Infarctus cérébral, infection VIH et syphilis méningovasculaire : étude de trois cas

doi:10.1016/j.neurol.2009.02.003

Revue Neurologique

Volume 166, Issue 1, January 2010, Pages 76-82

https://doi.org/10.1016/j.neurol.2009.02.003 Get rights and content

Résumé

Introduction

La syphilis peut entraîner des manifestations neurologiques multiples, dont une forme rare : la syphilis méningovasculaire. Nous rapportons les cas de trois patients ayant présenté un accident vasculaire cérébral en rapport avec une syphilis méningovasculaire et une infection par le VIH.

Observations

Trois hommes, âgés de 30, 31 et 41 ans, présentèrent un infarctus cérébral secondaire à une thrombose carotidienne interne dans deux cas et une sténose du tronc basilaire dans le troisième. L’étude du liquide céphalorachidien et les sérologies permirent de porter le diagnostic de syphilis méningovasculaire, associée à une infection par le VIH. Le reste du bilan étiologique exhaustif était normal.

Conclusion

La réémergence de la syphilis doit faire rechercher systématiquement une syphilis devant tout accident vasculaire cérébral du sujet jeune.

Abstract

Introduction

Various clinical manifestations can occur in syphilis, especially meningovascular syphilis. We report three cases of ischemic stroke related to meningovascular syphilis and HIV infection.

Case reports

Three men, aged 30, 31 and 41, presented typical neurologic deficit leading to the diagnosis of ischemic stroke. Radiographic investigations showed internal carotid thrombosis in two patients, and a basilar stenosis in the third. CSF analysis and blood samples revealed meningovascular syphilis associated with HIV infection. The other explorations were normal.

Conclusion

Due to the reemergence of syphilis, search for Treponema pallidum infection should be systematic in young stroke victims.

Introduction

La syphilis est une infection chronique multisystémique causée par une bactérie cosmopolite – le Treponema Pallidum. Elle a représenté pendant de nombreuses années l’une des principales causes de pathologie neurologique, et a été considérée comme la principale cause pour les accidents vasculaires cérébraux (AVC) du sujet jeune, jusqu’à l’avènement de l’ère des antibiotiques, permettant une diminution de l’incidence de cette pathologie. On assiste cependant depuis quelques années à une reémergence de cas de syphilis sur tous les continents. Parmi les conséquences les plus graves de la forme tertiaire de la maladie se trouvent celles liées à l’atteinte du système nerveux central, dont la forme méningovasculaire, parfois responsable de complications ischémiques cérébrales.

Nous rapportons les cas de trois patients hospitalisés en avril 2008 dans l’unité neurovasculaire du CHU de Nice, pour prise en charge d’un AVC ayant mené à la découverte d’une syphilis méningovasculaire (SMV).

Section snippets

Cas n^o 1

Un homme, âgé de 31 ans, droitier, hétérosexuel, se réveilla un matin avec une aphasie non fluente, et un déficit moteur du membre supérieur droit. Il présentait dans ses antécédents un psoriasis cutané non traité et un tabagisme actif (1 paquet par jour).

L’examen clinique initial notait un déficit moteur brachiofacial droit et des troubles phasiques non fluents (score NIHSS à 5).

L’IRM cérébrale réalisée en urgence montra un infarctus récent constitué, cortical et de petite taille, dans le

Discussion

Depuis les travaux de Heubner (1874), la syphilis a longtemps été considérée comme la principale étiologie d’AVC des sujets jeunes. L’avènement des traitements par la pénicilline à partir de 1946 a permis une réduction importante de l’incidence de la syphilis vénérienne et du système nerveux, faisant espérer par l’OMS une éradication future de la maladie (Chkili et al., 1989). Dans les années 1980, l’épidémie de l’infection par le VIH a cependant entraîné une résurgence de cas de neurosyphilis,

Références (26)

