Title : The great masquerader strikes again. Neurosyphilis presenting as general paresis of insane and stroke like syndrome: A case report

Abstract:

Introduction:
Syphilis, often considered “the Great Imitator”, due to its frequent atypical presentation with clinical phenotypes ranging from meningitis, meningovascular syphilis with strokes and in advanced stages as “general paralysis of the insane” to simple chancres. We present a case report of a young male with neurosyphilis presenting with a stroke-like picture and dementia.

Case report:
32-year-old unmarried gentleman, IT professional, known case of RHD and ankylosing spondylitis, presented with fever, slurring of speech, stiffness of limb, emotional lability, and memory impairment. Examination revealed punched out ulcers over the tongue and genital warts. The patient attenders did not report any promiscuous sexual relations. Neurological examination revealed bilateral upper and lower limb hypertonia with exaggerated DTRs- ankle and patellar clonus. He had a loud P2 and early diastolic murmur on auscultation. Neuroimaging was suggestive of right midbrain infarct. Due to the presence of cutaneous lesions he was tested for STIs and was positive for hepatitis-B and serum TPHA. CSF was positive for VDRL and TPHA. A diagnosis of tertiary syphilis with general paresis of insane with vasculitic stroke was made. He was treated with Benzathine penicillin and oral glucocorticoids, SAPT and statins, antipsychotics for cognitive impairment and tenofovir alafenamide for hepatitis-B. He was discharged on day 15 with significant neurological improvement.

Discussion:
This case underscores the importance of early diagnosis of neurosyphilis, and initiation of antibiotics. It also emphasises 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 high index of suspicion.

Biography:

Dr. Sukesh Gerard did his medical school training and residency at the St John’s Medical College and Hospital, Bangalore and graduated as MD in 2023. He then joined the department of Internal Medicine. He has since worked in the department over the last two years and was part of the research mentorship for undergraduates’ team. He has worked with several subspecialities and closely with the Infectious Disease Unit at the Institute and is part of the team analyzing the prevalence of Vaccine Preventable Infections in the state, a joint effort by the institute and the World Health Organization. He has several case reports detailing the rare presentations of multiple infectious diseases.