in general. A dramatic decline occurred by the early 1950s as a consequence of public health measures and the widespread use of antibiotics. The incidence had increased by the onset of the AIDS pandemic and has since corresponded with the adoption of safe sex practices. The CSF Venereal Disease Research Laboratory (VDRL) test remains the "gold standard" for diagnosis, but is not invariably positive. Penicillin remains the most effective and recommended therapy.

MRI findings and early diagnosis of general paresis of the insane

The objective of this study was to improve the knowledge of the clinical and MRI presentation of general paresis of the insane (GPI) and achieve its early diagnosis. Fifteen patients with GPI were gathered. Their clinical data and brain MRI information were analyzed. The age range was 33-62 years (mean: 48·8 years). The disease lasted 34 days-28 months (mean: 10·87 months). Treponema pallidum hemagglutination assays (TPHAs) on the cerebrospinal fluid (CSF) and sera were positive. All patients were human immunodeficiency virus (HIV) negative and primarily showed progressive cognitive impairment, mostly accompanied with emotional disturbance and psychosis. The accompanying symptoms included epilepsy (n  =  7), ataxia (n  =  5), cerebral vascular disease (n  =  3), and limbs tremor (n  =  2). Typical Argyll Robertson's pupil was observed in two cases. A CSF examination showed elevated white blood cell (WBC) and protein level. Purely cerebral atrophy was found in three cases. Abnormal high signals were found in nine cases in different brain area, mainly in bilateral temporal, insular, and frontal lobes and hippocampus in T2-weighted and fluid-attenuated inversion recovery (FLAIR), which was accompanied by cerebral and/or hippocampus atrophy. Purely atrophy of bilateral or unilateral hippocampus was found in two cases. Cerebral infarction lesions were found in three cases. Contrary to the previous reports, the hippocampal atrophy and bilateral abnormal signals of hippocampus and temporal lobe in brain MRI were more common in cases with GPI. Abnormal signals were probably related to proliferation of glial cells rather than cytotoxic edema. The pathogenesis of the abnormal signals needs to be further explored. General paresis of the insane has a wide variety of central nervous system manifestations, either clinically or neuroradiologically. Identification of these presentations could be important for early diagnosis.

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

BACKGROUND

Most patients with neurosyphilis are considered asymptomatic. The diagnosis is challenging and the role of neuroimaging is not yet well established. The present study was conducted to focus on the clinical findings and further characterize the imaging features of the disease, along with a review of the pertinent literature.

METHODS

Six male patients with neurosyphilis based on abnormal cerebrospinal fluid findings, five of whom were asymptomatic at presentation, underwent cranial computerized tomography (CT) and magnetic resonance imaging (MRI). They also underwent a complete physical, neurological, and ophthalmological examination, with special attention paid to atherosclerotic vascular risk factors. In addition, all were examined for cardiac involvement using electrocardiography and cardiac ultrasound.

RESULTS

The meticulous neurological and ophthalmological examination revealed abnormalities in five patients, most commonly cranial nerve involvement (three patients) and hemiparesis (two patients). The CT and MRI studies revealed abnormalities in five of the six patients, and in all six patients, respectively. The most common findings were brain infarcts, which were demonstrated in four of the six patients. MRI was found to be more sensitive than CT in detecting these brain infarcts, as expected.

CONCLUSIONS

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.

Neurosyphilis: MRI features and their phenotypic correlation in a cohort of 35 patients from a tertiary care university hospital

INTRODUCTION

The clinical and MR imaging features of neurosyphilis are highly varied. In this study, we describe the spectrum of the imaging findings in patients with neurosyphilis.

METHODS

The MR imaging observations of 35 patients diagnosed to have neurosyphilis on the basis of cerebrospinal fluid reactive for the Venereal Disease Research Laboratory test were reviewed.

