Neurosyphilis as a difficult problem in daily clinical practice – case report

Introduction . Syphilis still represents an important clinical problem. Involvement of the nervous system is one of the major features of late syphilis, but may also occur in early syphilis.

Objective . To present a case of neurosyphilis in relation to the current problems of diagnostics and therapy of Treponema pallidum infection.

Case report . We present a 31-year-old woman with neurosyphilis. At the beginning the patient was treated with erythromycin, and twelve months later, because of insufficient decrease of titre of syphilis tests in the serum, with doxycycline. Despite the second therapy the titres of syphilis tests remained high and therefore after another nine months the patient was referred to our department for further diagnostics and treatment. Because of the long course of the disease, high titres of syphilis tests in the serum and abnormalities in neurological examination (hypoaesthesia below the Th8 level, foot clonus and hyporeflexia in lower extremities) T. pallidum neuroinfection was suspected and cerebrospinal fluid was collected. The serological examination of cerebrospinal fluid revealed positive treponemal tests (FTA 1 : 10, TPHA ++), while VDRL was negative. Based on the whole clinical presentation and laboratory abnormalities, neurosyphilis was diagnosed and therapy with crystalline penicillin followed by procaine penicillin was performed.

Conclusions . Neurosyphilis is characterized by rich symptomatology and its diagnosis based only on clinical manifestation can be very difficult; particularly subtle symptoms may be easily overlooked. Therefore, evaluation of cerebrospinal fluid is necessary in all questionable patients in order to establish a correct diagnosis.