[Fast-evolving cognitive impairment: a home-based diagnosis]. / Troubles neurocognitifs d'évolution rapide.

Syphilis is a sexually transmitted disease which incidence increased over the last 10 years in Switzerland. The clinical and neurocognitive manifestations observed in case of symptomatic neurosyphilis can be very heterogeneous and can mimic neurocognitive disorders of other origins. This article discusses the diagnostic and management pitfalls in an older patient whose diagnosis of neurosyphilis was initially suspected during a home visit.

La syphilis est une maladie à transmission sexuelle dont l'incidence est en constante augmentation ces 10 dernières années en Suisse. Les manifestations cliniques et neurocognitives observées en cas de neurosyphilis symptomatique sont très hétérogènes et peu spécifiques, pouvant mimer des troubles neurocognitifs d'autre origine. Cet article discute des écueils diagnostiques et de prise en charge d'un patient âgé chez lequel un diagnostic de neurosyphilis a été évoqué lors d'une visite à domicile.

Chemokine Ligand 13 (CXCL13) in Neuroborreliosis and Neurosyphilis as Selected Spirochetal Neurological Diseases: A Review of Its Diagnostic Significance.

Neuroborreliosis (NB) and neurosyphilis (NS) are abnormal conditions caused by spirochetal bacteria which affect the nervous system. Diagnosis of neuroborreliosis and neurosyphilis is determined by clinical examination of visible symptoms, serum and cerebrospinal fluid (CSF) analysis, and serological detection of antibodies against Borrelia burgdorferi sensu lato and Treponema pallidum, respectively. Establishing a diagnosis may sometimes pose a number of diagnostic difficulties. A potential role of chemokine ligand 13 (CXCL13) as an accurate diagnostic biomarker of intrathecal inflammation has been suggested. In this review, we focused on changes in serum and cerebrospinal fluid concentration of chemokine ligand 13 in selected spirochetal neurological diseases neuroborreliosis and neurosyphilis reported in the available literature. We performed an extensive search of the literature relevant to our investigation via the MEDLINE/PubMed database. It has been proven that CXCL13 determination can provide rapid information regarding central nervous system inflammation in patients with selected spirochetosis. We described that neuroborreliosis and neurosyphilis are associated with an elevated CXCL13 concentration, mainly in the cerebrospinal fluid. Moreover, literature data suggest that CXCL13 determination is the most interesting additional marker for diagnosis and monitoring of neuroborreliosis and neurosyphilis thanks to its high sensitivity. Based on these published findings, we suggest that CXCL13 has high diagnostic utility and may be applied in laboratory diagnostics as a potential diagnostic marker in human spirochetal neurologic diseases.

Neurosyphilis prevalence at a Portuguese stroke unit care.

INTRODUCTION: Syphilis is a systemic human disease which is caused by infection with the spirochete Treponema pallidum. It is spread worldwide, and there has recently been an increase in its incidence. Neurosyphilis (NS) can have a variety of presentations; meningovascular NS is a specific affection of the Treponema which occurs in an early stage after the primary infection, causing an inflammatory arteriopathy which may result in an ischemic stroke. As a rare manifestation of syphilis, there are few prevalence and epidemiological studies, and data are almost non-existent. The objective of this study is to analyse the prevalence of meningovascular NS in a stroke unit in a tertiary hospital. METHODS: A descriptive retrospective study was carried out over a period of 44 months in a stroke unit. All patients admitted had neurological symptoms compatible with a vascular event, and routine blood tests including infectious screening were performed. Those with positive test results for syphilis were identified and proceeded to lumbar puncture to CSF cytochemical analysis and VDRL. NS was categorized as confirmed or probable (using CDC criteria). RESULTS: A total of 525 patients were admitted, and 62.53% were submitted to a routine screening for syphilis. A total of 309 patients (95.67%) revealed a negative screening; 12 patients (3.72%) had a positive syphilis serology. Among the 12 patients with positive screening, a single case of NS (0.31%) was identified. CONCLUSION: We observed a low prevalence of NS (0.31%), but this result was surprisingly higher than what was expected in an elderly population.

Frequency of Treponema pallidum invasion into cerebrospinal fluid in primary or secondary early-stage syphilis.

