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Neurosyphilis: Mighty Imitator forays with benign presentation and unique neuroimaging findings

Harmanpreet Tiwana , Aiesha Ahmed

Abstract

BACKGROUND: Common causes of temporal lobe hyper intensities are CNS infections like herpes simplex encephalitis, Lyme disease, limbic encephalitis and vascular pathology like CADASIL. DESIGN/METHOD: Personal assessment, laboratory data analysis and neuroimaging for the patient admitted in central Pennsylvania tertiary care referral center were done. RESULT: 52 year old male presented with one year history of diffuse dysesthesia in upper and lower extremities with associated intermittent headaches and neck stiffness. Evaluation with Lumbar Puncture revealed increased nucleated cells (50) with lymphocytic predominance (96%) and elevated protein of 109. MRI of Brain showed T2/FLAIR hyper intensity in bilateral subcortical temporal white matter, left greater than right and associated volume loss in cerebral parenchyma. Additional abnormal work up included reactive serum RPR and Treponema pallidum antibody particle agglutination. Diagnosis of Neurosyphilis was made and patient was treated with IM penicillin for 3 weeks. At the time of discharge his headache and neck stiffness resolved and dysesthesias were decreased in intensity. CONCLUSION: The diagnosis of Neurosyphilis is intricate, and no reference standard exists. Neuroimaging findings of Neurosyphilis commonly are cerebral infarctions, leptomeningeal enhancement or nonspecific white matter lesions. Less common features on a fluid-attenuated inversion recovery (FLAIR) sequences are cortical atrophy and mesial temporal parenchymal signal changes. It is prudent to keep Neurosyphilis in differential of mesial temporal lobe white matter changes as early diagnosis and treatment results in better prognosis.

SH17088  Accepted 19 December 2017

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