A case of parkinsonism associated with neurosyphilis, which improved markedly after appropriate treatment, is described, Although neurosyphilis is a rare cause of parkinsonism, it should be considered when parkinsonism appears in the 30-50-year age group, particularly if other anomalous neurological findings are present. Adequate therapy may improve the patient's condition and prevent further progression

Sandyk, R.

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SA MEDICAL JOURNAL VOLUME 63 23 APRIL 1983 665Parkinsonism secondary to neurosyphilisA case reportR. SANDYKSummaryA case of parkinsonism associated with neurosyphi-lis, which improved markedly after appropriatetreatment, is described, Although neurosyphilis is arare cause of parkinsonism, it should be consideredwhen parkinsonism appears in the 3D-SO-year agegroup, particularly if other anomalous neurologicalfindings are present. Adequate therapy may improvethe patient's condition and prevent further pro-gression,S A If Med J 1983: 63: 665-666.Although the association between neurosyphilis and parkinson-ism is rare, it is accepted that Treponema pallidufII can cause thefeatures of this condition,l The signs of involvement of the basalganglia may appear soon after the initial infection or may bedelayed for some years 1 Usually the classic neurological abnor-malities of neurosyphilis such as pupillary signs, optic atrophy,pyramidal signs, sensory loss and abnormal cerebrospinal fluid(CSF) findings are found together with the parkinsonism.Case reportA 48-year-old Black man was admitted to hospital complainingof chest pains and a productive cough of I week's duration, Onexamination he was demented, malnourished and dehydrated,pyrexial (38,9°C) and pale, His fingers were clubbed but there\\'as no jaundice or cyanosis, Bronchial breathing was heard overhis left dorsal lung base, No other abnormality was detected anda tentative diagnosis of lobar pneumonia was made and con-firmed by chest radiographs,A neurological examination performed during his stay in hos-pital revealed that he was poorly orientated for time, space andperson and that he had parkinsonism. There was no history ofparkinsonism in the family and the patient as well as his relativesdenied drug intake (e,g, phenothiazines or reserpine) and expo-sure to industrial toxins,Careful assessment of the patient revealed a bilateral restingtremor of 4 - 7 Hz in the upper limbs, cogwheel rigidity in the\Hists and neck muscles, a positive glabellar tap, poor eye blink-ing and limited facial expression, His gait was slow, shuffling andhesitant. He had bilateral primary optic atrophy and his pupilswere small (3 mm), irregular and failed to respond to light, butaccommodation was intact (Argyll Robertson pupils), There wasa mild bilateral coarse horizontal nystagmus and weakness ofupward gaze, sensory hearing loss on the right (tuning fork,Department of Medicine, Hillbrow Hospital, JohannesburgR. SA DYK, ,\I.D. (BO:,:>:), ARZTLICHE PRCFU-:G (SAl'KT AL'GLSTI:>:jDate received: I June 1982.examination), and wasting of the tongue causing dysarthric and;,Iow speech. Examination of the limbs disclosed slight general-ized \\'eaknes and bilateral brisk tendon jerks \\'ith slight pre-dominance in the lower limb. The left plantar respon e wasexten or and the right flexor. Hoffmann's sign was negative,Frontal lobe release signs were present (pout, palmomental andhead retraction), Co-ordination \\'a impaired and there \\'as;,ome degree of dy diadochokinesia and intention tremor in theupper limbs, Perception of pin-prick was normal in the arms andleg;" but position sense and vibration sense were impaired in alllimbs, predominantly on the right. A marked degree of romber-gi;,m \\'as also present, His sphincters as well as testicular sensa-tion were normal.Laboratory analysis revealed a white blood count of14,2 x 10"/1, a haemoglobin value of 9,7 g/dl, an erythrocyte;,edimentation rate of 40 mm/1st h (\X1estergren), and normalserum electrolyte and glucose \'alues, li\'er and renal function,\'itamin Bl~ and folate le\'els, The \X'assermann reaction in serum"'as repeatedly positive. The fluorescent treponemal antibodyabsorption (FTA-ABS) test was strongly