Frequency of Treponema pallidum invasion into cerebrospinal fluid (CSF) has not been clear at this present. Since it is impossible to culture T. pallidum in vitro at this present, we need molecular based-approach to detect it in CSF. Additionally, neurosyphilis is usually a late sequela, however it might result in asymptomatic neurosyphilis even at primary or secondary syphilis. This study was to reveal the frequency of T. pallidum invasion into CSF especially at primary or secondary syphilis with polymerase chain reaction (PCR) test. All patients were visited the Aichi Medical University Hospital or Izumi ladies' clinic between 2016 and 2017. Clinical CSF samples were collected from patients with early and late stages of syphilis. The PCR was done using primers targeting the tpN47gene. CSF samples were collected from 9 patients (4 patients with primary syphilis, 3 with secondary syphilis, and 1 early latent syphilis and 1 with late latent syphilis). PCR showed positive reaction in 2 of 7 (28.6%) primary and secondary syphilis patients, in 1 of 1 (100%) early latent syphilis patients, and in 1 of 1 (100%) late latent syphilis patients. Despite its lack of sensitivity for use alone as a diagnostic test, this PCR test should be preferred for the diagnosis of neurosyphilis. Because, T. pallidum was detected in the 28.6% CSF of patients at primary and secondary syphilis, which indicated that they invade the central nervous system from the early stages of infection. However, studies in a larger population are required to confirm these preliminary results.

Novel predictors of neurosyphilis among HIV-negative syphilis patients with neurological symptoms: an observational study.

BACKGROUND: Known predictors of neurosyphilis were mainly drawn from human immunodeficiency virus (HIV)-infected syphilis patients, which may not be applicable to HIV-negative populations as they have different characteristics, particularly those with neurological symptoms. This study aimed to identify novel predictors of HIV-negative symptomatic neurosyphilis (S-NS). METHODS: From June 2005 to June 2015, 370 HIV-negative syphilis patients with neurological symptoms were recruited, consisting of 191 S-NS patients (including 123 confirmed neurosyphilis and 68 probable neurosyphilis patients) and 179 syphilis/non-neurosyphilis (N-NS) patients. Clinical and laboratory characteristics of S-NS were compared with N-NS to identify factors predictive of S-NS. Serum rapid plasma reagin (RPR), Treponema pallidum particle agglutination (TPPA), and their parallel testing format for screening S-NS were evaluated. RESULTS: The likelihood of S-NS was positively associated with the serum RPR and TPPA titers. The serum TPPA titers performed better than the serum RPR titers in screening S-NS. The optimal cut-off points to recognize S-NS were serum RPR titer ≥1:4 and serum TPPA titer ≥1:2560 respectively. A parallel testing format of a serum RPR titer ≥1:2 and serum TPPA titer ≥1:1280 screened out 95.8% of S-NS and all confirmed cases of neurosyphilis. S-NS was independently associated with male sex, serum RPR titer ≥1:4, serum TPPA titer ≥1:2560, and elevated serum creatine kinase. Concurrence of these factors increased the likelihood of S-NS. CONCLUSIONS: Quantitation of serum TPPA is worthwhile and performs better than serum RPR in screening S-NS. Serum RPR, serum TPPA, male sex, and serum creatine kinase can predict S-NS. Moreover, patients with both a serum RPR titer <1:2 and a serum TPPA titer <1:1280 have a low probability of S-NS, suggesting that it is reasonable to reduce lumbar punctures in such individuals.

Neurological manifestations of HIV-AIDS at a tertiary care institute in North Eastern India.

BACKGROUND: The nervous system is among the most frequent and serious targets of human immunodeficiency virus (HIV) infection. The infection usually occurs in patients with profound immunosuppression. In 10 - 20% of the patients, the presence of a neurological disease is the first manifestation of symptomatic HIV infection. AIMS AND OBJECTIVE: Despite the wide prevalence of neurological manifestations in HIV, there is no study examining the clinical manifestations of this disease in the resource- limited communities from north-eastern parts of India. To characterize the neurological involvement in patients with HIV infection at a tertiary care institute in northeast India, we studied various neurological presentations of HIV. SETTING AND DESIGN: This was a retrospective observational study done at a tertiary care institute in northeast India over a period of 6 years from August 2008 to September 2014. MATERIAL AND METHODS: A total of 91 HIV seropositive patients of both genders, aged >18 years, showing clinical evidence of central nervous system (CNS) involvement, and admitted in a tertiary care institute were included. Their clinical manifestations, laboratory investigations, and imaging were studied. RESULT: Tuberculous meningitis was the most common presentation as secondary CNS illness (43.9%), followed by cryptococcal meningitis (14.2%) and cerebrovascular accidents (5.49%). Furthermore, 6.59% had neurosyphilis, 6.59% had acquired immune deficiency syndrome (AIDS) - associated dementia, and peripheral neuropathy occurred in 16.4% of the patients. Headache was the most common neurological symptom seen in 25% of the patients. Seizures were noted in 25% of the pateints. CD4 was significantly low in most of the patients with progressive multifocal leukoencephalopathy, HIV associated encephalopathy (HAD) and cryptococcal meningitis compared with other neurological manifestations. CD4 counts in tuberculous meningitis and HAD were 110.3/µl and 95/µl, respectively. CONCLUSION: CNS tuberculosis was the most common secondary infection seen in HIV patients followed by cryptococcal meningitis. A high index of clinical suspicion of neurological involvement in HIV patients helps in the early diagnosis and early institution of specific treatment, which in turn decreases the morbidity and mortality considerably.

