LAUSR

© Author(s) (or their employer(s)) 2021. No commercial reuse. See rights and permissions. Published by BMJ. CASE DESCRIPTION A 31yearold man presented with a 2week history of progressive paraparesis, leg numbness and urinary retention. He had no fever. Neurological examination identified paraplegia with hyperreflexia in both lower limbs. Pain and proprioceptive sensation were decreased below the T7 level. Magnetic resonance (MR) scan of the spine showed a T2hyperintense lesion extending from the fourth cervical vertebra level to the conus medullaris with the ‘flipflop sign’ and the ‘candle guttering appearance’ (figure 1). MR scan of the brain was unremarkable. Cerebrospinal fluid (CSF) examination showed an elevated opening pressure (25 cm H2O) with no pleocytosis, glucose 1.7 mmol/L (25% of glycaemia) and protein 1.6 g/L. CSF PCR testing for varicella zoster virus, herpes simplex virus, cytomegalovirus and tuberculous mycobacteria were negative. Serum antiaquaporin 4 antibodies were absent. He tested positive for HIV with a CD4 count of 246 cells/ μL. Venereal disease research laboratory (VDRL) tests were reactive in both his serum and CSF, confirming the diagnosis of syphilitic myelitis. Following 14 days of intravenous penicillin G 24 MU/day, his weakness and numbness gradually improved, and his strength was normal after 4 weeks.