Cerebral infarction as initial manifestation of meningovascular neurosyphilis in an immunocompetent patient - A case report with long term follow-up

Abstract

To present a 29-year-old immunocompetent patient with neurosyphilitic changes characterized by multiple acute ischemic brain strokes along with significant narrowing of several large intracranial arteries. Ceftriaxone treatment for 14 days followed by benzathine benzylpenicillin weekly for additional 3 weeks, showed improvement in meningovascular changes.

Keywords: magnetic resonance imaging; neurosyphilis; stroke; syphilitic arteritis.

FIGURE 1

Magnetic resonance of the brain at onset. (A) Diffusion‐weighted imaging, and the corresponding (B) apparent diffusion coefficient map showing acute ischemic infarcts (red arrows) involving the left caudate nucleus, left corona radiata as well as a small cortical and subcortical area of the left parietal lobe.

FIGURE 2

Three‐dimensional time‐of‐flight magnetic resonance angiography (MRA) of the brain at onset and 1 year after onset. (A) Coronal reconstruction of the MRA at onset showing significant narrowing of the terminal left internal carotid artery (ICA) segment (white arrow), left A1 segment (yellow arrow) and left M1 segment (red arrow). (B) MRA axial image at onset through the terminal left ICA segment presenting significant narrowing (dotted circle). (C) Maximum intensity projection MRA and (D) an MRA axial image displaying a high‐grade stenosis of the middle part of the basilar artery (white arrow and dotted circle, respectively). (E) Coronal reconstruction of the MRA done 1 year after onset showing almost complete regression of the terminal ICA segment narrowing (white arrow), complete regression of the left A1 segment narrowing (yellow arrow) and persistent narrowing of the left M1 segment. (F) MRA axial image 1 year after onset through the terminal left ICA segment presenting almost complete regression of the narrowing (dotted circle). (G) Maximum intensity projection MRA and (H) an MRA axial image displaying almost complete regression of the high‐grade stenosis of the middle part of the basilar artery (white arrow and dotted circle, respectively).