Acute hypophysitis and hypopituitarism in early syphilitic meningitis in a HIV-infected patient: a case report.

BACKGROUND: Sexually transmitted diseases and most notably syphilis-infections are rising amongst men who have sex with men. In HIV-co-infected patients, an accelerated clinical course of syphilis neurological involvement is known. CASE PRESENTATION: A 46 year old HIV-positive male patient came in to our emergency department in the late evening with acute fever, rapidly progressive cephalgia and photophobia. Palmar skin efflorescence was evocative of an active syphilis infection. A reactive Treponema pallidum particle agglutination (TPPA) assay with positive Treponema pallidum-specific IgG/IgM immunofluorescence as well as a highly reactive Veneral diseases research laboratory (VDRL) test confirmed the diagnosis. Liquor pleocytosis, liquor protein elevation and a highly positive VDRL test in cerebrospinal fluid (CSF) were interpreted in context of the clinical symptoms as neurosyphilitic manifestations within an early syphilis infection (stage II). Cranial nuclear magnetic resonance scans of the sella turcica, which were performed due to low thyroidea stimulation hormone (TSH) and thyroxin levels, showed signs of hypophysitis such as pituitary gland enlargement and inhomogeneous contrast enhancement. Advanced endocrine laboratory testing revealed hypopituitarism. Fourteen days of intravenous ceftriaxone treatment and levothyroxine- and hydrocortisone-substitution led to complete disappearance of all clinical symptoms. Two months later, nuclear magnetic resonance scan showed normal pituitary size and that the syphilis serology had normalized. CONCLUSION: We report to the best of our knowledge the first case of a HIV-positive patient with acute hypophysitis and hypopituarism due to early neurosyphilis infection. Ceftriaxone treatment and levothyroxine- and hydrocortisone-substitution led to the disappearance of all clinical symptoms. We strongly recommend to exclude syphilis infection in every clinical situation unclear in HIV-patients, especially when additional risk factors are known.

Analysis of lymphocyte subsets in HIV-negative neurosyphilis patients.

It is unclear how Treponema pallidum affects the immune response among various lymphocyte subsets in neurosyphilis patients with different clinical stages. In order to determine the immune response by T. pallidum infection, we detected the peripheral blood lymphocyte subsets among 14 asymptomatic neurosyphilis patients, 19 early neurosyphilis patients, 9 late neurosyphilis patients, and 50 healthy persons. The result indicated that the number of CD3+CD8+ lymphocytes was significantly higher in neurosyphilis patients than in the control group (χ(2) = 4.427, P = 0.035). The number of CD3+CD8+ lymphocytes was significantly higher in the asymptomatic neurosyphilis group than in the early neurosyphilis group, late neurosyphilis group, and control group (F = 4.644, P = 0.005). The number of NK cells was significantly lower in neurosyphilis patients than in the control group (χ(2) = 13.226, P = 0.000). The number of NK cells in neurosyphilis patients with different clinical stages was also lower than in the control group (F = 4.402, P = 0.006). The number of CD3+ lymphocytes, CD3+CD4+ lymphocytes, and B lymphocytes had no difference among the 4 groups. The results indicated that the progression of neurosyphilis may be related to the continued reduction in the number of NK cells and to the continued increase in CD3+CD8+ lymphocytes.

Optimal treatment for asymptomatic neurosyphilis.

In the pre-penicillin era, patients with asymptomatic neurosyphilis (ANS) were more likely to develop long-term neurological sequelae than those patients with normal cerebrospinal fluid (CSF). Although benzathine penicillin G cannot achieve treponemicidal levels in the CSF, decreased rates of neurological complications of syphilis and non-treponemal titre serological responses are usually observed after treatment with this antibiotic. We here a homosexual man with ANS successfully treated with benzathine penicillin G. This case suggests that reconsideration on the necessity of a lumbar puncture in HIV-infected patients with ANS is warranted.

Symptomatic and asymptomatic early neurosyphilis in HIV-infected men who have sex with men: a retrospective case series from 2000 to 2007.

BACKGROUND: The rise in serious complications of early syphilis, including neurosyphilis, particularly in those with HIV infection and in men who have sex with men (MSM), is of concern. OBJECTIVES: To review the manifestations and management of neurosyphilis in a population of HIV-infected MSM. METHODS: Retrospective review of patients with HIV and early neurosyphilis in three centres in Melbourne, Australia, in 2000-07. RESULTS: Eighteen male HIV patients met the criteria for diagnosis of early neurosyphilis. Thirteen patients (72.2%) had neurological symptoms: six with headache (33.3%), four with tinnitus (22.2%) and five with impaired vision (27.8%), and one patient each with ataxia, leg weakness and anal discharge with faecal incontinence. Five patients (27.8%) reported no neurological symptoms. All had serum rapid plasma reagin (RPR) titres ≥1:32 and all except one had cerebrospinal fluid positive for syphilis fluorescent treponemal antibodies-absorbed. After treatment with 14-15 days of 1.8 g intravenous benzylpenicillin 4-hourly, 12 of 17 patients (71%) demonstrated a four-fold drop in serum RPR titre over 6-12 months and were considered successfully treated. A rise in RPR was noted in three patients during the 12-month follow-up period, suggesting re-infection or recurrence. CONCLUSION: HIV-infected patients found to have syphilis either because of symptoms or by routine screening should be carefully assessed for neurological, ophthalmic and otological symptoms and signs. A low threshold for a diagnostic lumbar puncture to exclude the diagnosis of neurosyphilis enables appropriate administration and dose of penicillin for treatment, which appears successful in ~75% of cases.

