Neurosyphilis with Concomitant Cryptococcal Meningitis in a Patient with AIDS after COVID-19: a case report (preprint)

Background The common infections agents causing meningitis in patients with human immunodeficiency virus (HIV) include Cryptococcus neoformans and Treponema pallidum. Furthermore, there is an elevated risk of meningitis in patients with HIV concomitantly infected with SARS-CoV-2.Case presentation: A 38-year-old male presented with headache and dizziness. After hospitalization, polymerase chain reaction test for SARS-CoV-2 in nasopharyngeal swab was positive, and lumbar puncture revealed neurosyphilis with concomitant cryptococcal meningitis. He underwent Paxlovid, penicillin, antifungal and antiretroviral treatment. The patient had no other neurological symptoms and was stable during the 6-month follow-up period.Conclusions During the COVID-19 pandemic, patients with HIV, particularly those not underwent antiretroviral therapy, are at higher risk for severe infections, including central nervous system complications, due to their compromised immune systems.

Neurosyphilis mimicking giant cell arteritis both clinically and microscopically.

Temporal arteritis is usually caused by giant cell arteritis (GCA). However, inflammation of the temporal artery can also occur secondary to autoimmune diseases or infections.We present a remarkable case of a man in his 70s with biopsy proven temporal arteritis, who was later diagnosed with meningovascular neurosyphilis. The presentation of an acute onset monocular vision loss with inflammation of the temporal artery on biopsy appeared a GCA, misleading the physicians, as it turned out to be a manifestation of neurosyphilis.

Platelet Indices Are the Promising Biomarkers in Monitoring Disease Activities in Patients with Syphilis.

OBJECTIVES: To uncover the role of the platelet indices in patients with syphilis. METHODS: A total of 2061 patients with syphilis and 528 healthy controls were enrolled in this retrospective cohort study. The data of platelet count (PLT), mean platelet volume (MPV), platelet distribution width (PDW), and indicators of syphilis activities were collected. The correlations between the platelet indices and disease activities were analyzed. RESULTS: A total of 425 (20.6%) of the 2061 patients were of primary and secondary syphilis, 433 (21.0%) latent, 463 (22.5%) serofast, 350 (17.0%) asymptomatic neurosyphilis, and 390 (18.9%) symptomatic neurosyphilis. Compared with the healthy controls, PLT was significantly increased in the primary and secondary syphilis group; whereas, MPV and PDW were significantly decreased in all stages of syphilis. These changes of platelet indices were reversed after anti-treponemal therapy. Further correlation analysis showed that PLT was positively associated with the syphilis activity indicators [rapid plasma reagin (RPR) titer, cerebrospinal fluid white blood cell (CSF-WBC), CSF-protein, and CSF-VDRL (venereal disease research laboratory)] and inflammatory markers [WBC, C-reaction protein (CRP), and erythrocyte sedimentation rate (ESR)]. Conversely, PDW was negatively correlated with all of these parameters. MPV had an inverse relationship with RPR, ESR, and CRP. CONCLUSIONS: Platelet indices are associated with syphilis activities.

Response to Penicillin for Presumed Neurosyphilis in a Patient with Human Immunodeficiency Virus (HIV), a Normal CD4 Count, and an Undetectable Viral Load: A Case Report.

BACKGROUND Neurosyphilis is a bacterial infection of the brain and the spinal cord, caused by Treponema pallidum. Its nonspecific clinical presentation includes cognitive impairment and motor and/or sensory function compromise. Neurosyphilis infections in patients with HIV have increased over the past few years and many cases of neurosyphilis manifest in patients with HIV who have low CD4 T-cell counts and high viral loads (VL). However, there is extremely limited acknowledgement in the literature about neurosyphilis presentations in patients with HIV who have normal CD4 counts. CASE REPORT We present a neurosyphilis and HIV coinfection in a patient with a normal CD4 count and an undetectable VL. A 69-year-old woman with a medical history of HIV was on a prescribed antiretroviral treatment regimen. She presented in the Emergency Room in an unresponsive state, although this had been preceded by a period of rapidly progressive cognitive decline. Her brain computed tomography scan without contrast was unremarkable. Laboratory test results were within normal limits, except for a positive result for the microhemagglutination assay for Treponema pallidum antibodies and rapid plasma regain (RPR) test, which was highly suggestive of neurosyphilis as a presumed diagnosis. She showed remarkable clinical improvement after the initiation of conventional treatment for neurosyphilis, which is a 14-day regimen of intravenous penicillin G. CONCLUSIONS Given the broad neurological manifestations of neurosyphilis and its increasing incidence in patients with HIV, it is important to consider neurosyphilis in the differential diagnosis after ruling out other causes of encephalopathy, especially in patients with an undetectable VL and a normal CD4 count.

Neurosyphilis and the Jarisch-Herxheimer reaction: A therapy concern with HIV disease.

Jarisch-Herxheimer reaction (JHR) should be anticipated in treating neurosyphilis with coexistent human immunodeficiency virus (HIV) encephalitis. In that context we have devised a staging classification for JHR. In addition, an illustrative case is provided to emphasize the need to consider the diagnosis of neurosyphilis in HIV patients, and if delineated, to be prepared for a severe JHR.

COVID-19 relapse with prolonged viral shedding up to 60 days or re-infection, in 3 frontline healthcare workers with recurrent symptoms and persistent SARS-CoV-2 PCR positivity in Ireland, a developing diagnostic challenge: A case report (preprint)

Background:To date, the Corona Virus Disease-2019 (COVID-19) pandemic has resulted in more than 24,400 confirmed cases in Ireland, with more than 30% involving Healthcare Workers (HCW). As more staff become involved in the care of COVID-19 patients, many key clinical considerations remain uncertain, including the possibility of re-infection following initial illness, the clinical significance of prolonged viral shedding and the degree of protection conferred by development of anti- Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) antibodies.We present 3 cases of COVID19-infected HCWs, each with distinct episodes of recurrent symptoms following initial resolution and with persistently positive SARS-CoV-2 PCR results, ranging up to 60 days post onset of illness. PCR results, cycle threshold (Ct) values and clinical assessment are provided to discuss the diagnostic difficulties in assessing relapsed COVID-19 infection, or re-infection with new virus following return to work. Case presentations: Patient 1,2 and 3 (age range 25-36) tested positive for SARS-CoV-2 via rtPCR on oro/nasopharyngeal swab with initial Ct values of 21.72, 24.52 and 26.58 respectively, following presentation with respiratory symptoms. All completed 14 day periods of self-isolation with full resolution of symptoms. Each patient has a clinical role and was involved in the management of COVID-19 patients following return to work. Patient 1 was admitted to hospital 44 days after initial illness, with cough, dyspnoea and a concurrent diagnosis of neurosyphilis. SARS-CoV-2 PCR was positive with Ct value 31.36 and remained positive for at least 60 days following initial illness onset. A full clinical recovery followed. Patients 2 and 3 represented to the Emergency Department with recurrent respiratory symptoms 29 and 40 days following initial illness onset respectively. SARS-CoV-2 PCR was demonstrated in each with Ct values 31.16 and 30.72 respectively. Each subsequently made a full recovery following a second period of self-isolation. Anti-SARS-CoV-2 IgG was demonstrated in all 3 patients. Conclusions: These cases demonstrate the diagnostic difficulties in determining intermittent presentation of COVID-19 infection with prolonged viral shedding, or re-infection with new virus following return to work.  As the pandemic progresses, this represents a growing diagnostic challenge impacting patient assessment, staff deployment following illness and infection control.