Mobilizing Clouston in the colonies? General paralysis of the insane at the Auckland Mental Hospital, 1868-99.

This article examines the diagnosis of general paralysis of the insane (GPI) at the Auckland Mental Hospital, New Zealand, between 1868 and 1899, and changes in the identified causes of this condition. It argues that despite long-standing evidence citing the role of syphilis, asylum doctors working in New Zealand were as reluctant as their English and Scottish colleagues to blame syphilis alone for GPI. It also argues that although syphilis became a more popular cause in the aetiology of GPI by the end of the nineteenth century, medical and non-medical sources continued to cite other causes for GPI.

[Treponema pallidum subspecies pallidum -- the causative agent of neurosyphilis]. / Treponema pallidum, subspecies pallidum - puvodce neurosyfilis.

Neurosyphilis is defined as infection of central nervous system by Treponema pallidum subspecies pallidum. Neurosyphilis can develop at any stage after initial infec-tion and is reflected in laboratory results. The pathogenesis of neurosyphilis is similar to that of classical form of syphilis. Individuals with persistent abnormalities in the cerebrospinal fluid are at risk of the development of clinical manifestations. Proper understanding of particular forms of neurosyphilis for differential diagnosis is important to determine potential risk of the development of progressive disease in neurology.

LncRNA-ENST00000421645 promotes T cells to secrete IFN-γ by sponging PCM1 in neurosyphilis.

Aim: Neurosyphilis patients exhibited significant expression of long noncoding RNA (lncRNA) in peripheral blood T lymphocytes. In this study, we further clarified the role of lncRNA-ENST00000421645 in the pathogenic mechanism of neurosyphilis. Methods: lncRNA-ENST00000421645 was transfected into Jurkat-E6-1 cells, namely lentivirus (Lv)-1645 cells. RNA pull-down assay, flow cytometry, RT-qPCR, ELISA (Neobioscience Technology Co Ltd, Shenzhen, China) and RNA immunoprecipitation chip assay were used to analyze the function of lncRNA-ENST00000421645. Results: The expression of IFN-γ in Lv-1645 cells was significantly increased compared to that in Jurkat-E6-1 cells stimulated by phorbol-12-myristate-13-acetate (PMA). Then, it was suggested that lncRNA-ENST00000421645 interacts with PCM1 protein. Silencing PCM1 significantly increased the level of IFN-γ in Lv-1645 cells stimulated by PMA. Conclusion: This study revealed that lncRNA-ENST00000421645 mediates the production of IFN-γ by sponging PCM1 protein after PMA stimulation.

Lay abstract The mechanisms underlying Treponema pallidum (a type of bacterium that causes syphilis) invasion into the CNS have not yet been established. In this study, we further clarified the role of long noncoding RNA (lncRNA) in the pathogenic process causing nerve damage. The results suggested that lncRNA-ENST00000421645 interacts with an important protein named PCM1. Suppressing the expression of PCM1 significantly increased the level of IFN-γ cytokines (substances secreted by immune cells that effect other cells) with an increased level of lncRNA-ENST00000421645 when immune cells were stimulated by phorbol-12-myristate-13-acetate a specific activator of the PKC signaling enzyme involved in gene transcription pathways. This study revealed that lncRNA-ENST00000421645 mediates the production of IFN-γ by interacting with PCM1 protein.

[Neurosyphilis revealed by a multiple cranial neuropathy: magnetic resonance imaging findings]. / Neurosyphilis révélée par une atteinte multiple des nerfs crâniens: apport de l'imagerie par résonance magnétique nucléaire.

