Short communicationNeurosyphilis presenting as rapidly progressive psychosis & dementia – A forgotten entity
Introduction
Neurosyphilis is known to result in severe cognitive impairment and psychiatric features. The psychiatric manifestations can range from depressive symptoms, elation, mania, hallucinations, and delusions to schizophrenia like illness (Stefani et al., 2013; Mahanta et al., 2015). The cognitive symptoms range from mild cognitive deficits in the form of errors in judgement, executive dysfunction, memory deficits with gradual progression to frank dementia. Neurological examination may be normal other than cognitive impairment or show abnormalities of pupil, tremors of face, limbs and reflex abnormalities (Marra, 2009). Following primary infection by the bacterium Treponema pallidum, the spirochetes enter the CSF early during the illness. It may get spontaneously cured by body immunity or remain asymptomatic. After many years of dormant state, it will present as meningovascular syphilis or parenchymatous syphilis (General paresis of insane or Tabes dorsalis). Tabes dorsalis presents with sensory ataxia, bowel and bladder dysfunction (Khan et al., 2014). Syphilitic dementia also called as dementia paralytica results in severe cognitive impairment especially among younger and middle aged. Though less frequent, neurosyphilis can present as rapidly progressive dementia (Stefani et al., 2013; Mahanta et al., 2015).
The prevalence of syphilis has reduced due to the usage of effective antibiotics. The earlier studies such as Oslo study elucidated the natural course and stages of syphilis (Gjestland, 1955). The same study reported that 9.4% of males and 5.0% of females developed symptomatic neurosyphilis. The prevalence of syphilis in the antibiotic era is 3.7 per 100,000 in the developed countries (Singh and Romanowski, 1999). A study from United States reported the prevalence as 0.84% (de Voux et al., 2018). Another landmark study by Rosahn and Black-Schaffer based on retrospective autopsy finding reported that among the clinically diagnosed syphilis cases, 8% had autopsy findings suggestive of neurosyphilis (Rosahn and Black-Schaffer, 1943).The prevalence reported from Indian studies ranges from 2.62% to 3.4% (Khan et al., 2014). In this case report we describe a middle aged gentleman with neurosyphilis presenting as rapidly progressive dementia along with psychiatric manifestations.
Section snippets
Case history
A 54-year-old married gentleman; farmer from rural background presented with complaints of hallucinatory behaviour and memory disturbances of six months duration. He also had emotional lability, geographical disorientation, speech disturbances and gait disturbances. Hallucinations in the form of trying to touch imaginary people, serving food to imaginary people, irritability and decreased sleep were also noticed. Personal history revealed tobacco use in the form of smoking in dependence pattern
Discussion
Neurosyphilis can present as rapidly progressive dementia either in meningovascular stage or in tabes dorsalis stage. In meningovascular stage the cognitive impairment is due to ischemic strokes presenting as vascular dementia or might also be due to hydrocephalus due to blockage of cerebrospinal fluid (CSF) flow (Abdool et al., 2018). In the paretic stage there will be direct invasion of spirochetes into brain parenchyma. Along with it, there will be lymphocytic infiltration into meninges,
Conclusion
Neurosyphilis is an uncommon, infectious cause of cognitive impairment in modern era. Neurosyphilis in later stage presents with various psychiatric symptoms and cognitive impairment. The current case highlights rare presentation of neurosyphilis as rapidly progressive dementia. The case also emphasise the importance of evaluating infective or treatable causes especially in young-onset or rapidly progressive dementia. A high degree of suspicion is required with serological testing in cases with
Financial disclosure
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Acknowledgement
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