Stroke and syphilis: A retrospective study of 53 patients

Imaging features of neurosyphilis

Syphilis is an infectious disease caused by the spirochete Treponema pallidum, subspecies pallidum. Although its incidence has declined after the widespread availability of penicillin, it has recently re-emerged, especially in men who have sex with men and in people living with human immunodeficiency virus (HIV). The neurological manifestations of syphilis, generally known as neurosyphilis, may appear at any time during the infection, including the initial years after the primary infection. Neurosyphilis can be asymptomatic, only with cerebrospinal fluid abnormalities, or symptomatic, characterized by several different clinical syndromes, such as meningitis, gumma, meningovascular, brain parenchyma involvement, meningomyelitis, tabes dorsalis, and peripheral nervous system involvement. However, these syndromes may simulate several other diseases, making the diagnosis often a challenge. In addition, syphilis can also be vertically transmitted from mother to child during pregnancy, leading to neurological manifestations. Neuroimaging is essential to demonstrate abnormal brain or spinal cord findings in patients with neurosyphilis, aiding in the diagnosis, treatment, and follow-up of these patients. This article aims to review the imaging features of neurosyphilis, including the early and late stages of the infection.

Exploring Stroke Risk Factors and Outcomes in Sexual and Gender Minority People

Background and Objectives

Cerebrovascular disease in sexual and gender minority (SGM) people remains poorly understood. Our primary objective was to describe the epidemiology and outcomes in a sample of SGM people with stroke. As a secondary objective, we compared this group with non-SGM people with stroke to assess for significant differences in risk factors or outcomes.

Methods

This was a retrospective chart review study of SGM people admitted to an urban stroke center with primary diagnosis of stroke (ischemic or hemorrhagic). We evaluated stroke epidemiology and outcomes, summarizing with descriptive statistics. We then matched 1 SGM person to 3 non-SGM people by year of birth and year of diagnosis to compare demographics, risk factors, inpatient stroke metrics, and outcomes.

Results

A total of 26 SGM people were included in the analysis: 20 (77%) had ischemic strokes, 5 (19%) intracerebral hemorrhages, and 1 (4%) subarachnoid hemorrhage. Compared with non-SGM people (n = 78), stroke subtypes showed a similar distribution (64 (82%) ischemic strokes, 12 (15%) intracerebral hemorrhages, 1 (1%) subarachnoid hemorrhage, and 1 nontraumatic subdural hematoma, p > 0.05) but suspected ischemic stroke mechanisms had a different distribution (χ² = 17.56, p = 0.01). Traditional stroke risk factors were similar between the 2 groups. The SGM group seemed to have higher rates of nontraditional stroke factors, including HIV (31% vs 0%, p < 0.01), syphilis (19% vs 0%, p < 0.01), and hepatitis C (15% vs 5%, p < 0.01) but were more likely to be tested for these risk factors (χ² = 15.80, p < 0.01; χ² = 11.65, p < 0.01; χ² = 7.83, p < 0.01, respectively). SGM people were more likely to have recurrent strokes (χ² = 4.39, p < 0.04) despite similar follow-up rates.

Discussion

SGM people may have different risk factors, different mechanisms of stroke, and higher risk of recurrent stroke compared with non-SGM people. Standardized collection of sexual orientation and gender identity would enable larger studies to further understand disparities, leading to secondary prevention strategies.

Isolated middle cerebral artery stenosis caused by syphilitic vasculitis

BACKGROUND

Syphilitic vasculitis (SV) is rare and difficult to be diagnosed. High-resolution vessel wall magnetic resonance imaging (HR-VWI) might be valuable in the diagnosis by differentiating SV from other vessel wall pathologies.

METHODS

We report a rare case with severe isolated middle cerebral artery (MCA) stenosis and cerebral infarction, which was evaluated by serial HR-VWI.

RESULTS

A 46-year-old woman presented with an acute infarct in the left basal ganglia and severe isolated stenosis in left middle cerebral artery (MCA). Cerebrospinal fluid (CSF) analysis was performed and the findings were consistent with neurosyphilis diagnosis. The MCA stenosis was also suspected to be the result of SV. HR-VWI revealed the evidence of concentric thickening and circular uniform enhancement of the arterial wall. After two cycles of anti-syphilis treatment, subsequent HR-VWI showed that the MCA stenosis was reduced significantly except slight enhancement of the arterial wall, which confirmed that the SV caused the isolated MCA stenosis.

CONCLUSIONS

HR-VWI could be an important diagnostic tool for isolated middle cerebral artery stenosis caused by SV, which could serve as a biomarker for assessing the response to anti-syphilis treatment in the future.

Syphilis and Ischemic Stroke: Old Question Revisited by a Nationwide Cohort Study

BACKGROUND AND PURPOSE

In the era of easily available antibiotic use, this study provides epidemiological evidence for a re-examination of the relationship between syphilis and IS.

METHODS

Patients aged 18 years and older with newly diagnosed syphilis were included (N=1,585) from 2000, to 2012, and participants without syphilis in the control group (N=6,340) were matched by propensity score (age, sex, index year, insured amount, urbanization, seasons, and comorbidities). The Cox proportional hazard model was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) of IS. Five different Cox regression models, sensitivity analyses, and negative control were conducted to test our findings.

RESULTS

1,585 patients (1,055 [66.56%] men; mean [SD] age, 49.59 [20.32] years) had syphilis, and 3.8% had new-onset IS. The syphilis group had a higher risk of IS than the controls (adjusted HR, 1.35; 95% CI, 1.01-1.80; P-value<0.05) after full adjustment. Serial sensitivity analyses yielded consistent results.

