LAUSR

Learning Objectives: Neurosyphilis is a great imitator from clinical and radiologic perspective, often delaying prompt diagnosis. In a survey of neurologists of a real life case of neurosyphilis presenting as encephalopathy and white matter (WM) hyperintensity, only 14% considered it in their workup. We report a case of neurosyphilis presenting as encephalopathy in a HIV negative woman. Methods: A 61-year-old African American female with history of substance abuse presented with altered mental status. Family reported cognitive decline ongoing for 2 years, which rapidly worsened in the past 6 months. She had periods of decreased responsiveness, hallucinations, bladder/bowel incontinence and disorganized behaviors such as consuming her own feces. Evaluations during recurrent hospitalizations concluded dementia and urinary tract infections as underlying etiology. Exam was significant for unresponsiveness, left gaze preference, right facial droop and flexor posturing. CT head was unremarkable. She had 2 episodes of seizures inpatient. Emperic antibiotics for meningitis were initiated. Family did not wish to pursue aggressive measures believing that her decline was a part of natural aging and dementia process. After explaining the possibility of an undiagnosed reversible process, they agreed for intubation and further procedures. Cerebrospinal fluid analysis showed 22/uL leucocytes (90% lymphocytes) and total protein 66 mg/dL (reference range:15–45). Venereal Disease Research Laboratory test and rapid plasma reagin titers were 1:8 and 1:128 respectively, confirming neurosyphilis. Old infarcts in putamen and pons, confluent periventricular and multifocal WM hyperintensities, microhemorrhages in the cerebellum, hippocampus and thalamus were noted on MRI. Therapy with IV penicillin was instituted and her mental status improved. At one month follow up, her neuropsychiatric impairments had improved, although her dementia persisted. Results: While her chronic alcohol use cannot be discounted, delay in therapeutic intervention could account for persistence of memory deficits. General paresis of insane is seen in late stage of neurosyphilis and if untreated, can result in death in 3–5 years. Although it is not known the extent to which neurosyphilis is missed in clinical practice, our case serves to remind physicians to consider this curable condition in differential diagnosis of encephalopathy.