RESULTS

All the 35 patients, including four with human immunodeficiency virus coinfection, met the CDC diagnostic criteria for neurosyphilis. Patients were classified into three groups: (1) neuropsychiatric, (2) meningovascular, and (3) myelopathic, based on the dominant clinical manifestations. Fourteen patients with neuropsychiatric manifestations showed diffuse cerebral atrophy (14), parenchymal signal changes in the mesial temporal region (2) and temporal and basifrontal regions (1), infarcts (3), and nonspecific white matter changes (3). Eleven patients with meningovascular form showed infarcts (6), diffuse cerebral atrophy (3), signal changes in the mesial temporal region (3), sulcal exudates (1), progressive multifocal leukoencephalopathy (1), and a mass surrounding the carotid sheath (1). Spine imaging in ten patients with myelopathy showed long-segment signal changes (5), contrast enhancement (2), and dorsal column involvement (2). Three of these patients had normal spinal study. Six patients in the myelopathic group also underwent brain MRI that showed signal changes in the temporal region (2) and frontal region (1), multiple infarcts (1), and enhancing hypothalami (1). Three patients had normal study.

CONCLUSION

MRI abnormalities in neurosyphilis are protean and mimic of many other neurological disorders and thus require a high index of suspicion to reduce diagnostic omissions.

Neurosyphilis with dementia and bilateral hippocampal atrophy on brain magnetic resonance imaging

Background

This article reports a rare case of active neurosyphilis in a man with mild to moderate dementia and marked hippocampal atrophy, mimicking early onset Alzheimer’s disease. Few cases have so far described bilateral hippocampal atrophy mimicking Alzheimer’s disease in neurosyphilis.

Case presentation

The patient presented here is a 33 year old Bulgarian male, whose clinical features include progressive cognitive decline and behavioral changes over the last 18 months. Neuropsychological examination revealed mild to moderate dementia (Mini Mental State Examination score was 16/30) with impaired memory and attention, and executive dysfunction. Pyramidal, and extrapyramidal signs, as well as dysarthria and impairment in coordination, were documented. Brain magnetic resonance imaging showed cortical atrophy with noticeable bilateral hippocampal atrophy. The diagnosis of active neurosyphilis was based on positive results of the Venereal Disease Research Laboratory test/Treponema pallidum hemagglutination reactions in blood and cerebrospinal fluid samples. In addition, cerebrospinal fluid analysis showed pleocytosis and elevated protein levels. High-dose intravenous penicillin therapy was administered. At 6 month follow up, improvements were noted clinically, on neuropsychological examinations, and in cerebrospinal fluid samples.

Conclusion

This case underlines the importance of early diagnosis of neurosyphilis. The results suggest that neurosyphilis should be considered when magnetic resonance imaging results indicate mesiotemporal abnormalities and hippocampal atrophy. Neurosyphilis is a treatable condition which requires early aggressive antibiotic therapy.

Clinical presentation and imaging of general paresis due to neurosyphilis in patients negative for human immunodeficiency virus

The clinical presentations and MRI of six patients with general paresis due to neurosyphilis were reviewed. Diagnosis was based on neurological and psychiatric symptoms, positive Treponema pallidum hemagglutination in cerebrospinal fluid (CSF) and sera, and serology that was negative for human immunodeficiency virus by enzyme-linked immunosorbent assay. Most patients had lymphocytic, monocytic pleocytosis and high protein levels in their CSF. One patient had periodic lateral epileptiform discharges, one patient had epileptiform discharges and three patients had slowing of background activity on electroencephalography. Two patients had hyperintense signal abnormalities in the anterior and mesial temporal lobe, while four patients were found by MRI to have cerebral atrophy. Three patients developed white matter lesions. Therefore, clinical, electroencephalography and MRI findings are valuable in the diagnosis of general paresis of neurosyphilis.

Initially unrecognized dementia in a young man with neurosyphilis

BACKGROUND

In general paresis, the invading spirochetes destruct the neurons resulting in impairments in memory, intellect, affect, and judgment of the infected patients. If neurosyphilis is diagnosed early enough, a timely effective treatment may not only prevent further progression of the disease but also allow complete recovery.

CASE REPORT

We report a 35-year-old man with rapid cognitive deterioration. Neurotic depression with dementia was initially diagnosed and the patient was treated with antidepressants, with a poor response. Neurosyphilis with general paresis was diagnosed 1 year later. A 2-week course of intensive treatment with penicillin G was started. Persistent dementia and progressive brain atrophy were found 6 months later, despite an improved cerebrospinal fluid profile and cerebral blood flow indicated by serial single-photon emission computed tomography.

