Gummatous Neurosyphilis With Transient Worsening of Neurological Symptoms After Treatment Initiation

Abstract

Cerebral syphilitic gumma is an atypical presentation of neurosyphilis, the clinical manifestations of which depend on the size and location of the lesions. It radiologically presents as enhancing nodular lesion(s) in brain parenchyma. We present a case of a patient with cerebral syphilitic gummas who had worsening neurological symptoms a few hours after initiation of anti-syphilitic antibiotic treatment. We aim to illustrate the clinical and radiological characteristics that might be helpful to clinicians when approaching the challenges they might encounter while treating neurosyphilis.

Keywords: central nervous system infections; gumma; jarisch– herxheimer reaction; neurosyphilis.

Figure 1.

Brain magnetic resonance imaging performed at admission. Axial gadolinium-enhanced T1WI sequence shows avidly enhancing nodular lesions located within the left more than right medial temporal lobe (A), along the periphery of left midbrain, bilateral hypothalamus (B), and left more than right inferior basal ganglia (C).

Figure 2.

Brain magnetic resonance imaging performed 7 days before treatment (A, B), 5 days after starting penicillin (C, D), 3 weeks after starting penicillin (E, F), and 3 months after starting penicillin (G, H). Axial gadolinium-enhanced T1WI sequences (A, C, E, G) show an increase in enhancement in the right medial temporal lobe following initiation of antibiotics (C as compared to A), with subsequent progressive decrease in size of enhancing lesions within bilateral medial temporal lobe to near resolution (E, G as compared to A, C). Axial FLAIR sequences (B, D, F, H) show worse edema surrounding lesions within left more than right medial temporal lobe after starting anti-syphilitic treatment (D) that progressively improved and resolved (H).