The Great Masquerader: Recurrent Ischemic Strokes Secondary to Meningovascular Syphilis in a Man With Cardiovascular Stroke Risk Factors.

A male in his 60s with stroke risk factors presented with confusion and word-finding difficulties. He was diagnosed with acute ischemic stroke in the right basal ganglia. He was started on secondary stroke prevention measures including dual antiplatelet therapy and a high-dose statin. A highly reactive rapid plasma reagin (RPR) was performed as part of the workup and found to be positive. Follow-up fluorescent treponemal antibody absorption (TPA) test was also positive, confirming a diagnosis of syphilis. He was discharged home with a scheduled course of antibiotic treatment for tertiary syphilis but returned due to a new episode of transient facial paralysis. Further workup and physical exam findings revealed the patient had neurosyphilis. He was started on the appropriate antibiotic therapy, which significantly improved his confusion and prevented new episodes of stroke.

AEDV Expert Consensus for the Management of Syphilis. / Documento de expertos de la AEDV para el manejo de la sífilis.

Syphilis -the "great simulator" for classical venereologists-is re-emerging in Western countries despite adequate treatment; several contributing factors have been identified, including changes in sexual behaviour, which won't be the topic of this article though. In 2021, a total of 6613 new cases of syphilis were reported in Spain, representing an incidence of 13.9×100 000 inhabitants (90.5%, men). Rates have increased progressively since 2000. The clinical presentation of syphilis is heterogeneous. Although chancroid, syphilitic roseola and syphilitic nails are typical lesions, other forms of the disease can be present such as non-ulcerative primary lesions like Follmann balanitis, chancres in the oral cavity, patchy secondary lingual lesions, or enanthema on the palate and uvula, among many others. Regarding diagnosis, molecular assays such as PCR have been replacing dark-field microscopy in ulcerative lesions while automated treponemal tests (EIA, CLIA) are being used in serological tests, along with classical tests (such as RPR and HAART) for confirmation and follow-up purposes. The interpretation of these tests should be assessed in the epidemiological and clinical context of the patient. HIV serology and STI screening should be requested for anyone with syphilis. Follow-up of patients under treatment is important to ensure healing and detect reinfection. Serological response to treatment should be assessed with the same non-treponemal test (RPR/VDRL); 3-, 6-, 12-, and 24-month follow-up is a common practice in people living with HIV (PLHIV). Sexual contacts should be assessed and treated as appropriate. Screening is advised for pregnant women within the first trimester of pregnancy. Pregnant women with an abortion after week 20 should all be tested for syphilis. The treatment of choice for all forms of syphilis, including pregnant women and PLHIV, is penicillin. Macrolides are ill-advised because of potential resistance.

Tertiary syphilis and cardiovascular disease: the united triad: case report.

Background: Syphilis, owing to its natural course, can lead to long-term damage to the aortic valve, such as insufficiency and rarely stenosis, ostial coronary stenosis, and syphilitic aortitis. Cardiovascular involvement alongside neurological involvement dominates the prognosis. This should no longer be seen, thanks to awareness and prevention programmes, medical treatment, and antibiotics. Case summary: We report a case of a 54-year-old chronic smoker with no previous history, admitted for respiratory distress amid an impaired general condition. An electrocardiogram was performed, which showed sinus rhythm with lateral ST depression and T-wave inversion. Coronary angiography revealed an ostial stenosis of the left coronary artery. Echocardiography displayed a globular dilated left ventricle with a left ventricular ejection fraction of 40% and severe aortic insufficiency (AI). Computed tomography angiography of the aorta showed a dilation of the thoracic aorta and suprarenal abdominal aorta. Syphilitic serology was positive. The patient underwent angioplasty, resulting in a satisfactory outcome, and subsequently received optimal treatment. Following a consultation with a cardiovascular surgeon and vascular team, it was decided to proceed with mechanical aortic valve replacement and aorto-coronary double bypass surgery, but vascular surgery of the ascending aortic aneurysm was not possible at once. Discussion: Tertiary syphilis should always be considered when faced with isolated coronary ostial involvement, aortic aneurysm, and/or AI. What makes our case special is that the patient had almost all the cardiovascular complications of tertiary syphilis. Primary syphilis should always be prevented, diagnosed early, and treated appropriately with antibiotic therapy.

Surgery for Ascending Aortic Aneurysm and Aortic Valve Insufficiency in Conditions of Active Proceeding Syphilitic Aortitis and Valvulitis.

