Clinical Review

Man, 54, With Delusions and Seizures

Clinician Reviews. 2011 April;21(4):20, 22, 24

References

1. Golden MR, Marra CM, Holmes KK. Update on syphilis: resurgence of an old problem. JAMA. 2003;290(11):1510-1514.

2. Simon RP. Chapter 20. Neurosyphilis. In: Klausner JD, Hook EW III, eds. Current Diagnosis & Treatment of Sexually Transmitted Diseases. USA: The McGraw-Hill Companies; 2007:130-137.

3. Sanchez FM, Zisselman MH. Treatment of psychiatric symptoms associated with neurosyphilis. Psychosomatics. 2007;48:440-445.

4. Marra CM. Neurosyphilis. Curr Neurol Neurosci Rep. 2004;4(6):435-440.

5. CDC. Sexually transmitted diseases surveillance, 2007: STD surveillance case definitions. www.cdc.gov/std/stats07/app-casedef.htm. Accessed March 23, 2011.

6. CDC. 2008 Sexually Transmitted Diseases Surveillance: Table 1. Cases of sexually transmitted diseases reported by state health departments and rates per 100,000 population: United States, 1941-2008. www.cdc.gov/std/stats08/tables/1.htm. Accessed March 23, 2011.

7. CDC. Sexually transmitted diseases (STDs): Syphilis: CDC fact sheet. www.cdc.gov/std/syphilis/STDfact-syphilis.htm. Accessed March 23, 2011.

8. Tramont EC. Chapter 238. Treponema pallidum (syphilis). In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 7th ed. Philadelphia: Elsevier Churchill Livingstone; 2009.

9. Ghanem KG. Neurosyphilis: a historical perspective and review. CNS Neurosci Ther. 2010; 16(5):e157-e168.

10. Workowski KA, Berman SM; CDC. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006;55(RR-11):1-94.

11. CDC. Sexually transmitted diseases: treatment guidelines 2006. www.cdc.gov/std/treatment/2006/genital-ulcers.htm#genulc6. Accessed March 29, 2011.

12. Drugs for sexually transmitted infections. Treatment Guidelines from the Medical Letter. 2010;95:95a. http://secure.medicalletter.org. Accessed March 23, 2011.

13. Russouw HG, Roberts MC, Emsley RA, et al. Psychiatric manifestations and magnetic resonance imaging in HIV-negative neurosyphilis. Biol Psychiatry. 1997;41(4):467-473.

14. Hooshmand H, Escobar MR, Kopf SW. Neurosyphylis: a study of 241 patients. JAMA. 1972;219 (6):726-729.

15. Miller CA, Joyce DM. Toxicity, phenytoin. http://emedicine.medscape.com/article/816447-overview. Accessed March 23, 2011.

16. Earnest MP, Marx JA, Drury LR. Complications of intravenous phenytoin for acute treatment of seizures: recommendations for usage. JAMA. 1983; 246(6):762-765.

17. Geschwind MD, Shu H, Haman A, et al. Rapidly progressive dementia. Ann Neurol. 2008;64(1): 97-108.

18. Mechem CC. Chapter 143. Altered mental status and coma. In: Ma J, Cline DM, Tintinalli JE, et al, eds. Emergency Medicine Manual, 6e. www.access emergencymedicine.com/content.aspx?aID=2020. Accessed March 23, 2011.

19. Knopman DS, DeKosky ST, Cummings JL, et al; Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: diagnosis of dementia (an evidence-based review). Neurology. 2001;56(9):1143-1153.

20. CDC. Syphilis testing algorithms using treponemal tests for initial screening—four laboratories, New York City, 2005-2006. MMWR Morb Mortal Wkly Rep. 2008;57(32):872-875.

21. Anderson CA, Filley CM. Chapter 33. Behavioral presentations of medical and neurologic disorders. In: Jacobson JL, Jacobson AM, eds. Psychiatric Secrets. 2nd ed. St. Louis, MO: Hanley & Belfus; 2001.

Patients with a penicillin allergy should undergo desensitization, as penicillin is the preferred agent; the potential exists for cross-reactivity with ceftriaxone, a possible alternative for patients with neurosyphilis.¹¹ All patients diagnosed with syphilis should also be tested for HIV and other sexually transmitted diseases.^10-12

The prognosis of patients treated for neurosyphilis is generally good if the condition is diagnosed and treated early. In patients with cerebral atrophy, frontal lesions, dementia, or tabes dorsalis, the potential for recovery decreases.^2,13,14

Teaching Points
There are several teaching points to take away from this case:

• Remember to rule out a CVA in any patient who presents with numbness, paresthesias, or slurred speech. In this case, a brain CT and CT angiography of the brain were both obtained in the ED before the patient was admitted. They both yielded negative results; because the patient’s history was consistent with alcohol and drug use and he had a history of seizures, he was monitored closely for signs of withdrawal or further seizure.

• Phenytoin is an antiepileptic agent whose use requires proper patient education and drug level monitoring. Appropriate follow-up must be ensured before phenytoin therapy is begun, as toxicity can result in nystagmus, ataxia, slurred speech, decreased coordination, mental confusion, and possibly death.^15,16

• For patients with a suspected acute change in mental status, a workup is required and should be tailored appropriately, based on findings. This should include, but not be limited to, a thorough history and physical exam, CT of the brain (to rule out an acute brain injury¹⁷), and, if warranted, MRI of the brain. Also, a urine drug screen and alcohol level, a complete blood count, a TSH level (to evaluate for altered thyroid function that may explain mental status changes), comprehensive panel, RPR testing and/or a VDRL titer should be obtained, depending on the facility’s protocol^18,19; at some facilities, a treponemal test, rather than VDRL, is being obtained at the outset.²⁰ Levels of vitamin B12 (as part of the dementia workup), folate, thiamine, and ammonia (in patients with suspected liver disease) can also be obtained in patients with change in mental status.^18,19 Urinalysis should not be overlooked to check for a urinary tract infection, especially in elderly patients.²¹

• If primary syphilis is suspected, treatment must be undertaken.²⁰

Conclusion
Despite the decline seen since the 1940s in cases of primary and secondary syphilis, and the effectiveness of penicillin in treating the infection early, patients with late-stage syphilis, including those with neurosyphilis, may still present to the emergency care, urgent care, or primary care setting. Immediate treatment with penicillin is recommended to achieve an optimal prognosis for the affected patient.