Neurosyphilis in a middle-aged woman with rapid cognitive decline and psychosis: A case report

Dear editor,

Neurosyphilis is an infection caused by the Treponema pallidum bacterium, affecting the central nervous system1. Considering the mutable manifestations of neurosyphilis, its diagnosis should be suspected in patients presenting psychiatric symptoms, including psychosis2, mania3, and decline in cognitive function4. Furthermore, early differential diagnosis may facilitate its treatment management and improve its prognosis. Therefore, the possibility of organic etiology, including neurosyphilis, should be considered by clinicians when neuropsychiatric manifestations develop.

We report the case of a 44-year-old female patient, who continuously reported rapid cognitive decline, auditory hallucination, and persecutory delusion for 1 year and was admitted to the psychiatric ward of our hospital. Although a suboptimal therapeutic dose of antipsychotic was administered to the patient the previous year to alleviate her psychotic symptoms, extrapyramidal symptoms (EPS) were observed. While unsteady gait with frequent falls were reported in the following months, brain computed tomography and magnetic resonance imaging did not show any significant findings. Single-photon emission computed tomography revealed mild decreased frontal and parietal perfusion.

Given the patient's Mini-Mental State Examination score of 10/30, the possible organic cause of her rapid cognitive decline was evaluated. Therefore, syphilis testing was also arranged. Following serologic tests on blood serum, rapid plasma reagin (RPR) and treponema pallidum hemagglutination (TPHA), positive results were observed at serum titers of 1/8 and >1/5120, respectively. In contrast, the cerebrospinal fluid (CSF) analysis reported both the protein and glucose levels to be 46 and 69 mg/dl, respectively, and an absence of white blood cells. In addition, the RPR and TPHA were positive at 1/2 and >1/5120 serum titers, respectively. As a result, the neurologist confirmed the neurosyphilis diagnosis. Therefore, a benzathine benzylpenicillin treatment was prescribed to the patient, together with an amisulpride (200~600 mg/day) and valproate (1200 mg/day) therapy to alleviate her psychiatric symptoms. The patient was thus able to maintain relatively stable mental conditions in the nursing home for more than a year and admission to acute psychiatric ward was not required.

This case report may support the consideration of neurosyphilis as a differential diagnosis for patients with psychotic symptoms, especially when combined with rapid cognitive decline, sensitivity to antipsychotics, and neurological symptoms. Indeed, an early diagnosis is fundamental for a successful treatment. Irreversible neuronal loss may occur as progressive of disease5. In a previous paper, O'Neil and McCaffrey suggested the selective serologic screening of five groups: subjects with signs of an organic component, a clinical picture of dementia, abnormal neurological signs, atypical illnesses not responding to treatment, and taking risky sexual behaviors6. In addition, a combination of valproate and a low to moderate dose of amisulpride was here reported to be effective for the treatment of psychotic symptoms and aggressive behavior in this EPS-vulnerable patient.

To conclude, serologic tests for syphilis should be included in the differential diagnosis of patients with psychotic symptoms, especially when combined with cognitive decline or other neurological symptoms. Importantly, an early intervention can prevent neuronal damage and improve the prognosis of patients.

Acknowledgments

The authors declared no conflicts of interest associated with this manuscript.

This study was conducted in Taipei Veterans General Hospital, Yuli Branch, (Address: No. 91, Xinxing St., Yuli Township, Hualien County 981, Taiwan).

References

• 1. Chahine LM, Khoriaty RN, Tomford WJ, Hussain MS. The changing face of neurosyphilis. Int J Stroke. 2011;6(2):136-43.
• 2. Friedrich F, Aigner M, Fearns N, Friedrich ME, Frey R, Geusau A. Psychosis in neurosyphilis -- clinical aspects and implications. Psychopathology. 2014;47(1):3-9.
• 3. Seo EH, Yang HJ, Kim SH, Park JH, Yoon HJ. Psychotic mania as the solitary manifestation of neurosyphilis. Ann Gen Psychiatry. 2018;17(1):24.
• 4. Wlodarczyk A, Szarmach J, Jakuszkowiak-Wojten K, Galuszko-Wegielnik M, Wiglusz MS. Neurosyphilis presenting with cognitive deficits - a report of two cases. Psychiatr Danub. 2017;29(Suppl 3):341-4.
• 5. Conde-Sendin MA, Amela-Peris R, Aladro-Benito Y, Maroto AA. Current clinical spectrum of neurosyphilis in immunocompetent patients. Eur Neurol. 2004;52(1):29-35.
• 6. O'Neill T, McCaffrey B. Further support from an Irish psychiatric hospital for lack of value of routine serological tests for syphilis. Ir J Psychol Med. 1989;6(2):142-3.

Publication Dates

• Publication in this collection
  30 Apr 2021
• Date of issue
  Nov-Dec 2020

History

• Received
  06 May 2020
• Accepted
  29 June 2020