Neurosyphilis: An Important Cause of Recurrent Strokes

Background: Neurosyphilis can manifest as recurrent brain infarction, although not frequently, but can be challenging to diagnose due to atypical presentations. Case report: A 43-year-old male with history of smoking presented to the Midland Regional Hospital, Tullamore (MRHT), Offaly, Ireland, with focal speech deficit and arm/leg weakness for 3 days. Neuroimaging showed acute cerebral infarction. He denied any high-risk sexual contacts. Forty-eight hour telemetry, trans-thoracic echocardiogram, cerebral catheter angiogram, and magnetic resonance angiogram were normal. He was treated with high-dose aspirin for 14 days and then discharged on aspirin with a follow-up plan. Trans-oesophageal echocardiogram performed after 2 weeks showed no evidence of subacute bacterial endocarditis, but there was evidence of fibroelastoma on the aortic valve. The cardiology department felt this was not a likely cardioembolic source. The patient presented 2 months later with recurrent stroke symptoms of loss of speech to another hospital. However, he was discharged for follow-up in MRHT as symptoms resolved. Brain computed tomography (CT) showed ‘old’ stroke. One week later he re-presented to MRHT with dysarthria, ataxia, and a National Institute of Health Stroke Scale (NIHSS) score of three. Repeated neuroimaging showed multiple ‘new’ and ‘old’ cerebral infarcts. The patient was anticoagulated based on recurrent thromboembolic events and magnetic resonance imaging was repeated. CT aortogram and 48-hour Holter results were normal. A repeated magnetic resonance angiogram showed multiple stenosis areas due to vasculitis. As aetiology was complex, a lumbar puncture was performed and blood tests repeated (viral serology, vasculitic and thrombophilia screens). Cerebrospinal fluid and serum analysis displayed a diagnosis of neurosyphilis with co-infection of HIV. Treatment with penicillin was commenced, after which the patient greatly improved and is now under long-term follow-up. Conclusion: Stroke in a young patient is rare and recurrent stroke-like events in a young person raise the clinical suspicion of an alternative diagnosis. It is therefore imperative to investigate neurosyphilis in all HIV-positive patients, as it can cause early clinical manifestation in such patients