INTRODUCTION: We report the magnetic resonance imaging (MRI) findings in a case of neurosyphilis revealed by the involvement of two cranial nerves. CASE REPORT: A 41-year-old man developed a right cochleovestibular and left trigeminal neuropathy, associated with high serum titers of VDRL and TPHA, high titers of TPHA in the cerebrospinal fluid (CSF) and several CSF oligoclonal IgG bands. On MRI, hypertrophy and gadolinium contrast enhancement of these cranial nerves were associated with several supratentorial cortical nodules surrounded by marked cerebral edema, corresponding to syphilitic gummas. One of these cortical nodules was biopsied. Microscopic examination showed lesions of meningoencephalitis with necrosis and granulomatous vasculitis. After penicillin therapy, the serum VDRL titers and the MRI abnormalities disappeared, a partial clinical recovery was observed and a significant reduction of the serum TPHA titers was found. DISCUSSION: Such MRI abnormalities are not specific and can be observed in various tumoral, auto-immune and infectious diseases. They can also mimic neurofibromatosis type II. Cranial nerve involvements in neurosyphilis can result from nerve inflammation in basal meningitis, nerve ischemia in meningovasculitis or from compression by an adjacent gumma. In our case, the cranial neuropathy was related to a mixed meningovascular and parenchymatous form of neurosyphilis.

[Neurosyphilis: A retrospective study of 13 cases at Strasbourg University Hospital]. / La neurosyphilis, étude rétrospective de 13 cas survenus aux hôpitaux universitaires de Strasbourg.

OBJECTIVE: After a decade of constant decline, the number of syphilis cases has been steadily increasing since the 2000s, particularly in HIV infected patients. Neurosyphilis is a rare manifestation of this sexually transmitted disease for which we performed a retrospective study and analyzed clinical manifestations. PATIENTS AND METHODS: We reviewed retrospectively all the neurosyphilis cases admitted to Strasbourg University Hospital between 2004 and 2014. We included and analyzed 13 patients admitted during this period who met the diagnostic criteria for neurosyphilis. RESULTS: Nine of 13 patients had isolated visual manifestations; three (23.1%) experienced posterior uveitis, two (15.4%), panuveitis, and 4 (30.8%) had papillitis. Out of five patients (38.5%) who were HIV positive, three (60%) had a CD4 cell count above 400/mm3 at the time of diagnosis of neurosyphilis. All patients received parenteral penicillin G or cephalosporin, and 5/13 (38.5%) received systemic corticotherapy. CONCLUSION: Ophthalmologists appear as key players in the identification, management and follow-up of neurosyphilis, since ocular findings are key diagnostic features in these patients.

Meningovascular syphilis after 'appropriate' treatment of primary syphilis.

Meningovascular syphilis developed in a patient two years after the treatment of primary syphilis with a single intramuscular injection of 2.4 million units of penicillin G benzathine as recommended by the Centers for Disease Control. Although it could not be established with certainty whether this infection represented a reinfection or a treatment failure, the case emphasizes the necessity for serologic follow-up examination in all patients treated for primary syphilis.

Association of Interleukin-10 promoter polymorphisms with neurosyphilis.

Interleukin 10 (IL-10) is a potent anti-inflammatory cytokine. Increased production of IL-10 has been found in late syphilis, presumably creating favorable conditions for bacteria persistence. Single-nucleotide polymorphisms (SNPs) within the promoter of IL-10 gene have been found to influence IL-10 production. We investigated whether SNPs in the IL-10 gene promoter are associated with cerebrospinal fluid (CSF) levels of IL-10 and neurosyphilis. Polymorphisms in the gene for IL-10 (G→A mutation at the position -1084 and C→A mutation at the position -592) were sought in 35 patients with syphilis and 24 healthy volunteers. CSF examination (i.e. routine laboratory tests and IL-10 levels) was performed in all syphilis patients. Neurosyphilis was defined as reactive CSF VDRL test or CSF white blood cells⩾5/µL and CSF protein concentration⩾45mg/dL. Overall, 31% of patients with syphilis had neurosyphilis. CSF IL-10 levels were significantly higher in patients with neurosyphilis when compared to those with syphilis but not neurosyphilis. -1082 GG and -592 CC genotypes were significantly associated with higher CSF IL-10 levels. Moreover, these genotypes were found to be more frequent in individuals with neurosyphilis in comparison to those without neurosyphilis. Anti-inflammatory immune response seems to be important in pathogenesis of neurosyphilis. Our data suggest that host-related factors, such as SNPs of immune regulatory genes may influence the susceptibility to neurosyphilis.