positi\'e in the bloodand CSF, On lumbar puncture the CSF was under normalpre sure (160 mm H20) and clear \\'ith 105 cell (80% lympho-cnes), protein 1,1 g/l (normal 0,1 - 0,4 g/I), glucose 2,6 mmol/I(normal 2,5 - 5,5 mmol/I), and chloride 118 mmol/l. Bacteria\\'ere not observed, Computed tomography sho\\'ed no ma s, butfeatures of communicating hydrocephalus associated with mod-erate cortical and cerebellar atrophy were present.The patient was gi\'en a course of procaine penicillin G(600000 U intramuscularly daily for 21 days) which followed a3-day administration of prednisone 60 mg daily to avoid a possi-ble Jarisch-Herxheimer reaction, When seen 3 months later, hewas much more alert and les handicapped by his parkinsonism,He was able to walk without much support, although his gaitremained slow with poor arm swing, The initiation and accom-plishment of mo\'ements improwd significantly and there wa noretro-, pro-, or anteropulsion, The rigidity in his limbs decreasedand there was only slight residual trembling in his hands, Hisspeech was clearer and the facies less expressionless. Repeatlumbar puncture re\'ealed clear fluid \\'ith 31 cells (mo tly Iym-phocytes), protein 0,82 g/I and normal glucose content. TheFTA-ABS test was positive.DiscussionThis patient had typical parkinsonian signs, Argyll Robensonpupils, a positive Babinski reflex on the left, cerebellar signs,impaired intellectual capacity and abnormal CSF finding,Although there i little doubt that acquired syphilis can cau eaparkinsonian syndrome, the association of these two conditionsin the same patient could have been coincidental.' However, thefact that a significant improvement in the patient's condition andthe CSF findings followed treatment with penicillin stronglysuggests that the syphilitic infection of the nervous system was insome way connected with the development of the parkinsoniansyndrome as well as the associated neurological signs, It is pos i-ble that cure of the pneumonia and the patient's rehydrationcontributed to the improvement of hi parkinsonism,666 SA MEDIESE TYDSKRIF DEEL 63 ~3 APRIL 1983Parkinsonism is a rare sequel of neurosyphilis. There are only59 reported cases of syphilis as a cause of Parkinson's disease.The first one by Hutchinson l appeared in 1898. The syphiliticmanifestations were thought to be hereditary and the patientsubsequently developed paralysis agitans in his forties. This isinteresting historically because there was no eyidence that par-kinsonism had any relation to the syphilis. In 1953 Neill4 des-cribed a case of a man aged 43 who de\·eloped parkinsonismslowly over 2 years, with tremor, rigidity and other typical signsof the disease. He was treated vigorously with penicillin, and asignificant improvement of his parkinsonism was noted. In 1954Lit' described 2 patients both of whom improved on eradicationof the syphilitic process, one much more than the other. In 1968Siegfriedb reported a case in which parkinsonism was associatedwith neurosyphilis, but no mention of response to therapy wasmade.The pathological findings associated with meningovascularsyphilis suggests that the inflammatory process may occasionallyspread to involve basal ganglia and other mesencephalic struc-tures. Wilson and Cobb' introduced the term 'mesencephalicsyphilis' to describe the pathological association between neuro-s\·philis and parkinsonism. Mella and Katz (quoted by Neill4)recorded typical mesodermal syphilitic involvement of the basalganglia in a 46-year-old man with a diagnosis of paralysis agitans.Autopsy revealed peri\·ascular infiltration in the globus pallidus,chronic leptomeningitis, atrophy of the frontal lobes and granu-lations in the fourth \·entricle, all pathognomonic of neurosyphi-lis. Ste\·enson and Allen (also quoted by NeilJ4) recorded asimilar case of parkinsonism which showed typical changes ofdementia paralytica in the cerebral cortex together with wide-pread lesions in the corpus striatum and its connections atautopsy.Since neurosyphilis definitely affects the midbrain area andsmall vascular lesions throughout the mesencephalon have beendescribed, it would seem logical to conclude that there is anaggravation of an underlying parkinsonian process in the