A syphilitic aortitis is a late cardiovascular lesion of tertiary syphilis that has become exceptionally rare in the antibiotic era but not eradicated completely. Syphilitic aortitis of ascending aorta complicates in ascending aortic aneurysm formation and aortic valve regurgitation, both requiring surgical treatment. After surgery, lifelong surveillance of the remainder of the aorta is recommended because of a priori supposed high incidence of delayed involvement of noninvolved aortic segments. A 3-year follow-up result of surgery of syphilitic ascending aortic aneurysm with aortic valve regurgitation in condition of active ongoing syphilitic aortitis and valvulitis is described with addressing the dimensions of remaining aortic segments. This case demonstrates that the dilatation of the remainder of the aorta does not occur during 3 years, at least when anti-syphilitic course of antibiotic is used just after operation without additional treatment during the follow-up period. A few reports on surgical treatment of syphilitic aneurysms of the ascending aorta are discussed.

A Narrative Review of the Many Psychiatric Manifestations of Neurosyphilis: The Great Imitator.

Neurosyphilis is an infection of the central nervous system caused by the spirochete, Treponema pallidum. New syphilis infections have been increasing around the world each year. This disease was much of a concern in the pre-penicillin era, where when left untreated many cases progressed to tertiary syphilis which can commonly manifest as neurosyphilis. Of particular interest, neurosyphilis has been linked to masquerading itself as various psychiatric conditions. This narrative review focuses on exploring psychiatric manifestations of neurosyphilis as well as the importance of screening in psychiatric settings and clinicians maintaining high clinical suspicion of the disease. A systematic search was conducted for published articles from 2003 to 2023 using PubMed, EMBASE, and Google Scholar. A total of 66 articles met the criteria and were used for detailed analysis, where psychiatric manifestations and clinical progression of patients were discussed in detail. Psychiatric manifestations that were explored include dementia, delirium, depression, mania, personality changes, and psychosis. One of the most common manifestations of neurosyphilis appears to be severe neurocognitive impairment. There are also rare psychiatric conditions neurosyphilis mimics that have been described in literature such as Capgras syndrome and Geschwind syndrome. A narrative review of the literature revealed a low level of clinical awareness of neurosyphilis as a possible etiology of various psychiatric disorders. This resulted in delayed or inaccurate diagnosis and consequently delayed initiation of adequate treatment. Considering that many psychiatric manifestations of neurosyphilis are reversible with proper treatment, it is imperative to implement routine screening for syphilis among psychiatric patients.

A Rare Case of Neurosyphilis Manifesting as Psychosis in an HIV-Negative Patient.

Neurosyphilis is a rare disease now, given the availability of antibiotics to treat syphilis. Patients with neurosyphilis could present with psychiatric symptoms. We present a rare case of neurosyphilis with only psychiatric symptoms. The patient was a 49-year-old male who presented with self-neglect and was not interacting with others. Treponema antibodies were positive, and rapid plasma reagin (RPR) was 1:512 with a positive venereal disease research laboratory test (VDRL) in the cerebrospinal fluid. The patient was treated with an IV penicillin regimen for neurosyphilis and improved remarkably with a return to baseline on follow-up.

Tertiary Syphilitic Gumma Mimicking Testicular Neoplasms.

Palpable testicular masses in men aged 20 to 50 years usually represent testicular germ cell tumors. Diagnostic work-up involves ultrasound examination as well as serum tumor markers alpha fetoprotein, beta-human chorionic gonadotropin and lactate dehydrogenase, and particularly the novel marker M371. Orchidectomy is mandatory for germ cell tumors. We report the rare case of testicular involvement by tertiary syphilis mimicking testicular neoplasms with testis-sparing management. A 46-year-old Caucasian male presented with a painless firm mass in the right testicle and multiple cutaneous plaques at the skin of the scrotum, penis and right forearm. Testicular serum tumor markers were negative. Syphilis Rapid Plasma Reagin test and Treponema pallidum immunoglobulin antibodies tests were positive. Radiological examination revealed bilateral testicular lesions as well as bipulmonal pleural-based opacities. Conservative management was attempted and treatment with ceftriaxone (2 g/day) intravenously for 14 days was administered. The testicular findings improved rapidly and significantly during antibiotic treatment. Radiological follow-up examinations after two weeks and two months showed further regression of the testicular and pulmonary lesions. This case represents an extremely rare testicular manifestation of tertiary syphilis. Due to rising syphilis incidence in Europe, tertiary syphilis with formation of gumma should be a differential diagnosis of testicular tumor. Thus, syphilis-specific treatment is safe and orchidectomy can be avoided.

Neurosyphilis-Induced Psychosis: A Unique Presentation of Syphilis With a Primary Psychiatric Manifestation.