Neurosyphilis.

PURPOSE OF REVIEW: This article reviews the etiology, clinical manifestations, diagnosis, and treatment of neurosyphilis, with a focus on issues of particular relevance to neurologists. RECENT FINDINGS: The number of cases of infectious syphilis in the United States has steadily increased since 2000. The highest rates are among men who have sex with men, and approximately half of these individuals are infected with human immunodeficiency virus (HIV). Neurosyphilis is a serious complication of syphilis that can develop at any time in the course of syphilis. Two neuroimaging patterns should alert the neurologist to a diagnosis of neurosyphilis: cerebral gummas, which are dural-based lesions that can mimic meningiomas, and medial temporal lobe abnormalities that can mimic herpes encephalitis. Penicillin G is the recommended treatment for neurosyphilis, but ceftriaxone may be an acceptable alternative. SUMMARY: The diagnosis of neurosyphilis can be challenging. A sound understanding of the clinical manifestations and the strengths and limitations of diagnostic tests are essential tools for the neurologist.

[Clinical course and serial brain MRI findings in a patient with Lissauer form of general paresis].

A 60-year-old man presented with progressive dementia and generalized convulsions. An initial MRI revealed a widespread high-intensity area with a mass effect in the right frontal and temporal lobes on T2-weighted images. Findings on digital subtraction angiography were normal. Serum and CSF tests showed high titers of antibodies to Treponema pallidum, which helped to distinguish neurosyphilis from glioma. He was initially treated with penicillin injection; however, it caused liver dysfunction and penicillin was switched to erythromycin. Even after antibiotic therapy for 2 months, his dementia did not improve. He underwent brain MRI four times during the treatment course, and they showed steady progression of brain atrophy in the right hemisphere. Taking these findings together, we diagnosed Lissauer form of general paresis. To the best of our knowledge, this is the first case of Lissauer form of paretic neurosyphilis, in which the progression of brain atrophy was clearly demonstrated on MRI.

Prevalence of neurosyphilis at Government Rajaji Hospital, Madurai, India.

Forty patients (34 males and 6 females) with neurological complaints/manifestations and with a past history of multiple sexual partners attending the Government Rajaji Hospital, Madurai, India between April 1992 and October 1992 were investigated for neurosyphilis. Metabolic disorders, hypertension, ischaemic heart disease, arrhythmias and trauma were excluded. Seven males (17.5%) were found to have neurosyphilis. The youngest was 26 years old and the oldest was 47. All were married and of low socioeconomic background. Meningovascular syphilis was the predominant presentation (6:1). Associated cardiovascular involvement was noticed in one of the cases. There was no associated HIV infection in these cases. The incidence is higher than previous reports from this centre.

[Syphilitic uveitis and human immunodeficiency virus infection]. / Uvéite syphilitique et infection par le virus de i'immunodéficience humaine.

Ocular syphilis is rare in human immunodeficiency virus infected individuals. We think that syphilis should be considered in evaluating such patients presenting with uveitis. Most often, ocular syphilis includes retinitis associated with anterior or posterior uveitis, sometimes with optic neuritis. Concurrent neurosyphilis is frequent and may be more aggressive; it may progress more rapidly and cause more atypical signs than in patients without human immunodeficiency virus infection. This suggests the need for lumbar puncture in the evaluation of coinfected patients. The standard serological tests for syphilis (in blood and cerebrospinal fluid) may be nonreactive in human immunodeficiency virus seropositive patients. It may be because of the alteration of immunologic response of such patients. All coinfected patients with human immunodeficiency virus and syphilis should be treated with high-dose intravenous penicillin G sodium as recommended for neurosyphilis. We describe two human immunodeficiency virus infected patients with ocular syphilis and neurosyphilis.

[Clinical picture of early syphilis in patients with HIV infection in the light of literature data]. / Obraz kliniczny kily wczesnej u osób zakazonych retrowirusem hiv w swietle danych z pismiennictwa.

A literature survey is presented concerning the clinical pattern of early syphilis in subjects infected with HIV. The course of syphilis infection in HIV-positive subjects differs often from the usual one, the clinical picture may be that of the so called malignant syphilis with early development of syphilitic lesions in the central nervous system and involvement of the visual system; Serological reactions differ also, they may give negative results or may appear with delay, sometimes high titres of these reactions are found.