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Yokota Y, Ishihara M, Ninomiya S, Mitsuke K, Kamei S, Nakajima H. Locked-in Syndrome Due to Meningovascular Syphilis: A Case Report and Literature Review. Intern Med 2022; 61:1593-1598. [PMID: 34670896 PMCID: PMC9177359 DOI: 10.2169/internalmedicine.8269-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/01/2021] [Indexed: 11/29/2022] Open
Abstract
We herein report a 46-year-old man presenting with locked-in syndrome secondary to meningovascular syphilis. Brain magnetic resonance imaging (MRI) demonstrated multiple acute infarctions in the left ventromedial pons, right basis pontis, and left basal ganglia. His locked-in syndrome was hypothesized to have been caused by thrombosis of the small paramedian branches of the basilar artery due to syphilitic arteritis. This is a unique case of bilateral ventromedial pontine infarction caused by meningovascular syphilis that presented as locked-in syndrome. Meningovascular syphilis should be included in the differential diagnosis of uncommon stroke, particularly in young men.
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Affiliation(s)
- Yuki Yokota
- Department of Neurology, Graduate School of Medicine, Nihon University School of Medicine, Japan
| | - Masaki Ishihara
- Department of Neurology, Graduate School of Medicine, Nihon University School of Medicine, Japan
| | - Satoko Ninomiya
- Department of Neurology, Graduate School of Medicine, Nihon University School of Medicine, Japan
| | - Kazutaka Mitsuke
- Department of Neurology, Graduate School of Medicine, Nihon University School of Medicine, Japan
| | - Satoshi Kamei
- Department of Neurology, Center for Neuro-infection, Ageo Central General Hospital, Japan
| | - Hideto Nakajima
- Department of Neurology, Graduate School of Medicine, Nihon University School of Medicine, Japan
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Krothapalli N, Desai N, Tunguturi A, Hou Y, Patel SD. Neurosyphilis presenting with a large vessel occlusion: A case report. Brain Circ 2021; 7:285-288. [PMID: 35071847 PMCID: PMC8757502 DOI: 10.4103/bc.bc_39_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 06/21/2021] [Accepted: 07/15/2021] [Indexed: 12/03/2022] Open
Abstract
We describe a case of a 36-year-old man who presented with stroke in the right paramedian pons in the pontine perforator territory, manifesting as intermittent headache, slurred speech, left-sided weakness, and paresthesia. This case highlights the diagnostic challenge in identifying neurosyphilis as a cause of stroke in young individuals. Clinicians should maintain vigilance for this uncommon etiology through conducting a detailed history and investigation in susceptible patients with key risk factors. Once the diagnosis was confirmed in our case, a multidisciplinary approach was used for management with neurologists, infectious disease specialists, and the neurointerventional team. Our patient ultimately underwent successful therapy with mechanical thrombectomy for basilar artery thrombosis from meningovascular syphilis.
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Affiliation(s)
| | - Ninad Desai
- Department of Neurology, St. Vincent's Medical Center, Hartford Healthcare, Hartford, Connecticut, USA
| | - Ajay Tunguturi
- Department of Neurology, Hartford Hospital, Hartford, Connecticut, USA
| | - Yan Hou
- Department of Neurology, Hartford Hospital, Hartford, Connecticut, USA
| | - Smit D Patel
- Department of Neurology, UCONN School of Medicine, Connecticut, USA
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Munshi S, Raghunathan SK, Lindeman I, Shetty AK. Meningovascular syphilis causing recurrent stroke and diagnostic difficulties: a scourge from the past. BMJ Case Rep 2018; 2018:bcr-2018-225255. [PMID: 29884669 DOI: 10.1136/bcr-2018-225255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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.