major-ity of the so-called parkinsonian syphilitic patients, and in a fewrare cases the luetic lesion is responsible for the entire parkinson-ian picture, since it may disappear when proper treatment isinstituted. In the present case it seems that the parkinsonianpicture was probably aggravated by an underlying neurosyphilissince an improvement (but not complete cure) of the patient'Scondition occurred after appropriate therapy had been instituted.This case report is noteworthy in that neurosyphilis and Par-kinson's disease are both uncommon conditions in the Blackpopulation. Neurosyphilis should therefore be considered in thedifferential diagnosis of parkinsonism, specifically when otheranomalous associated neurological symptoms are present. In thisevent adequate therapy may improve the patient' condition andhelp in averting further progression of the parkinsonism.REFERE~CES1. Pires w. Parkinsonisme par neuro-recidive. Rn: Nellrol (Paris) 1935; 64:767-772.2. Crechia Cl. La syphilis peut-elle reproduire le syndrome de Parkinson' Rn:Xellral (P"ris 1921; 37: 5 4-587.3. Hutchinson J. Paralvsis agitans in a man who had had s\·philis but probabl\·hereditary. Arch SlIrg (Lof/d) 1898; 9: 357-361.4. ~eill KG. An unusual case of syphilitic parkinsonism. Br Med] 1953; 2:320-322.5. Lit AC. Luetisch parkinsonisme. Ned Tljdschr Geneeskd 1954; 98: 3661-3665.6. Siegfried J. Die Purkimol1sc!ze Krcl1lklzeillllld ihre Behandlullg. Vienna: Sprin-ger, 1968; 38.7. \X'ilson SAK, Cobb S. Mesencephalitis syphilitica.] l\"ellrol Psvchopuch 1924;5: 44-60.News and Comment/Nuus en KommentaarWatch that childA survey of childhood accidents in Israel (lsr J Med Sci 1982; 18:917) revealed that, surprisingly, lack of supervision was not amajor feature of accidents in the home, and that a responsibleperson was present when 69,2% of the accidents occurred. Atense family atmosphere was, however, thought to predispose toaccidents. Accidents on the road occurred almost exclusively inthe absence of a responsible caretaker (85,7%), and the mostvulnerable group were boys of school age \\·ho crossed the roadby themselves. The report recommended that educational andpreventi\·e measures, such as guards at road crossings nearschools, should be directed at this group.Alcoholics unanimousPossibly the ultimate in semantic vertigo has been provided bythe New Jersey motorist who has challenged the State's drunkdriving statute on constitutional grounds because it fails to makespecial provisions for alcoholics (AMA News, 5 November 1982,p. 19). This is reminiscent of the child accused of murdering hisfather and mother who pleaded for clemency on the grounds ofbeing an orphan.Prevention and/or cure?There is a school of thought that holds that medical effort shouldbe concentrated on prevention rather than cure. Combat thesocial and economic causes of disease, its proponents say, andyou will eventually work curative medicine out of a job.This philosophy is particularly favoured by somepaediatricians, especially in relation to the Third World. In aprovocative editorial in Medecine et Hygiene (1983; 41: 499)Pierson, the professor of paediatrics at Nancy, calls for a littlemore balance between prevention and cure. By all means let thepaediatricians collaborate with the authorities and the public inpreventing childhood diseases, an area which they may haveneglected in the past, but let this not grow into a confrontationbetween the preventive paediatricians and the curativepaediatricians. This is not an either-or situation, for both areindispensable.Immunization campaigns do not eliminate the need to treatsevere infections, and nutrition campaigns do not abolish theneed for the qualified paediatrician to diagnose and treat cases ofgluten intolerance. Nor does improving obstetric trainingsuppress all neonatal infections. According to Pierson, somehave wanted to concentrate on combating social inequality at theexpense of university hospitals. This makes no sense -sacrificing quality for quantity never does on the long haul.

Parkinsonism secondary to neurosyphilis

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Parkinsonism secondary to neurosyphilis

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