Maladies neuroinfectieuses

Abstrait

Meningovascular Neurosyphilis: Illustrative Case

Isabel Martinez-Fernandez MD, Francisco Hernandez-Fernandez MD, PhD, Francisca Panadero Moratalla MD, Jose Javier Blanch Sancho MD, Juan David Molina-Nuevo MD, Julian Eloy Solis Garcia del Pozo MD, PhD, Tomas Segura MD, PhD

Background: Meningovascular neurosyphilis is not a common clinical presentation of Treponema pallidum infection. Only 20% of primary syphilis cases have central nervous system invasion, most of them asymptomatic. However, recent years have seen an increase in incidence, probably related to the reemergence of the human immunodeficiency virus (HIV) epidemic. Patients with HIV infection are more susceptible to early meningeal infection associated with meningitis, cranial nerve damage or acute ischemic stroke. Since it is a rare entity, experience is limited and neuroimaging reports are scarce.

Case presentation: A 45-year-old woman presented subacute headache, fever, dysarthria and right hemiparesis. Neuroimaging revealed a subacute ischemic lesion in the posterior arm of the internal capsule and a moderate stenosis of the supraclinoid portion of the left internal carotid artery, so inflammatory process or vasospasm in the origin of the left anterior choroidal artery was suspected. Lumbar puncture showed meningovascular neurosyphilis, and HIV was detected in blood. Control angiography computed tomography (CT) revealed resolution of stenosis.

Conclusions:In patients with HIV and syphilis co-infection, progression to meningovascular complications is accelerated, often with early strokes. Since it is a potentially treatable cause, routine serological tests in young stroke patients are essential. Leptomeningeal or extra-axial enhancement should also be suspected, as well as white matter changes in this population. The incidence of endarteritis in the neuroimaging tests is not entirely defined, probably due to the more frequent typical presentation in the form of subacute encephalitis.