A. Bourazza et al.
Meningovascular syphilis: Study of five cases
Rev Neurol
(2008)
E.G. Clark et al.
The Oslo study of the natural course of untreated syphilis: an epidemiologic investigation based on a restudy of the Boeck-Bruusgaard material; a review andd appraisal
J Chron Dis
(1955)
P. Del Giudice et al.
Syphilis outbreak in southeast France
Ann Dermatol Venereol
(2006)
M. Revest et al.
Syphilitic aortis. Experience of an internal medicine unit
Rev Med Interne
(2006)
M.S. Aldrich et al.
Angiographic findings in a young man with recurrent stroke and positive fluorescent treponemal antibody (FTA)
Stroke
(1983)
N. Asdaghi et al.
The reemergence in Canada of meningovascular syphilis: 2 patients with headache and stroke
CMAJ
(2007)
V. Assuerus et al.
Ischémie cérébrale et infection par le virus de l’immunodéficience humaine
STV
(1995)
J.R. Berger et al.
Cerebrovascular disease in AIDS: a case-control study
AIDS
(1990)
E.J. Bloom et al.
Lupus anticoagulant in the acquired immunodeficiency syndrome
JAMA
(1986)
H. Blystad et al.
Syphilis outbreak in Noraway and Sweden among men who have sex with men 1998–2002
Euro Surveill
(2003)

F. Boue et al.

Lupus anticoagulant and HIV infection: a prospective study

AIDS

(1990)

T.C. Brightbill et al.

Neurosyphilis in HIV-positive and HIV-negative patients: neuroimaging findings

Am J Neuroradiol

(1995)

T. Chkili et al.

Manifestations neurologiques et psychiatriques de la syphilis cérébrale

EMC psychiatrie

(1989)

Cited by (13)

