A clinical study of new cases of parenchymal neurosyphilis: has tabes dorsalis disappeared or been missed?

Tabes dorsalis (TD) was documented as the most common parenchymal neurosyphilis, but its incidence dramatically declined in the antibiotic era. Syphilis has resurged on the China mainland since the 1980s. In recent years, physicians have been reporting parenchymal neurosyphilis, and the overwhelming majority was general paresis, but this was not the case in the authors' hospital. To make clear the real situation of parenchymal neurosyphilis in the authors' hospital, a retrospective review was carried out of the records of patients during 2009-2012. Overrepresented clinical new cases of tabetic and paretic parenchymal neurosyphilis were collected. Clinical characteristics, neuroimaging, laboratory data, and responses to penicillin were analyzed in two groups. The efficiency of two current criteria based on CSF antibodies tests was inspected. In the 43 cases with positive serum rapid plasma reagin (RPR) and TPPA tests, 18 patients met the criteria of this study: 11 presented with symptoms of general paresis, and seven had typical presentations of TD. There were statistical differences in serum RPR titers, CSF RPR, white blood cell count, and TP between the paretic and tabetic groups. The response to penicillin was relatively poor in TD. The efficiency of two current criteria was lower in the diagnosis of TD. TD was not uncommon in our area. Its clinical features remained typical, but underdiagnosis with CSF-based criteria and a decreased response to penicillin were prominent issues.

Magnetic resonance imaging of the spinal cord in a man with tabes dorsalis.

BACKGROUND: Tabes dorsalis is a late manifestation of untreated syphilis that is characterized by ataxia, lancinating pains, and urinary incontinence. A form of tertiary syphilis or neurosyphilis, it is the result of slow, progressive degeneration of the nerve cells in the spinal cord. METHOD: Case report. FINDINGS: A 39-year-old man presented with tingling paresthesia in the lower limbs, difficulty in walking, and loss of vision. Magnetic resonance imaging (MRI) of the dorsal spine showed intramedullary hyperintensity and cord atrophy, similar to changes seen in subacute combined degeneration. MRI features of tabes dorsalis have not been described previously to the best of our knowledge. CONCLUSION: MRI findings in this patient with tabes dorsalis were similar to those seen in subacute combined degeneration, which is characterized predominantly by cord atrophy and intramedullary hyperintensities.

Medullary involvement in neurosyphilis: a report of 12 cases and a review of the literature.

Study design: Retrospective case series. Objectives: To describe the epidemiological, clinical, MRI and therapeutic features and the outcomes of patients with syphilitic myelitis in a third-level hospital in Marrakesh in southern Morocco. Setting: The Neurology Department, University Hospital Mohamed VI Marrakesh, Morocco. Methods: Twelve charts of persons with syphilitic myelitis over a period of 17 years were reviewed to determine demographics, presenting symptoms, clinical and radiological findings, biological features, treatment received and outcomes. Results: There were 120 reports of neurosyphilis. Twelve patients (10%) had syphilitic myelitis. Eleven patients (92%) were male with mean age of 44 at presentation. Tabes dorsalis was the most common clinical form. Cerebrospinal fluid analysis showed lymphocytic meningitis in nine patients (75%). Spine MRI was abnormal in four patients (33%). All patients were treated with 30 million units of aqueous penicillin G IV per day for 10 days, every 3 months. In follow-up, two patients (17%) with clinical syphilitic meningomyelitis improved significantly, eight patients (66%) with tabes dorsalis and subacute transverse myelitis showed partial improvement but clinical status was stationary for two patients (17%) with Erb paraplegia. Conclusions: All patients with myelopathy should undergo syphilitic serology because of nonspecific manifestations and curability of this disease.

Neurosyphilis manifesting as spinal transverse myelitis.