Neurosyphilis manifesting with unilateral visual loss and hyponatremia: a case report.

BACKGROUND: Syphilis is called the chameleon of the diseases due to its variety of its clinical presentations, potentially affecting every organ of the body. Incidence of this ancient disease is once again on the increase worldwide. CASE PRESENTATION: We here report an unusual case of neurosyphilis manifesting with unilateral visual loss and hyponatremia. The patient also had primary syphilitic lesions and was concomitantly diagnosed with Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) infection. Treatment with ceftriaxone and prednisolone, completely resolved the hyponatremia and visual acuity was partially restored. CONCLUSION: Awareness of syphilis as a differential diagnosis is important as previously unreported presentations of neurosyphilis can arise, especially in HIV infected patients.

Metagenomic analyses of viruses in stool samples from children with acute flaccid paralysis.

We analyzed viral nucleic acids in stool samples collected from 35 South Asian children with nonpolio acute flaccid paralysis (AFP). Sequence-independent reverse transcription and PCR amplification of capsid-protected, nuclease-resistant viral nucleic acids were followed by DNA sequencing and sequence similarity searches. Limited Sanger sequencing (35 to 240 subclones per sample) identified an average of 1.4 distinct eukaryotic viruses per sample, while pyrosequencing yielded 2.6 viruses per sample. In addition to bacteriophage and plant viruses, we detected known enteric viruses, including rotavirus, adenovirus, picobirnavirus, and human enterovirus species A (HEV-A) to HEV-C, as well as numerous other members of the Picornaviridae family, including parechovirus, Aichi virus, rhinovirus, and human cardiovirus. The viruses with the most divergent sequences relative to those of previously reported viruses included members of a novel Picornaviridae genus and four new viral species (members of the Dicistroviridae, Nodaviridae, and Circoviridae families and the Bocavirus genus). Samples from six healthy contacts of AFP patients were similarly analyzed and also contained numerous viruses, particularly HEV-C, including a potentially novel Enterovirus genotype. Determining the prevalences and pathogenicities of the novel genotypes, species, genera, and potential new viral families identified in this study in different demographic groups will require further studies with different demographic and patient groups, now facilitated by knowledge of these viral genomes.

Clinical and magnetic resonance imaging findings of HIV-negative patients with neurosyphilis.

There have been no serial studies about neuroradiological findings of neurosyphilis in the literature. There have been only case reports concerning HIV negative patients with neurosyphilis. We present 8 HIV negative neurosyphilis patients two of whom are women. The mean age of the patients was 48 years+/-12.37. Five of the 8 patients had general paresis, two optic atrophy and one multiple cranial neuropathies. The CSF findings were quite similar in 6 of 8 patients. In half of the patients cranial MRI showed mild cerebral atrophy. Nonspecific hyperintense small foci in 3 patients are thought to be related to syphilis. Hyperintensity involving bilateral medial and anterior temporal regions more prominent on the left side was seen in one of the patients with general paresis. This finding may be due to cytotoxic edema associated with status epilepticus and may mimic herpes simplex and other limbic encephalitides. Though not typical, certain MRI findings guides for the diagnosis of neurosyphilis.

Neurosyphilis showing transient global amnesia-like attacks and magnetic resonance imaging abnormalities mainly in the limbic system.

We report a case of neurosyphilis with transient global amnesia (TGA)-like attacks on the first presentation. MRI abnormalities in bilateral limbic systems, including a few lesions in the basal ganglia and thalamus, were identified. Depression and dementia became apparent, accompanied by a high treponemal antibody titer and mild cortical atrophy. Antisyphilitic therapy brought about mild improvement, and the MRI abnormalities decreased.

Genetic analysis of wild polioviruses towards the eradication of poliomyelitis from the Western Pacific Region.

Since a laboratory network to eradicate poliomyelitis in the Western Pacific Region started in 1991, the Department of Virology II, National Institute of Infectious Diseases, has been functioning as a Regional Reference Laboratory. From 1992 to 1998, we examined 5453 stool samples collected from 3501 patients with acute flaccid paralysis in Cambodia, Vietnam, and Laos, and we isolated 392-type 1 and 10-type 3 wild polioviruses. As a result of the extensive immunization during this time in this area, the numbers of poliomyelitis cases by wild polioviruses have drastically decreased. In 1997, only nine type 1 wild polioviruses were isolated. Eight out of the nine cases were found in Cambodia, and one was in mid-Vietnam. Since then no wild polioviruses have been isolated in the Western Pacific Region for more than two years. A nucleotide sequence analysis of these 1997 isolates indicated that they all belonged to the same strain that has been prevailing in the Indochina area, suggesting the complete interruption of wild poliovirus transmission in the region.

Dual infective pathology in patients with cryptococcal meningitis.

Coinfection of the nervous system by two distinct nonviral organisms is uncommon and often undiagnosed. Medical teaching emphasizes that a single pathologic process should be sought; however, in the presence of severe immunocompromise this approach may not hold true. We describe seven HIV-1 seropositive patients with cryptococcal meningitis, three of whom had a proven nervous system infection with a second organism: concurrent tuberculous meningitis, a tuberculoma, and the first documented case of cryptococcal meningitis and neurosyphilis.