Syphilis is a predominantly sexually transmitted infection caused by the spirochete Treponema pallidum. The infection presents with four different stages and although rare, can lead to behavioral symptoms if not treated in its earliest form. It can cause psychosis, mania, depression, anxiety, and personality changes. Screening and early treatment of syphilis are essential in preventing neurosyphilis and its neuropsychiatric symptoms. Neurosyphilis is rarely the initial presentation of syphilis. This is a case report of a 30-year-old female with neurosyphilis who presented with psychosis as the primary presentation.

Temporal Arteritis Caused by Tertiary Syphilis.

A 77-year-old man arrived at our hospital with bilateral shoulder pain persisting for several months and headache for 1 month. Giant cell arteritis with polymyalgia rheumatica was suspected. However, considering his medical history of testing positive for syphilis, we submitted a sample for a syphilis serology test, which yielded positive results. The Treponema pallidum hemagglutination assay of cerebrospinal fluid was positive, and a temporal artery biopsy revealed vasculitis, confirming the diagnosis of tertiary syphilis. He was successfully treated for two weeks with penicillin G infusions. Symptoms reminiscent of giant cell arteritis and polymyalgia rheumatica may reveal syphilis, which is called the "great imitator."

Syphilitic ostial coronary artery occlusion treated with percutaneous coronary intervention: Case series and literature review.

Introduction: Non-atherosclerotic causes of acute coronary syndrome (ACS) are important contributors to a substantial number of acute ischemic coronary events. Syphilitic aortitis is a rare complication of tertiary cardiovascular syphilis that may result in ostial coronary artery stenosis, aortic insufficiency, and ascending aortic aneurysm. Methods: In this manuscript, we present two Case Reports of patients with bilateral syphilitic coronary artery ostial occlusion, and we review the associated literature. The immunofluorescent test was positive for syphilis in both patients. Results: Diagnostic coronary angiography revealed bilateral occlusions of the left main coronary artery (LMCA) and right coronary artery (RCA), which were successfully treated with percutaneous coronary intervention (PCI) with bare metal stents (BMS). After deployment of the stents, arterial blood flow was re-established with TIMI flow grade 3. Discussion: The angiographic finding of bilateral coronary ostial lesions in young patients should raise the suspicion of cardiovascular syphilis. Options for revascularization should be discussed amongst the patient and the Heart Team. PCI may be an option for treatment of isolated syphilitic coronary stenosis in the setting of acute hemodynamic instability or chronic inflammation.

Challenges in the Diagnosis of Tertiary Syphilis: Case Report with Literature Review.

Tertiary syphilis is a large diagnostic challenge. It is rarely the case that it affects the skin, bone tissue and the eyes at the same time. The presented case shows that extensive symptomatology of syphilis poses a challenge in making a proper diagnosis in patients whose history does not suspect STDs. The study aims to present the case of a young woman hospitalized with a suspected autoimmune disease, diagnosed with symptomatic late syphilis with involvement of the skin, bones and eyes.

Tertiary Syphilis Masquerading as Oropharyngeal Cancer.

Syphilis is re-emerging in the United States. Treponema pallidum, the spirochete bacterium responsible for syphilis, has immunoevasive properties that facilitate pathogenesis and widespread tissue involvement. Host immune status, particularly the presence of HIV/AIDS, can influence the presentation and severity of the disease. Patients co-infected with HIV and syphilis may develop atypical lesions, including those involving the oropharynx. Any immunocompromised patient with tongue lesions and lymphadenopathy is presumed to have a wide differential diagnosis, and tissue sampling with histopathologic analysis is indicated. We present a patient with gumma of the tongue as the initial manifestation of tertiary syphilis.

Nodulo-ulcerative syphilis - case report and the review of literature.

We describe the case of tertiary syphilis involving the skin. The lesions had a nodular-ulcerative form, localized on both arms. The patient had high titers of treponemal and non-treponemal serological tests for syphilis and histopathological picture was indicative for nodulo-ulcerative syphilis. No cardiological, neurological or ophtalmological abnormalities were found. The patient was treated with 2.4 million units i.m. of benzathine benzylpenicillin three times at weekly intervals, according to European Guideline. Unfortunately, the patient was lost for scheduled follow-up. More than two years later the skin lesions healed completely leaving discrete scars and a four-fold decline in a titre of Venereal Disease Laboratory Test was noticed.

A peculiar case of syphilis infection: The great imitator is on the rise.

