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.

Syphilitic meningomyelitis presenting with visceral crisis: A case report.

RATIONALE: We report a rare case of syphilitic meningomyelitis presenting with visceral crisis and possessing characteristic imaging findings. PATIENT CONCERNS: The patient, a 50-year-old woman, complained of pain in the upper abdomen and back. She then developed numbness in both lower extremities and weakness in the left lower limb. DIAGNOSIS: Magnetic resonance imaging (MRI) of the spinal cord revealed the candle guttering sign and irregular enhancement at the T6 level. Rapid plasma reagin test of the cerebrospinal fluid yielded a titer of 1:8. Thus, the patient was diagnosed with syphilitic meningomyelitis. INTERVENTIONS: She was treated with ceftriaxone and dexamethasone after the failure of penicillin treatment. OUTCOMES: She could perform the activities of daily living, and her pain completely disappeared. LESSONS: A patient with syphilitic meningomyelitis can present with visceral crisis caused by the involvement of the posterior nerve roots or the posterior horn, which usually occurs in patients with tabes dorsalis. Considering the non-specific symptoms and MRI features, we should be aware that abdominal pain may be a symptom of myelopathy, and syphilitic meningomyelitis ought to be taken into account in a patient with longitudinally extensive myelitis.

Tabetic arthropathy. A report of 43 cases.

Destructive tabetic arthropathy (TA) has become rare in the course of syphilis because of early diagnosis and treatment. TA is difficult to manage because of the severity of the handicap and the absence of a specific treatment. We describe the clinical, biological, and radiological characteristics of TA. In this paper, we performed a retrospective study of 24 patients with TA from 1983 to 2003. Inclusion criteria were typical radiological findings and positive syphilitic serology in blood and/or synovial fluid and/or cerebrospinal fluid. Included in the study were 15 men and 9 women, their mean age was 53.71+/-12.25 years, and the delay of diagnosis was 36.83+/-53.03 months. Thirteen patients (54.2%) had a known primary syphilitis. In the studied cases, 43 of the patients' joints were involved, which concerned knees, hips, the spine, and ankles in 91.66, 8.33, 8.33, and 4.16% of cases, respectively. TA was bilateral in 62.5% and multifocal in 8.3%. The neurological exam found signs suggesting tabes dorsalis in seven cases. The osteoarticular exam showed an abnormal range of mobility (n=25), hydarthrosis, and articular deformation (n=17). Syphilitic serology tests were positive in synovial fluid, cerebrospinal fluid, and blood in 12 (50%), 8 (33.33%), and 24 (100%) cases, respectively. Radiological exam showed atrophic and hypertrophic forms. The frequency and severity of TA in our study may be explained by the frequency of atypical forms of syphilitis and the absence of penicillin in Morocco in the 1950s.

Tibial nerve SEPs localized the lesion site in a patient with early tabes dorsalis.

There is controversy regarding the initial pathology of tabes dorsalis. In a patient with early tabes dorsalis, tibial nerve somatosensory evoked potentials elicited normal P15, a delayed traveling peak in the lumbar bipolar leads, and absent subsequent components. Based on the comparison with normative data and stimulation at different intensities, the authors conclude that only the slower conducting antidromic motor volleys are preserved, whereas the dorsal root is damaged at its distal end.

Tabes dorsalis progressing to general paresis after 20 years despite routine penicillin therapy.

A man with a history of treatment for early syphilis presented with tabes dorsalis. Despite receiving a course of penicillin accepted as adequate by the World Health Organisation the illness progressed to tabo-paresis after 20 years. Reinfection cannot be excluded.

Tabes dorsalis with sudden onset of paraplegia.

A case is presented of tabes dorsalis with spinal gumma producing collapse of the L5 vertebra followed by paraplegia.

Neurosyphilis, or chronic heavy metal poisoning: Karen Blixen's lifelong disease.

BACKGROUND: Since the 1490s, the treatment of syphilis has consisted of heavy metals--first mercurial and later arsenic and bismuth preparations. Tabes dorsalis, as described by Duchenne in the 1850s, is made up of various characteristic neurologic symptoms. "Gastric crises," sudden stabbing pains followed by vomiting and diarrhea, was originally included by Duchenne, but later, syphilologists disputed its relevance to syphilis. Poisoning by heavy metals, including mercury, may produce similar pain reactions and tabes-like neurologic symptoms. METHODS: According to an earlier published pathography, the Danish author Karen Blixen (1885-1962), also known under the pseudonym Isak Dinesen, suffered from a lifelong disease described as tabes dorsalis. She got syphilis in 1914 and took mercury pills for a year, after which she experienced a severe mercurial intoxication. The Wassermann reaction (WR) in peripheral blood was positive only once, in 1915, before treatment with arsphenamine (Salvarsan), which she received during hospitalization in Copenhagen in 1915 to 1916. Her spinal fluid was examined several times from 1915 to 1956. Apart from an increased number of cells in 1915, the fluid remained unremarkable and the WR was always negative. RESULTS AND CONCLUSIONS: It was postulated that her illness, ending with a cachectic state, was the result of heavy metal poisoning from the various treatments and not a monosymptomatic tabes dorsalis with negative serology.

Efficacy of baclofen in trigeminal neuralgia and some other painful conditions. A clinical trial.

Baclofen (beta-4-chlorophenyl-gamma-aminobutyric acid) shows analgesic properties in rats and resembles carbamazepine and phenytoin in its effects on the spinal trigeminal nucleus of cats. We have, therefore, conducted a clinical trial in 25 subjects, 16 suffering from trigeminal neuralgia, and 9 patients were affected by different painful conditions such as postherpetic neuralgia, tabes dorsalis, postarachnoid radiculitis. 5 of the former groups were refractory to or unable to tolerate carbamazepine. Baclofen has significantly exhibited analgesic efficacy: all groups, as a whole, were improved by 68.61%. These results substantiate that baclofen is useful in the treatment of trigeminal neuralgia and other painful conditions.

Cauda equina compression due to tabetic arthropathy of the spine.

A case of tabetic neuroarthropathy of the lumbar spine causing cauda equina compression with paraplegia and retention of urine is described. The literature is reviewed and the role of surgery in such cases is discussed.