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Título

Cranial nerve involvement by Neurosyphylis

RESUMO

CASE PRESENTATION: A 67 yo female patient presented with right peripheral facial paralysis, followed by scotomas in the left eye (LE) and decreased visual acuity. On evaluation, she presented ocular pain and anterior uveitis, low visual acuity (20/100) and relative afferent pupillary defect in the LE, with scotomas in the left temporal hemifield, marked papillitis and bilateral red desaturation. There was also mild peripheral facial paralysis and right sensorineural hearing loss. She also had erythematous, scaly and diffuse infiltrative plaques and papules in the lower limbs, hypogastric, paravertebral and inframammary regions. The serum Veneral Disease Research Laboratory (VDRL) test was positive, with a titer of 1/512, and the Microparticle Chemiluminescence for Syphilis (CMIA) also had a positive result, of 24.21. In the cerebrospinal fluid, mild pleocytosis was observed, with 9 cells/dL, normal total protein (12 mg/dL), reagent FTA-ABS test and negative VDRL. Anatomopathological result of skin biopsy pointed lymphohistiocytic dermatitis, suggesting treponematosis. Brain Magnetic Resonance demonstrated enhancement in the auditory canals, greater on the left. The patient was treated with intravenous crystalline penicillin G for 14 days, with improvement of the skin lesions and visual acuity.
DISCUSSION: Neurosyphilis can occur at any stage of the disease, as the bacterium Treponema pallidum spreads throughout the body early in the infection, including the central nervous system. The patient in question had involvement of the cranial nerves most commonly reported in cases of neurosyphilis (II, VII and VIII), at the secondary stage of the disease. Syphilis diagnosis demands a positive treponemal test and a positive non-treponemal test, while neurosyphilis diagnosis requires a compatible clinical picture and cerebrospinal fluid. CSF in neurosyphilis is marked by pleocytosis and hyperproteinorraquia. CSF's VDRL is highly specific with a sensitivity between 30-70%, therefore, it does not exclude the diagnosis. CSF treponemal test is highly sensitive but not very specific for the disease.
FINAL COMMENTS: Neurosyphilis is a manifestation that can occur at any stage of the disease, however, it is treatable and, if diagnosed and treated early, serious sequelae can be avoided.

Palavras Chave

Neurosyphilis; Facial paralysis; Optic neuropathy; Sensorineural hearing loss

Área

Neuroinfecção