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Affiliation(s)
- Sunil Munshi
- Department of Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Ileana Lindeman
- Department of Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ashit K Shetty
- Department of Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Abstract
A wide range of infections (virus, bacteria, parasite and fungi) may cause cerebral vasculitides. Headache, seizures, encephalopathy and stroke are common forms of presentation. Infection and inflammation of intracranial vessels may cause pathological vascular remodelling, vascular occlusion and ischemia. Vasculitis in chronic meningitis may cause ischemic infarctions, and is associated with poor outcome. Appropriate neuroimaging (CT-angiography, MR-angiography, conventional 4-vessel angiography) and laboratory testing (specific antibodies in blood and CSF, CSF culture and microscopy) and even brain biopsy are needed to quickly establish the aetiology. Enhancement of contrast, wall thickening and lumen narrowing are radiological signs pointing to an infectious vasculitis origin. Although corticosteroids and prophylactic antiplatelet therapy have been used in infectious cerebral vasculitis, there are no randomized clinical trials that have evaluated their efficacy and safety. Stable mycotic aneurysms can be treated with specific antimicrobial therapy. Endovascular therapy and intracranial surgery are reserved for ruptured aneurysms or enlarging unruptured aneurysms.
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Affiliation(s)
- Francisco Javier Carod Artal
- a Neurology Department , Raigmore hospital , Inverness , UK.,b Health Sciences Faculty , Universitat Internacional de Catalunya (UIC) , Barcelona , Spain
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Abstract
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.
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Affiliation(s)
- Joseph R Berger
- Department of Neurology, University of Kentucky College of Medicine, Lexington, KY, USA.
| | - Dawson Dean
- Department of Internal Medicine, Indiana University, Indianapolis, IN, USA
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Tóth V, Hornyák C, Kovács T, Tóth B, Várallyay G, Ostorházi E, Köles J, Bereczki D, Marschalkó M, Kárpáti S. Meningovascular neurosyphilis as the cause of ischemic cerebrovascular disease in a young man. Orv Hetil 2011; 152:763-7. [DOI: 10.1556/oh.2011.29115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Authors report a case of a 35-year-old male with right-sided mild paresis, incontinence, dysexecutive syndrome, short-term memory loss and behavioral changes. Bilateral cerebral infarcts in the region of the caudate nuclei and the adjacent white matter were proved by brain MRI and multiple stenoses of the branches of Willis-circle were confirmed by MR angiography. Elevated protein level and pleocytosis were found in the cerebrospinal fluid with intrathecal IgG synthesis. Serum rapid plasma reagin, Treponema pallidum Particle Agglutination test, Treponema pallidum ELISA, liquor Venereal Disease Research Laboratory tests were positive. Meningovascular neurosyphilis was diagnosed. 24M U/day intravenous penicillin-G treatment was given for 14 days. The patient has vascular dementia due to the bilateral strategic infarcts disconnecting the prefrontal circuits; his symptoms are similar to general paresis. Laboratory and radiologic improvement was observed. Still, the patient have severe residual cognitive decline. Orv. Hetil., 2011, 152, 763–767.
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Affiliation(s)
- Veronika Tóth
- Semmelweis Egyetem, Általános Orvostudományi Kar Bőr-, Nemikórtani és Bőronkológiai Klinika Budapest
| | - Csilla Hornyák
- Semmelweis Egyetem, Általános Orvostudományi Kar Neurológiai Klinika Budapest
| | - Tibor Kovács
- Semmelweis Egyetem, Általános Orvostudományi Kar Neurológiai Klinika Budapest
| | - Béla Tóth
- Semmelweis Egyetem, Általános Orvostudományi Kar Bőr-, Nemikórtani és Bőronkológiai Klinika Budapest
| | - György Várallyay
- Semmelweis Egyetem, Általános Orvostudományi Kar MR-Kutató Központ Budapest
| | - Eszter Ostorházi
- Semmelweis Egyetem, Általános Orvostudományi Kar Bőr-, Nemikórtani és Bőronkológiai Klinika Budapest
| | | | - Dániel Bereczki
- Semmelweis Egyetem, Általános Orvostudományi Kar Neurológiai Klinika Budapest
| | - Márta Marschalkó
- Semmelweis Egyetem, Általános Orvostudományi Kar Bőr-, Nemikórtani és Bőronkológiai Klinika Budapest
| | - Sarolta Kárpáti
- Semmelweis Egyetem, Általános Orvostudományi Kar Bőr-, Nemikórtani és Bőronkológiai Klinika Budapest
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