The incidence of syphilis is on the rise worldwide and can pose many diagnostic and therapeutic difficulties for doctors. Given the wide variety of presenting symptoms, syphilis is also known as the great imitator, which in turn frequently leads to a pronounced diagnostic- and therapeutic delay for patients. Here we present a case report of syphilitic uveitis and papillitis accompanied by acute vision loss, a rare presentation of a tertiary syphilis infection that clinically mimicked a giant cell arteritis (GCA) or arteritic anterior ischemic optic neuropathy (AAION). The patient was treated with high-dose intravenous benzyl penicillin after which full vision was restored. By presenting this case, we hope to raise awareness for the increasing incidence of syphilis infections and stress the importance of syphilis testing in patients with otherwise unexplained uveitis.

Neurosyphilis: A Monkey Among Men.

Neurosyphilis is the progression of the untreated sexually transmitted infection caused by Treponema pallidum. When the initial infection is not adequately treated, progression of primary syphilis can lead to a wide variety of serious health sequelae. While neurosyphilis can appear up to 10-30 years after the initial infection, syphilis can invade the nervous systemat any stage of infection and can imitate symptoms of many other diseases. This variety of symptoms is why syphilis has been called "The Great Pretender" or "Themonkey among diseases"(Krämer et al., 2018).12 This is a case report of an 83-year-old female with a history of multiple TIAs, dementia, and breast cancer who presented to the emergency department with complaints of her head "not feeling right" and intermittent ataxia (episodes of imbalance and difficulty ambulating) reported by patient and patients' son. Physical exam only pertinent for chronic shuffling gait, but no ataxia. The patient underwent further work-up, demonstrating negative brain imaging for cerebral vascular accident and laboratory findings negative initially, for acute infection. An RPR was drawn as part of an broadened altered mental status workup as the patient and family stated she was not back to baseline mental status and was positive with a quantitative titer of 1:8. Fluorescent treponemal antibody absorption (FTA-ab) was found to be positive as well. The patient was started on three million units intravenous Penicillin G every 4 h and was discharged with a peripherally inserted central catheter in order to receive two weeks of Rocephin at two grams daily. Patient returned to prior baseline following completion of treatment. Through this case, we hope to provide information on neurosyphilis and its differentiation from other disease processes and when neurosyphilis should be suspected during an evaluation of altered mental status.

Tertiary syphilis mimicking metastatic rectal cancer.

Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum. Tertiary syphilis, a late-stage multi-visceral complication of the disease is characterized by its diversity of clinical manifestations. Here, we present the first documented case of tertiary syphilis that clinically and radiologically mimicked primary rectal cancer with hepatic metastasis.

Syphilitic Popliteal Pseudoaneurysm Complicated by Acute Lower-Limb Ischemia.

Case presentation: We present a case of a patient with a syphilitic popliteal pseudoaneurysm who developed acute lower-limb ischemia secondary to thromboembolism related to the pseudoaneurysm. The diagnosis of a syphilitic popliteal aneurysm was made due to positive syphilitic serological testing and with exclusion of all other potential causes. The pseudoaneurysm was surgically repaired using a great saphenous vein patch angioplasty, which was done without delay to prevent further thromboembolic complications. This was then followed by a course of intravenous benzyl penicillin. Discussion: Peripheral arterial involvement of tertiary syphilis remains exceedingly rare, with the vast majority of reported cases of vascular syphilis relating to aortic involvement. Given the paucity of literature on this condition, there is no good evidence to guide current management. Conclusion: With the globally increasing rates of syphilis, more cases of peripheral arterial involvement may become apparent, as was the case in the early 20th century.

The Great Impostor Did It Again: Syphilitic Arthritis.

Syphilis-related bone and joint involvement is commonly found in congenital form, but it can also be seen in adults with acquired syphilis as a rare sequela of infectious syphilis. We report a case of syphilitic arthritis where the patient presented with multiple problems over the course of several visits and was eventually diagnosed with tertiary syphilis as the source of his musculoskeletal complaints. The clinical manifestations of syphilis can be diverse and challenging, as evidenced by our case. Unusual clinical manifestations might be seen in syphilis, and clinicians may not be familiar with these clinical presentations while diagnosing. Being aware of arthropathy in syphilis and including it in the differential diagnoses will help improve patient outcomes and avoid unfavorable consequences, particularly in the high-risk group.

Impending Aortic Rupture in a Patient with Syphilitic Aortitis.

We report the case of a 48-year-old man, admitted for atrial fibrillation with rapid heart rate and intense chest pain. A quick evaluation revealed a giant aortic aneurysm with severe aortic regurgitation and pericardial fluid without a trace of aortic dissection. Because of high suspicion of aortic rupture, an emergency surgery was planned, and a Bentall procedure was performed. On examination of the aortic wall revealing vertical wrinkling with a tree bark aspect, suspicion of syphilitic aortitis arose. The diagnosis was confirmed through postoperative serologic testing and histological examination. Histopathologic differential diagnosis, special treatment and follow-up are presented.