Short Communication Open Access

Neurosyphilis: An unresolved case of meningitis- Shagufta Ahsan- Atlanticare Regional Medical Center

Abstract

 Neurosyphilis can cause both symptomatic and asymptomatic meningitis. Management of syphilis cases can be complicated. Syphilis presenting with a skin rash and an extremely high RPR titer could indicate CNS infection rather than simply secondary syphilis, because rash is a non-specific manifestation of disseminated infection. Here we present a case of early neurosyphilis/symptomatic syphilitic meningitis in a non- HIV patient who presented with rash and relatively high RPR titer but was mistakenly treated for early latent or secondary syphilis. A 24 y/o female with PMH of two STDs, non-recurrent genital herpes and syphilis (treated with oral acyclovir) presented with palmar rash at PCP’s office. Rash was diagnosed as secondary syphilis (for extremely high RPR titer of 1:500). She was given 1.6 million units of benzathine PCN G intramuscularly. The rash resolved in few weeks. Her rash recurred on the left hand 7 months after treatment. This time 2.4 million units of benzathine penicillin given intramuscularly. The rash resolved in one to two days. Follow up RPR titer in 4 weeks was 1: 16, a fold decline. So further RPR follow up was not done. During the whole period of her illness, the patient continued to have headaches, on and off. Again, 8 months after, she presented to ER with dizziness and persistent headache of two weeks duration and moderate neck stiffness. Her serum VDRL titer was 1: 64. HIV rapid test was non-reactive. Lumbar puncture showed leukocytosis with lymphocytes 94%, quantitative CSF VDRL was reactive at 1:16. CSF cultures showed no growth. Thus, the final diagnosis was early symptomatic Neurosyphilis or syphilitic meningitis, which would explain the persistent headache, vertigo, and recurrence of rash secondary to inadequate prior treatment. PCN G, 4 million units intravenously every four hours was started. The patient’s symptoms resolved completely in 4 to 5 days. Thus, any RPR titer > 1: 32 is highly suggestive of diseases of an active case of replicating spirochetes.

 Shagufta Ahsan

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