Syphilis is caused by an infection with Treponema pallidum which is sexually transmitted. Neurosyphilis is the tertiary stage of the infection, and it causes multiple, variable, and complex presentation within the central nervous system (CNS). There are numerous nonspecific manifestations including stroke-like symptoms, hemiparesis, sudden blindness, and optic neuritis. 1-4 Due to a wide range of clinical symptoms, establishing the diagnosis and initiating treatment in a timely manner can be challenging. Cerebrospinal fluid (CSF) findings of elevated protein and lymphocyte count with positive venereal disease research laboratory test (VDRL) suggest neurosyphilis. Neurosyphilis usually presents many years after initial infection in immunocompetent host. However, in human immunodeficiency virus (HIV)-infected patients, the symptoms appear much earlier than expected. 5-7 We present a 34 years old HIV-positive African American man who presented with diplopia caused by isolated left cranial nerve (CN) 6 palsy. He was diagnosed with neurosyphilis with CSF analysis. 2 | CASE A 34-year-old man with AIDS came to Emergency Department with 3 days of diplopia. Two months prior to this visit, he was admitted for headache and mild altered mental status. CT and MRI brain were negative. His peripheral blood rapid plasma reagin (RPR) test was positive with a titer of 1:8. His fluorescent treponemal antibody absorption test (FTA-ABS) was positive. He was found to have neurosyphilis as cerebrospinal fluid analysis showed VDRL at 1:16 titer. CSF white blood cell count (WBC) was 45 cell/cubic mm, 95% lymph. CSF protein was 50 mg/ dL, and glucose was 39 mg/dL. His maximum temperature was 39.9℃ during that hospitalization. There was no focal neurological finding on examination. Antibiotics and
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