Late Onset Neurosyphilis in a 30-year-old Male Patient

Abstract

Background Neurosyphilis, a severe manifestation of syphilis, can emerge years after the initial infection, affecting the central nervous system. Diagnosing neurosyphilis is challenging; the cerebrospinal fluid (CSF) test, though highly specific, has a sensitivity ranging from 49% to 87% (Marra et al., 2020). Consequently, a negative CSF result does not exclude neurosyphilis, especially in patients with neurological symptoms and positive syphilis serology. In such cases, additional CSF treponemal - specific antibody tests are recommended due to their high sensitivity. This case report aims to identify the main signs of late-onset neurosyphilis and raise awareness about diagnostic challenges. Case Report Medical history: since September 2024, the patient experienced chest, head, and eye pain, blurry vision, and neck and shoulder pain. Over time, chest pain worsened with deep breathing, radiating to the third intercostal space and armpit. Later, additional symptoms have appeared, including tinnitus, nasal congestion when lying down, and coordination issues causing abnormal gait. On January 10, 2025, the patient was observed by a family physician, who suspected syphilis. Serology tests confirmed the diagnosis with results showing RPR 1:8 and TPHA 1:1280. The patient’s last sexual encounter was three years ago. A dermatovenerologist evaluated the patient on January 23, scheduling hospitalization for January 27. Testing on January 28 showed no specific changes. On January 29, a cerebrospinal fluid (CSF) sample was collected, with a Treponema pallidum result of 0.54 (negative). CSF protein was normal at 0.301 g/L. History suggests the initial syphilis infection occurred approximately three years ago, indicating a late-stage presentation. The patient was hospitalized for 14 days, receiving IV Penicillini 3 million IU 6×/day, followed by single administration of Benzathine benzylpenicillin 2.4 million IU IM. Symptoms improved, though mild neurological issues persist. Regular neurology follow-ups will be required. Due to past chest pain, ongoing cardiology consultations are also needed. The patient was discharged for outpatient follow-up. Conclusions This case highlights the challenges of diagnosing late-onset neurosyphilis and the risk of irreversible neurological damage if left untreated. Early detection through regular STD screening is crucial in preventing such cases, ensuring timely treatment before severe complications develop.