Meningovascular syphilis causing recurrent stroke and diagnostic difficulties

What is it about?

We describe a case of a 49-year-old man who presented with recurrent strokes in the left middle cerebral artery territory, manifesting with dysphasia, higher cognitive deficits, motor deficits and subsequent infarcts in the right middle cerebral and anterior cerebral artery territories, manifesting with seizures, behavioural and social issues. A key issue of the case was the diagnostic difficulty faced by the physicians. ’Meningovascular syphilis’ was subsequently confirmed and appropriate treatment was given but there was subsequent relapse with worsening of the symptoms. Multiple specialists were involved in the management, namely stroke team, neurologists, psychiatrists, infectious disease and multidisciplinary therapy teams. This case highlights the need to be vigilant to the resurgence of syphilis, a scourge from the past, as a cause of stroke, especially in individuals who have had exposure to affected people. A key issue of the case was the diagnostic difficulty faced by the physicians. It is easy to miss the diagnosis and mistake it for other conditions unless a detailed history is taken and appropriate investigations are conducted, with a low threshold for diagnosis.

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Why is it important?

►► The resurgence of syphilis in the modern era is of great public interest. ►► Neurosyphilis is a great ‘mimicker’ and can present with a wide array of signs and symptoms. ►► Taking a detailed history in susceptible individuals is paramount. ►► Meningovascular syphilis should be considered as a diagnostic possibility in unexplained strokes in vulnerable individuals. ►► Prior to giving toxic immunosuppressive therapy for presumed primary angiitis of the nervous system or other vasculitides, infective aetiologies should be excluded.

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