Spinal myelitis caused by neurosyphilis is an extremely rare disease, and there are only few visual examples of magnetic resonance imaging scans. We present a clinical case of neurosyphilis, which is of great importance concerning diagnostic, differential diagnosis, and tactics of management. A patient complaining of progressive legs weakness, numbness, and shooting-like pain in the legs as well as pelvic dysfunction was admitted to the hospital. Neurological examination revealed spinal cord lesion symptoms: legs weakness, impairment of superficial and deep sensation together with pathological symptoms in the legs. Hernia of intervertebral disc or tumor was suspected, and myelography with computed tomography of the spine was performed. No pathological findings were observed. More precise examination of the patient (a small scar in the genitals and condylomata lata in anal region were noticed) pointed to possible syphilis-induced spinal cord lesion. Serologic syphilis diagnostic tests (Treponema pallidum hemagglutination assay, reagin plasma response, serum enzyme-linked immunosorbent assay) and cerebrospinal fluid tests (general cerebrospinal fluid test and Venereal Disease Research Laboratory test) confirmed the diagnosis of neurosyphilis. Spinal cord lesion determined by magnetic resonance imaging was evaluated as spinal syphilis or syphilis-induced myelitis. Conventional treatment showed a partial effect.

[2-dimensional immunoelectrophoresis of CSF proteins]. / Immuno-électrophorèse bidimensionnelle des protéines du L.C.R.

Two-dimensional electrophoresis isolates the various proteins in the CSF in peaks ; this a method which gives very reliable results ; the height of the peaks has a certain quantitative value, similar to that obtained with electro-immunodiffusion. The peaks visible in the CSF can be increased separately -- mainly the "alpha 2", "alpha 2 beta", the IgA and IgG peaks -- in another type of recording, the height and number of the peaks may be increased, indicating the presence in the CSF of normally absent protein originating in the serum. An increase in the "alpha 2" or "alpha 2 beta" peaks is not specific, but it is always indicative that the development of a neurological process is under way ; the increase of IgG and IgA retains its character of great specificity in evolutive inflammatory conditions. Multiple peaks indicate the passage of serum proteins into the CSF in oedematous and destructive processes, in expansive or compressive processes and in polyradiculoneuritis. This method with its well-codified technique, which may be carried out on an unconcentrated CSF without risk of denaturing the proteins, may be carried out routinely in clinical practice with human anti-serum immune serum or with more specific serum, anti CSF for example, which seems to give quite reliable results.

[Myelin basic protein in cerebrospinal fluid in neurosyphilis (author's transl)]. / Basisches Myelinprotein im Liquor cerebrospinalis bei Neurosyphilis.

Myelin basic protein (MBP) was demonstrated in the CSF of 15 out of 41 patients with assumed or ascertained neurosyphilis using a radio-immunoassay. In parenchymatous syphilis (progressive paralysis, tabes dorsalis) more than 50% of patients had MBP-positive CSF independent of immunological findings and previous treatment. CSF of patients with meningovascular neurosyphilis was mostly negative, only in 2 cases with acute symptoms was MBP demonstrable. In one of these patients MBP was no longer demonstrable in the CSF 6 months after treatment. The frequent occurrence of MBP in CSF in parenchymatous neurosyphilis can be taken as evidence of persistence of demyelinising activity even in cases where immunological finding point to "syphilis satis curata" (sufficiently treated syphilis).

[Diagnosis of spinal diseases by cerebrospinal fluid examination]. / Zentralblatt für Neurochirurgie.

