Elsevier

Asian Journal of Psychiatry

Volume 40, February 2019, Pages 103-106
Asian Journal of Psychiatry

Short communication
Neurosyphilis presenting as rapidly progressive psychosis & dementia – A forgotten entity

https://doi.org/10.1016/j.ajp.2019.02.010Get rights and content

Highlights

  • What is Known.

  •  Neurosyphilis is less recognised neurological complication of syphilis in the recent years due to effective use of antibiotics.

  •  Infective causes form part of the treatable cause of rapidly progressive dementia.

  • What is New.

  •  Though, neurosyphilis is rare, it needs to be recognised as one of the causes of rapidly progressive dementia.

  •  When clinical suspicion is high and CSF VDRL is negative, serum TPHA which is more specific needs to be tested to rule out neurosyphilis.

  •  CSF VDRL can be negative in cases of Neurosyphilis in view of low sensitivity of the test.

  •  Penicillin is the drug of choice for Neurosyphilis. Patients of Neurosyphilis respond better to Penicillin than other antibiotics. Hence, it becomes important to treat with Penicillin than newer antibiotics.

Abstract

Syphilis is described often as great imitator due to its varied clinical manifestations. Neurosyphilis a tertiary form of syphilis can present in the form of meningitis, meningovascular syphilis with strokes and in advanced stage as general paralysis of insane. Paretic stage of neurosyphilis presents with progressive psychiatric and cognitive impairment. The cognitive impairment can range from subtle to advanced dementia. This is the rationale for routing screening for syphilis in evaluation of dementia. There are few reports on neurosyphilis presenting as rapidly progressive dementia. We report a case of neurosyphilis presented with rapidly progressive dementia along with psychotic symptoms.

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

None.

Acknowledgement

None.

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