CONCLUSIONS

Syphilis patients have higher risk of IS, and our data raise the question of implementation of prophylactic treatment for IS.

[Infection associated cerebral vasculitis]

Infections are a frequent cause of cerebral vasculitis, important to diagnose because a specific treatment may be required. Infection-associated vasculitis can be caused by angiotropic pathogens (varicella zoster virus, syphilis, aspergillus). They can be associated with subarachnoidal meningitis (tuberculosis, pyogenic meningitis, cysticercosis). They can appear contiguously to sinuses or orbital infection (aspergillosis, mucormycosis). Finally, they also may be due to an immune mechanism in the context of chronic infections (hepatitis B virus, hepatitis C virus, human immunodeficiency virus). Cerebral vasculitis are severe conditions and their prognosis is directly linked to early recognition and diagnosis. Infectious causes must therefore be systematically considered ahead of cerebral vasculitis, and the appropriate investigations must be determined according to the patient's clinical context. We propose here an update on the infectious causes of cerebral vasculitis, their diagnosis modalities, and therapeutic options.

Infections causing stroke or stroke-like syndromes

BACKGROUND

Stroke has relevant morbidity and mortality despite appropriate treatments and early diagnosis. Beside common risk factors such as diabetes and atrial fibrillation, infections can be involved in stroke pathogenesis, probably causing a systemic release of cytokines and other inflammatory mediators, triggering a latent pro-thrombotic state or damaging the vascular endothelium. In other cases, infections can occur as stroke-like syndromes, requiring a high grade of suspicion to avoid a delay in establishing a correct diagnosis.

RESULTS

Treatment of stroke or stroke-like syndromes of infectious origin can be difficult. When a previous infective event triggers stroke, Alteplase administration can be associated with a higher incidence of bleeding and the extension of the ischaemic area can be major than expected. On the other hand, when stroke is part of some infectious diseases' presentation as in endocarditis, bacterial or tuberculous meningitis and meningo-vascular syphilis, a correct diagnosis can be difficult. The management of these stroke-like syndromes is not standardised because common treatments proven to be effective for patients with stroke of vascular origin can worsen the prognosis, as it can be demonstrated after to be incorrect Alteplase administration to patients with endocarditis with septic embolism to the brain is associated with an increase of the risk of haemorrhage.

CONCLUSIONS

Stroke or stroke-like syndrome of infectious origin can be observed in an important proportion of case presenting with sensory-motor deficit of unknown origin; their accurate diagnosis has a considerable impact in terms of treatment choices and outcome.

Young male with syphilitic cerebral arteritis presents with signs of acute progressive stroke: A case report

INTRODUCTION

Neurosyphilis is a chronic infection of the central nervous system that is commonly found in adult with long latency periods. Neurosyphilis-attributed deaths in young patients have grown exponentially in the past decade, yet there have been few studies on the early stages of neurosyphilis.

PATIENT CONCERNS

A young male patient with syphilitic cerebral arteritis was evaluated in our clinic for the clinical signs of progressive ischemic stroke.

DIAGNOSIS

The progression of syphilitic cerebral arteritis was observed through computed tomography imaging, magnetic resonance imaging, magnetic resonance angiogram, and transcranial color Doppler. The pathological changes and clinical outcomes were reviewed. In this specific case, the development of syphilitic cerebral arteritis was dynamic, continuous, and rapid. The pathogenesis was related to Heubner arteritis, in which the formation of a mural thrombus (MT) causes the severe obstruction of blood flow without complete occlusion, leading to an increased risk of infarction. In this patient, formation of the MT resulted in the infarction of the smaller vessels and narrowing of the larger vessels. The partial dislodgment of the MT from the arterial wall of the larger vessels occluded the smaller vessels, leading to infarction.

INTERVENTIONS

Standard pharmacotherapy for the treatment of the cerebral infarction and a single course of penicillin were applied.

OUTCOMES

Muscle strength was recovered. The Glasgow Coma Scale score was 15, whereas the NIH Stroke Scale score was 0. The increase in blood flow of the right MCA was accompanied by severe stenosis with compensation of the anterior communicating artery. In addition, moderate to severe stenosis of the right vertebral artery and the basilar artery was suspected. There was a possibility that the right posterior communicating artery was recruited for compensation.

CONCLUSION

Progressive stroke was the initial symptom of the neurosyphilis. Disease progression is rapid and difficult to control with a single course of penicillin.

Ischemic stroke and infectious diseases in low-income and middle-income countries

PURPOSE OF REVIEW

To address the important relationships between stroke and infection, focusing on the most frequent infections found in low-income and middle-income countries.

RECENT FINDINGS

Stroke is one of the leading causes of mortality and disability worldwide, with a great proportion of the stroke burden occurring in low-income and middle-income countries. Infectious diseases are still a great health problem in developing countries and it is possible that the proportion of infection-related strokes is greater in these nations. Infectious diseases and stroke have a bidirectional relationship. Common infections may act as risk factors and can trigger stroke through different mechanisms in their acute phase. Several intracranial and systemic infections can cause stroke as a direct complication, such as Chagas disease, neurosyphilis, tuberculous meningitis, and neurocysticercosis. These conditions are of particular interest to low-income and middle-income countries, but also relevant to high-income nations because of increasing migration. Finally, infection is a frequent poststroke complication, with great impact in the patient outcome.

SUMMARY

Infectious diseases and stroke are common problems in low-income and middle-income countries. More studies are necessary to fully elucidate the real impact of infectious diseases on stroke burden, especially in countries where epidemiological data are still scarce.