In this work, changes in the cerebrospinal fluid in acute and chronic polyneuritis as well as in the Guillan-Barré-Strohl syndrome are discussed and and it is pointed out that a specific coordination of the inflammatory cerebrospinal fluid syndromes to certain pathogens or noxae cannot be made. For the differentiation of the Guillain-Barré-Strohl syndrome and existence of increased gamma-globulin bands with identical mobility in the serum is pointed out. In myelitic disease pictures, acute and chronic cerebrospinal fluid syndromes are distinguished also in the cerebrospinal fluid according to the clinical course; regular changes, however, cannot be derived. Syphilitic cerebrospinal-fluid syndromes can easily be differentiated by their immunoactive findings. In multiple sclerosis, we distinguish between typical and atypical changes in the cerebrospinal fluid. Above all, the oligoclonal bands, i. e. the discontinuous proceeding of the gamma-globulin zone and the existence of several bands in the agar gel electrophoresis, play an essential role. In 95 per cent of the cases, oligoclonal bands can be shown. There are no greater differences with respect to oligoclonal bands between intermittent and chronic-progressive courses. For the differential diagnosis of haemorrhagic syndromes, the cerebrospinal fluid cell picture can make a considerable contribution. Macrophages loaded with erythrocytes indicate that a haemorrhage occurred 12 to 18 hours before; macrophages loaded with haemosiderin indicate a haemorrhage that occurred 6 to 8 days before; and macrophages loaded with erythrocytes and haemosiderin indicate a seeping haemorrhage or an event that occurred several times. The Nonne-Froin syndrome indicates a massive protein increase often with a regular or only slightly increased number of cells. The importance of the Queckenstedt tests is pointed out. A particular role is played by meningitis carcinomatosa et sarcomatosa with the demonstration of a great number of tumour cells.

Diagnosis of neurosyphilis: a critical assessment of current methods.

Clinical features of 74 patients with neurosyphilis and 38 syphilitic patients with nonsyphilitic neurologic disorders were correlated with results of their serum and cerebrospinal fluid (CSF) VDRL and FTA tests, and with the WBC count and total protein level in the CSF. The most common clinical features in those having neurosyphilis were reflex changes (53.9%), peripheral neuropathy (44.5%), ataxia (38%), and cranial nerve palsies (24.3%). In 27% of the patients with neurosyphilis the CSF was VDRL-reactive, while in 77% the CSF was FTA-reactive. The frequency of elevated WBC counts in various serologic categories ranged from 23% to 46%, and the frequency of elevated protein levels ranged from 23% to 27%; neither the mean WBC count nor the protein level differed significantly among the different serologic categories (P less than .05). Only two of the 74 patients with neurosyphilis had elevation of both the WBC and protein level. None of the syphilitic patients without neurosyphilis had an elevated WBC or protein level, though the CSF was FTA-reactive in all 38. Among the neurosyphilis patients whose CSF was VDRL-nonreactive but FTA-reactive, 21% had an elevated protein level and 26% had an elevated WBC count. These results support the view that patients having neurosyphilis will not necessarily have either VDRL-reactive CSF or the other expected CSF abnormalities.

Current clinical spectrum of neurosyphilis in immunocompetent patients.

BACKGROUND: Neurosyphilis (NS) is nowadays a less frequent disease. Its incidence and clinical spectrum have changed over time. OBJECTIVE: To estimate the incidence of NS and describe the clinical spectrum of NS in immunocompetent patients in the last decade. METHODS: Demographic and clinical features, cerebrospinal fluid (CSF) changes, neuroimaging findings and outcome were retrospectively analyzed. RESULTS: Forty-three patients met NS criteria. The yearly incidence was 0.2- 2.1 cases per 100,000 inhabitants. The mean age was 48.1 years, males being more frequently involved. The most frequent clinical patterns were meningovascular (30.2%), meningeal (25.6%) and general paresis (25.6%). Compared to prepenicillin series, we observed a decrease in late forms, mainly tabes dorsalis. CSF titers studied by the Venereal Disease Research Laboratory were higher in early NS. Neuroimaging findings were nonspecific. Outcome was better for early forms. CONCLUSIONS: Compared to the preantibiotic era, a lower frequency of late NS was observed, similar to that reported in other modern series which include patients with HIV infection. Therefore, this trend seems to be due to the impact of antibiotics rather than to HIV infection.