Acute Ischaemic Stroke in the Context of Neurosyphilis: How Does Antibiotic Therapy Help, and When Should It Be Given?

Pedro Gomes Santos; Pedro Martins Dos Santos; Teresa Abegão; Rita Rosa Domingos; Ana Verónica Varela; André Florêncio; Ana Paula Fidalgo

doi:10.12890/2024_004231

Acute Ischaemic Stroke in the Context of Neurosyphilis: How Does Antibiotic Therapy Help, and When Should It Be Given?

Eur J Case Rep Intern Med. 2024 Jan 8;11(2):004231. doi: 10.12890/2024_004231. eCollection 2024.

Authors

Pedro Gomes Santos¹, Pedro Martins Dos Santos¹, Teresa Abegão¹, Rita Rosa Domingos¹, Ana Verónica Varela², André Florêncio², Ana Paula Fidalgo²

Affiliations

¹ Internal Medicine Department, Centro Hospitalar Universitário do Algarve, Hospital de Faro, Faro, Portugal.
² Stroke Unit, Centro Hospitalar Universitário do Algarve, Hospital de Faro, Faro, Portugal.

Abstract

Introduction: Neurosyphilis (NS) refers to a central nervous system infection caused by Treponema pallidum. In recent years, there has been an increasing incidence of syphilis; however, NS is uncommon compared to the era before the discovery of penicillin. Manifestations are usually non-specific, ranging from asymptomatic cases to syphilitic meningitis, meningovascular syphilis, general paresis and tabes dorsalis. Meningovascular syphilis can cause an inflammatory arteritis of cerebral arteries, leading to vascular occlusion and cerebral infarction.

Case description: We report a case of an ischaemic stroke in a patient with several vascular risk factors, presenting with right hemiparesis, hemihypesthesia and dysarthria. Initial computed tomography with angiography of the head and neck was normal; however, magnetic resonance imaging of the brain revealed a thalamic and internal capsule infarct. Serum T. pallidum antibodies were positive, as well as a rapid plasma reagin test. Cerebrospinal fluid analysis confirmed the diagnosis of neurosyphilis, and the patient was treated with ceftriaxone for 14 days due to a penicillin allergy.

Discussion and conclusion: Although there is a high prevalence of stroke in patients with NS, this condition is typically underdiagnosed. Untreated NS carries a higher risk of stroke recurrence compared to other risk factors. Therefore, early diagnosis and treatment are essential. This case highlights the importance of considering NS in stroke victims, even in older patients with several additional vascular risk factors, to prevent recurrence and other complications.

Learning points: Neurosyphilis (NS) can occur at any stage of syphilis infection, and it can be asymptomatic or symptomatic, presenting as syphilitic meningitis, meningovascular syphilis, general paresis or tabes dorsalis.Ischaemic strokes are a frequent complication of NS, occurring in 14% of the cases. However, only 19% of the cases are correctly diagnosed.NS should be considered as a potential cause of stroke, even in older patients with several other vascular risk factors. This is essential to prevent future strokes, as well as dementia and other complications.

Keywords: Neurosyphilis; acute cerebrovascular event; arteritis; meningovascular syphilis; stroke.