Ocular Syphilis and Syphilitic Meningitis as the Initial Symptoms of Neurosyphilis in an HIV-Negative Patient: A Case Report

Abstract

Syphilis is an infectious disease caused by the spirochete bacteria Treponema pallidum and is most commonly transmitted via contact of mucous membranes with infectious lesions during sexual intercourse. It is called the "great mimicker" due to its ability to infect a wide variety of organs and, as a result, produce a multitude of symptoms. Neurosyphilis, an infection of the central nervous system, can occur at any stage of infection. Cases of early neurosyphilis may not present with any prior history of syphilis infection or classical symptoms of primary or secondary infection. Homosexual men are disproportionately affected by the increasing rate of transmission.In this case, a 43-year-old man was diagnosed with neurosyphilis, initially presenting with bilateral papilledema concerning for idiopathic intracranial hypertension. A detailed social history revealed that the individual was sexually active with a male partner. Despite nonreactive results from the rapid plasma reagin and CSF Venereal Disease Research Laboratory tests, further serum workup yielded positive results for treponemal antibodies. Evidence of facial nerve involvement was also found on MRI. These findings were consistent with a diagnosis of ocular syphilis with syphilitic meningitis involving cranial nerve VII. This case demonstrates the importance of clinical suspicion for syphilis when indicated by social history, even when screening tests are negative, due to the potential for false negatives and highly variable clinical presentation.

Keywords: neurosyphilis; ocular syphilis; syphilis screening; syphilitic meningitis; visual disturbances.

Figure 1. Axial post-contrast T1 (A), axial FLAIR (B), coronal pre-contrast T1 (C), coronal post-contrast T1, and (D) brain magnetic resonance imaging

The image shows enhanced linear areas within the internal auditory canals bilaterally, with the left side exhibiting more enhancement than the right, specifically along the intracanalicular segment of the facial nerves, accompanied by a corresponding FLAIR hyperintense signal (white arrow). FLAIR, fluid-attenuated inversion recovery.

Figure 2. Timeline of disease course from onset of symptoms to resolution

LP, lumbar puncture.