October 15, 2020
A 32-year-old man with daily methamphetamine use and high-risk sexual practices presented with acute left hemiplegia in the context of chronic headaches and recurrent episodes of transient unilateral weakness.
Meningovascular Syphilis
- Background:
- Neurosyphilis can cause a medium-to-large vessel arteritis and is an uncommon but increasingly recognized cause of ischemic stroke in young adults, particularly those with HIV.
- Clinical Presentation:
- The classic presentation is ischemic stroke in an intracranial large vessel territory in a young patient without traditional vascular risk factors.
- Patients typically endorse a prodrome of several weeks to months of headaches, malaise, and/or personality changes.
- Key Diagnostic Features:
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CSF typically demonstrates a mild-to-moderate lymphocytic pleocytosis, and the diagnosis is established by positive CSF-VDRL.
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Vascular imaging demonstrates focal arterial narrowing or occlusion with circumferential mural enhancement on vessel wall MRI, typical of vasculitis.
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- Differential Diagnoses:
- Reversible cerebral vasoconstriction syndrome (RCVS): Typically little to no mural enhancement
- Intracranial atherosclerosis: Eccentric layered mural plaque with or without enhancing cap; clinical history of vascular risk factors
- Autoimmune vasculitis: Clinical and laboratory evaluation may help differentiate.
- Treatment:
- Intravenous penicillin G with close follow-up
- Test for and treat HIV coinfection