CONCLUSION

This case underscores the importance of early diagnosis of neurosyphilis, and the clinicians should alert the possibility of neurosyphilis in patients who present with dementia.

CT and MR findings in HIV-negative neurosyphilis

BACKGROUND AND PURPOSE

The purpose of this study was to describe and evaluate neuroimaging findings of patients with neurosyphilis.

METHODS

The neuroimaging studies of 14 patients with documented neurosyphilis were reviewed. Diagnosis was established in 14 patients with cerebrospinal fluid for a Treponema Pallidum Particle Agglutination (TPPA) test. All patients had reactive TPPA and Unheated Serum Regain test (USR) in their sera. Imaging studies included plain, contrast-enhanced CT of the brain, plain and gadolinium-enhanced MR, and MR angiography.

RESULTS

In the 14 HIV-negative patients with neurosyphilis, CT and MR showed the presence of cerebral infarction in six cases, arteritis in four cases, nonspecific white matter lesion in three cases, acute syphilitic meningitis in one case and normal neuroimaging finding in one case. In addition, 4 in 14 patients had general paresis, and MRI showed high signal intensity on T2 -weighted images involving frontotemporal lobes, hippocampus and periventricular area. Treatment with penicillin significantly diminished the size of these high signal intensity on T2-weighted images with general paresis.

CONCLUSION

These results suggest that MR and CT images have some characteristic manifestations in patients of neurosyphilis. Because early diagnosis and treatment of neurosyphilis are crucial to avoid persistent brain damage, the neuroimaging findings are valuable adjunct to clinical diagnosis and to provide useful information to follow-up after therapy.

Clinical and magnetic resonance imaging findings of HIV-negative patients with neurosyphilis

There have been no serial studies about neuroradiological findings of neurosyphilis in the literature. There have been only case reports concerning HIV negative patients with neurosyphilis. We present 8 HIV negative neurosyphilis patients two of whom are women. The mean age of the patients was 48 years+/-12.37. Five of the 8 patients had general paresis, two optic atrophy and one multiple cranial neuropathies. The CSF findings were quite similar in 6 of 8 patients. In half of the patients cranial MRI showed mild cerebral atrophy. Nonspecific hyperintense small foci in 3 patients are thought to be related to syphilis. Hyperintensity involving bilateral medial and anterior temporal regions more prominent on the left side was seen in one of the patients with general paresis. This finding may be due to cytotoxic edema associated with status epilepticus and may mimic herpes simplex and other limbic encephalitides. Though not typical, certain MRI findings guides for the diagnosis of neurosyphilis.

The Role of Conventional MR and CT in the Work-Up of Dementia Patients

Dementia is a clinical syndrome with many causes. There often is overlap in the clinical manifestations of various forms of dementia, making them difficult to categorize. Neuroimaging can play an important role in distinguishing one form of dementia from another. Advanced imaging techniques continue to provide greater insight into the underlying pathologic processes in patients who have dementia. Conventional MRI and CT, however, still can contribute useful information when interpreting radiologists are familiar with the patterns of volume loss and signal or density changes that are characteristic of various forms of dementia.

The role of conventional MR and CT in the work-up of dementia patients

Neuroimaging can play an important role in distinguishing one form of dementia from another. Advanced imaging techniques continue to provide greater insight into the underlying pathologic processes in patients who have dementia. Conventional MRI and CT, however, can contribute useful information when interpreting radiologists are familiar with the patterns of volume loss and signal or density changes that are characteristic of various forms of dementia.

Magnetic Resonance Image-Reversible Findings in a Patient With General Paresis

MATERIAL AND METHODS

We describe clinical, cerebrospinal fluid (CSF), and magnetic resonance imaging (MRI) findings in a patient with general paresis. MRI demonstrated cortical-subcortical atrophy and broad-coalescent high-intensity T2 lesions in right frontotemporal lobes.

RESULTS

After intravenous penicillin therapy, the size of these lesions diminished dramatically. That regression correlated with improvement in neuropsychologic test and CSF analysis.

CONCLUSION

To our knowledge, this is the first case reported in the literature of MRI-reversible lesions in a patient with general paresis. We suggest that MRI is of prognostic value in patients with general paresis. Severe atrophy, especially in the temporal lobe, could be a marker of bad clinical outcome.