A 26-year-old woman who was positive for the human immunodeficiency virus presented with focal motor seizures, a CD4 cell count of 238 per cubic millimeter, a rapid plasma reagin titer of 1:32, and a positive test for serum treponemal IgG antibody. One year earlier, she had received a single dose of intramuscular penicillin (dose and rapid plasma reagin titer not known). On admission, gadolinium-enhanced T 1 -weighted magnetic resonance imaging showed multiple syphilitic cerebral gummas (Panels A and B). Studies of cerebrospinal fluid revealed a white-cell count of 20 per cubic millimeter (92 percent lymphocytes and 8 percent monocytes), protein concentration of 27 mg per deciliter, glucose concentration of 53 mg per deciliter (2.9 mmol per liter), and a nonreactive Venereal Disease Research Laboratory test. The patient was treated with 12 million U of penicillin G per day intravenously for seven days, followed by 24 million U per day for an additional seven days. After nine days of treatment, imaging demonstrated a dramatic improvement (Panels C and D). Corticosteroids were not administered. The patient voluntarily stopped taking phenytoin one month after discharge. Seven months later, she continues to be seizure-free, with a CD4 cell count of 78 per cubic millimeter and a rapid plasma reagin titer of 1:8. Other possible causes of this radiographic appearance, such as toxoplasmosis, bacterial or fungal cerebral abscess, sarcoidosis, neuroborreliosis, tuberculosis, and lymphoma, were ruled out by tests and by the patient's clinical response to penicillin.
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