Issue: 2016 > June > photo quiz

Answer to Photo Quiz: A 49-year-old woman presenting with aphasia

D. van Casteren, K.S. Adriani
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Her past medical history revealed a syphilitic infection in 1987. In 2010, when a lumbar puncture was needed to rule out neurosyphilis, she withdraw herself from medical control. Treponema pallidum haemagglutination assay (TPHA) in serum was grossly reactive (1:10,240), while rapid plasma reagin (RPR) was not reactive (1:1). A lumbar puncture was performed and cerebrospinal fluid (CSF) analysis showed an elevated protein of 1.27 g/l, a slightly raised cell count of 8 x 106/l and a glucose level of 3.4 mmol/l. The TPHA was increased (1:16) in the CSF, but RPR was negative. A HIV test was negative. Because of the presence of a recent infarction in the distribution of the left middle cerebral artery on MRI imaging of the brain, the diagnosis neurosyphilis of the meningovascular type was made.1,2
The patient was treated with intravenous benzylpenicillin, but substantial aphasia persisted. Two months later follow-up MRI of the brain revealed the same grey matter and white matter lesions, with a reduced degree of enhancement after administration of gadolinium (figure 1D) and the aphasia had improved. 
Neurosyphilis is an infection of the central nervous system caused by Treponema pallidum and can occur at any time in the course of the infection.1 There are four different types of symptomatic neurosyphilis: tabes dorsalis, dementia paralytica, syphilitic meningitis and meningovascular syphilis. In case of neurological symptoms in a patient with a medical history of a syphilitic infection, neurosyphilis should be considered. In CSF, the RPR has a high false-negative rate and also TPHA can be negative in case of tertiary syphilis.1,3 In these cases, the main diagnostic criteria are protein level and cell count in CSF. Treatment of neurosyphilis consists of intravenous administration of benzylpenicillin 18 to 24 million units a day for 10-14 days. During follow-up a lumbar puncture should be repeated every six months until the protein level and cell count have normalised.4
In general, comparable to our patient’s situation, patients with meningovascular syphilis do not always recover completely. 


The authors thank Dr. Herderscheê, neurologist at Tergooiziekenhuizen, for his help and reviewing this case.


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  3. Harding AS, Ghanem KG. The Performance of Cerebrospinal Fluid Treponemal-Specific Antibody Tests in Neurosyphilis: A Systematic Review. Sex Transm Dis. 2012;39:291-7. 
  4. Workowski KA, Bolan GA; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64:1Y137.