A Blurry Disguise for the Great Imitator! · By, Dr Kamaljit Kaur Khalsa (ST2 Medical Microbiology)...
Transcript of A Blurry Disguise for the Great Imitator! · By, Dr Kamaljit Kaur Khalsa (ST2 Medical Microbiology)...
A Blurry Disguise for the
Great Imitator!
By, Dr Kamaljit Kaur Khalsa
(ST2 Medical Microbiology)
Greater Glasgow & Clyde
The story…
• 61 year old man
– 3m before diagnosis:
• Left sided hearing loss, tinnitus
• Gait disturbance: needing a walking stick
• MRI normal ?labrynthitis
– 2m before diagnosis
• Admitted for 2 days; malaise, sweats and eye symptoms
• Non-contrast spiral CT brain & MRI
‘small vessel change’
• Diagnosed ?acoustic neuroma ?labyrinthitis
• High dose steroids & home with O/P ENT review
• 61 year old man
– O/P Ophthalmology review
• Swollen left optic disc
• VA 6/9 right, 6/5 left, enlarged blind spot
• CRP 41, ESR 16
• Colour vision declining
• CT orbit NAD
• Finally admitted as an emergency:
• Nystagmus on left lateral gaze, reduced
visual acuity, declining colour vision,
presence of ‘zig-zag’ lines obstructing
vision.
• Gait ataxic and generalised
maculopapular rash noted on chest.
A diagnostic test was performed..
What is the next most appropriate
investigation?
A autoantibodies
B CSF PCR for multiple viruses
C HIV testing
D serum B12
E syphilis serology
Results
Syphilis EIA positive HIV test-negative
• VDRL 1:128
• TPPA> 1:280
• IgM Positive
CSF
• Normal opening pressure
• Pleocytosis with 17 WBC/ cu mm
• CSF +ve VDRL at neat, protein 0.69 g/L (0.10-0.50
g/L), glucose 3.0 mmol/L (2.5-4.5 mmol/L)
Final diagnosis
Acute Meningovascular
Neurosyphilis
Management
• Treatment with procaine penicillin 2.4 mega
units I/M daily for 21 days with oral
probenecid 500mgs qds and a tapering
course of high dose prednisolone.
• He has a made a reasonable recovery and
responded serologically although has residual
tinnitus.
• Arrange three monthly VDRL serum tests for
a year and repeat LP after one year to ensure
clearance of CSF VDRL reactivity.
CNS Invasion with Treponema pallidum
Clearance/Resolution Transient Meningitis
Persistent/asymptomatic meningitis (early onset disease)
Clearance/Resolution
Early symptomatic neurosyphilis
(Weeks-Months)
Late symptomatic neurosyphilis
(Years)
Symptomatic Meningitis
•Headache, meningism, nausea,vomiting
Cranial neuropathies
Ocular involvement
Meningovascular stroke + meninigits
General paresis Dementia
Personality change
Tabes dorsalis Spinal cord involvement Sensory ataxia
Incontinence
Number of syphilis diagnosis in the
UK by sex and sexual orientation:
1997-2007
Key Learning Points
• Cases of syphilis are on the rise;
clinicians should be aware of its many
‘disguises’
• Clinical presentation of neurosyphilis
changed in recent years so difficult to
categorise
• Routine testing for syphilis in adults
presenting with unexplained visual or
auditory disturbance should be
considered.
Special Thanks…
• Dr Andrew Winter, Consultant in GUM
• Dr Krishna Dani, SpR in Neurology
• West of Scotland Regional Virus
Laboratory
• Patient
Any Questions?