Syphilitic Gummas in a Patient with Human Immunodeficiency Virus Infection

Abstract

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.

Intracranial syphilitic gumma resembling malignant brain tumour

“…1,2 Cerebral syphilitic gumma is a rare complication of tertiary syphilis in immunocompetent as well as immunocompromised hosts, 3 with only a few reported cases in the literature. [3][4][5][6][7][8][9][10][11][12] The majority of reported cases were in the cerebrum, with some cases in other locations, including the spinal cord, 6 pituitary gland, 8 brain stem 10 and cerebellopontine angle. 12 Most reported cases were either multiple 4 or showed ring enhancement suggestive of an infectious process.…”

Síndromes neuropsiquiátricos causados por Treponema pallidum

“…El efecto de masa pseudotumoral comprensiva se diagnostica por la tomografía axial computada (TAC) o la RM y se confirma en la biopsia y con la aplicación molecular de la reacción de polimerasa en cadena (RPC). Los gomas múltiples desaparecen rápidamente bajo un tratamiento con penicilina-6 a dosis altas 17,26,53,54 . J. M. Flood y cols., investigaron retrospectivamente 117 pacientes de NS, diagnosticados así: asinFigura 4.…”

Neuroimaging findings of cerebral syphilitic gumma

“…Cerebral syphilitic gumma is a rare disease of the central nervous system that is an unusual type of tertiary syphilis. Due to the lack of knowledge regarding the imaging of cerebral syphilitic gumma, pre-operative misdiagnosis often occurs, with glioma being the most commonly misdiagnosed (6–9). Treatment with penicillin G can treat most gummas and only a few patients with intracranial hypertension crisis or penicillin-resistance require surgical resection (7,10).…”

“…Therefore, a definitive diagnosis of syphilitic gumma may help clinicians choose an appropriate treatment strategy and reduce the risk of unnecessary surgery. There have been limited case reports describing the neuroimaging features of intracranial syphilitic gumma (6–9). Magnetic resonance imaging (MRI) of a cerebral gumma was first described by Agrons et al (11) in 1991.…”