Cerebral syphilitic gumma mimicking a brain tumor in the relapse of secondary syphilis in a human immunodeficiency virus-negative patient

Abstract

Diagnosis of cerebral syphilitic gumma is frequently determined at the time of surgery, because imaging and laboratory findings demonstrate the elusive results. A 59-year-old woman presenting dysarthria showed a mass on her brain computed tomography. She was first suspected of brain tumor, but histological results from surgical resection revealed cerebral gumma due to neurosyphilis. After operation, she presented fever and rash with an infiltration on a chest X-ray. Histological assessment of skin was consistent with syphilis. Fluorescent treponemal antibody absorbed test IgG in cerebrospinal fluid was positive. She was successfully treated with ceftriaxone for 14 days.

Keywords: Ceftriaxone; Gummatous neurosyphilis; HIV negative; Latent syphilis.

Fig. 1

Brain magnetic resonance imaging (MRI) scans of the patient. A : The preoperative T1-weighted images showed a round mass-like lesion with isointensity in the peripheral and hypointensity in the central portion of the left frontal region. B : Non-contrast-enhanced, T1-weighted image demonstrated severe cerebral edema around the enhancing mass. C : Sagittal sections revealed a mass adjacent to the enhanced dura over the cerebral convexity. D, E and F : Three months after operation, the postoperative MRI scans showed that the rim enhancing mass in the left frontal region had disappeared with a small amount of remaining extraaxial fluid collection.

Fig. 2

Intraoperative and histopathological findings of a central nervous system gumma. A : The cerebral parenchyma was severely adhesive to the dura. B : The lesion had a rubbery appearance and was yellowish in color. En bloc resection was performed. C : High-power view of the mass showing occlusion of small arterioles as endoarteritis obliterans, and spirochetes were not detected on Warthin-Starry staining of this region (hematoxylin and eosin stain, ×400). D : The portion immediately below the meninges containing necrotic material infiltrated with predominantly plasma cells (×100). E : The peri-vascular region with fibrosis contained lymphocytes and plasma cells (×400). F : Parenchymal infiltration of lymphocytes and plasma cells in the gumma of the brain (×400).

Fig. 3

A and B : The rash was reddish-brown, non-itchy maculopapular and widespread over the whole body including the palms of the hands and soles of the feet. C : Chest computed tomograpic images show centrilobular nodules and infiltration with an interstitial pattern in both lower lung fields.