Neurosyphilis Presenting with Anxiety: A Case Report

Abstract

The number of cases of late and late latent syphilis in the United States is on the rise. This diagnosis is often forgotten when an elderly patient is being worked up for altered mental status. Rarely does a 70-year-old male with neurosyphilis present simply with anxiety. Due to the decreased severity of the presentation, this patient was sent home from the emergency department multiple times until the anxiety progressed to psychosis. He was finally admitted with delirium, suicidal ideation, and paranoia. A routine Treponema pallidum antibody test returned positive and a further workup of confirmatory lab work, a thorough neurological exam, and magnetic resonance imaging (MRI) revealed a chronic syphilis infection. This case study explores signs in the history and physical examination that should quickly prompt a provider to consider neurosyphilis in their differential. This patient presented with Argyll-Robertson pupils and significant risk factors. The goal of this discussion is to bring awareness to this infrequent presentation and share simple examination techniques that could have been used to diagnose and treat this patient’s symptoms more promptly. In doing so, the hope is to raise awareness for the diagnosis of neurosyphilis, especially in the elderly patient presenting with psychiatric symptoms.

Re-emerging Neurosyphilis in Korea as a Possible Etiology of Psychotic Disorders with Pleomorphic Symptoms and Cognitive Dysfunction: a Case Report and Literature Review

“…These symptoms are considered to be caused by progressive frontotemporal meningoencephalitis with diffuse cortical atrophy. 2 …”

“…4 Cases of primary and secondary syphilis have increased in the US every year since 2000, with 9.5 cases per 100,000 persons in 2017, and the number of cases of late and late latent syphilis has increased by 17.2% yearly. 2 5 Rates of neurosyphilis in various series have been estimated at 0.47–2.1 cases per 100,000 in the population. In Korea, the cases of meningovascular syphilis in 2009, 16 neurosyphilis with mesiotemporal abnormalities in 2009 17 and neurosyphilis with cerebral gumma in 2009 18 and 2013 19 were reported.…”

“…As 'general paresis of the insane,' which is a later symptomatic form of neurosyphilis, it involves neuropsychiatric deficits such as delusion, hallucination, and disorientation, and can mimic a variety of psychiatric disorders such as psychosis, mania, delirium, personality changes, and dementia. [1][2][3] Neurosyphilis was an important concern in psychiatric wards before and after the 1900s, because 20%-30% of psychiatric inpatients at the time had neurosyphilis. With the advent of penicillin, the prevalence of neurosyphilis has decreased to less than 2% since the 1950s.…”