Ischemic strokes revealing neurosyphilis: Study of six (6) observations at the neurology Department of the University Hospital of Conakry
2023, eNeurologicalSci
In sub-Saharan Africa (SSA), stroke is a major public health problem and the etiological aspects are poorly studied and documented because of under-medicalization; the syphilitic etiology is rarely mentioned.
We performed a retrospective study of 472 patients hospitalized for ischemic stroke between 2016 and 2021 in the Neurology Department of the University Hospital of Conakry, confirmed by neuroradiological explorations (brain CT, MRI-Angio) and a biological workup including VDRL-TPHA serological reactions in blood and CSF.
Syphilitic etiology was retained for six (6) patients (4 men and 2 women) with a mean age of 43 years (extremes 36 and 49 years). The clinical picture was dominated by carotid syndromes: superficial and deep sylvian syndrome, anterior cerebral artery syndrome and vertebro-basilar syndromes and one case of lacunar syndrome.
The diagnosis was based on the positivity of serological reactions (VDRL-TPHA) in blood and cerebrospinal fluid (CSF) and the presence of a predominantly lymphocytic hypercellularity and a hyperproteinorachy in the CSF in the absence of any other etiology.
These neurological vascular syndromes consecutive to a cerebral treponematous attack are often the result of a still poorly conducted management of primary and secondary syphilis in our country.
Stroke and syphilis: A retrospective study of 53 patients
2018, Revue Neurologique
Citation Excerpt :
The frequency of seroconversion (SCV) is variously described in the literature as representing 11–14.9% of cases [3,4,14], compared with 10.3% of all our present neurosyphilis cases. Most of the cases described in the literature were younger than typical stroke patients [7,9,10] and, indeed, 50% of our patients were aged < 40 years. Our results are consistent with those described in the literature.
The aim of this study was to describe the clinical, biological and radiological characteristics of patients with syphilitic vasculitis, and to assess the outcome after treatment.
A retrospective review was carried out based on the records of patients with ischemic stroke, and reactive CSF TPHA and VDRL results. None of these patients showed symptoms of any other diseases or had received high doses of penicillin.
A total of 53 patients with stroke met the diagnostic criteria for syphilitic arteritis. Their average age was 41 ± 12 years. Nine patients had a history of genital ulcer (17%), and the median duration of illness after presenting a chancre was 8 [range: 1–14] years. A prodromal syndrome was seen in 27 patients (50.9%) and included changes in mental status in 14 patients (26.4%), seizures in 10 cases (18.9%), headache in eight (15.1%) and memory loss in seven (13.2%). Neurological events included focal motor deficits in 29 cases (54.7%), ataxia in 11 (20.8%) and movement disorders in 15 (28.3%). HIV serology was performed in 31 patients and proved negative in every case. Disease evolution was generally favorable: 12 patients (22.6%) were autonomous at the time of hospital discharge; 29 (54.7%) had partially recovered; and only seven (13.2%) still had signs of severe sequelae.
A diagnosis of syphilitic stroke should be suspected in young patients as a manifestation of syphilis, and tests for neurosyphilis should be routine in neurology departments to make a prompt diagnosis, thereby preventing psychological sequelae.
Infectious causes of stroke
2014, The Lancet Infectious Diseases
Citation Excerpt :
By contrast with typical stroke syndromes, strokes caused by meningovascular syphilis are preceded by a prodromal clinical course of weeks to months of a combination of headaches, malaise, personality changes, and emotional lability before the identifiable vascular syndrome.45 Findings from case series have reported stroke in the setting of HIV and syphilitic aortic disease.48 Reports of intracranial haemorrhage in neurosyphilis are rare.49
Most infectious pathogens have anecdotal evidence to support a link with stroke, but certain pathogens have more robust associations, in which causation is probable. Few dedicated prospective studies of stroke in the setting of infection have been done. The use of head imaging, a clinical standard of diagnostic care, to confirm stroke and stroke type is not universal. Data for stroke are scarce in locations where infections are probably most common, making it difficult to reach conclusions on how populations differ in terms of risk of infectious stroke. The treatment of infections and stroke, when concomitant, is based on almost no evidence and requires dedicated efforts to understand variations that might exist. We highlight the present knowledge and emphasise the need for stronger evidence to assist in the diagnosis, treatment, and secondary prevention of stroke in patients in whom an infectious cause for stroke is probable.
Neuroradiology - Images vs symptoms
2021, Neuroradiology - Images vs Symptoms
Neurosyphilis
2021, CONTINUUM Lifelong Learning in Neurology
Acute hemiplegia: Aetiology and outcome in Nigerian children
2020, Pan African Medical Journal

View all citing articles on Scopus

View full text

MémoireInfarctus cérébral, infection VIH et syphilis méningovasculaire : étude de trois casStroke, HIV and meningovascular syphilis: Study of three cases

Résumé

Introduction

Observations

Conclusion

Abstract

Introduction

Case reports

Conclusion

Introduction

Section snippets

Cas no 1

Discussion

Rev Neurol

J Chron Dis

Ann Dermatol Venereol

Rev Med Interne

Angiographic findings in a young man with recurrent stroke and positive fluorescent treponemal antibody (FTA)

Stroke

The reemergence in Canada of meningovascular syphilis: 2 patients with headache and stroke

CMAJ

Ischémie cérébrale et infection par le virus de l’immunodéficience humaine

STV

Cerebrovascular disease in AIDS: a case-control study

AIDS

Lupus anticoagulant in the acquired immunodeficiency syndrome

JAMA

Syphilis outbreak in Noraway and Sweden among men who have sex with men 1998–2002

Euro Surveill

Lupus anticoagulant and HIV infection: a prospective study

AIDS

Neurosyphilis in HIV-positive and HIV-negative patients: neuroimaging findings

Am J Neuroradiol

Manifestations neurologiques et psychiatriques de la syphilis cérébrale

EMC psychiatrie

Mémoire
Infarctus cérébral, infection VIH et syphilis méningovasculaire : étude de trois casStroke, HIV and meningovascular syphilis: Study of three cases

Cas n^o 1