The Journal of International Medical Research 2006; 34: 335 – 337 Psychosis or Simply a New Manifestation of Neurosyphilis? E KARARIZOU1, C MITSONIS2, N DIMOPOULOS2, K GKIATAS3, I MARKOU3 AND N KALFAKIS1 1Department of Neurology, Eginition Hospital, Athens National University, Athens, Greece; 2Psychiatric Hospital, Athens, Greece; 3Neurological Clinic, Air Force Hospital, Athens, Greece The widespread use of antibiotics in recent years has caused a significant reduction in the incidence of neurosyphilis and changes in its clinical features. We present a case that initially presented as persistent headache and untreatable psychosis. Neurosyphilis was diagnosed during the clinical evaluation. Blood serum analyses for syphilis were positive for rapid plasma reagin titres, the Venereal Disease Research KEY WORDS: VENEREAL DISEASE; Laboratories test and fluorescent treponemal antibody absorption. A lumbar puncture was performed and cerebrospinal fluid analysis resulted in the diagnosis of neurosyphilis. The patient completed a 2-week course of treatment with aqueous crystalline penicillin G and his symptoms subsequently improved. We suggest that neurosyphilis should always be included in the differential diagnosis of untreatable psychosis. NEUROSYPHILIS; PSYCHOSIS; LUMBAR Introduction The widespread and somewhat indiscriminate use of antibiotics during recent years has considerably altered the clinical patterns of syphilis and neurosyphilis.1,2 The disease has not been eliminated and its typical forms are frequently replaced by atypical or masked forms, which have psychiatric symptoms that include depression, fury and/or psychosis.3 – 5 This not only creates diagnostic problems but also leads to the wrong therapeutic decisions being made. The diagnosis and treatment of neurosyphilis becomes even more complicated and clinically important when we consider the resurgence of syphilis worldwide, not only in developing countries but also in Western societies, and the increase in immigrant populations.6 – 8 PUNCTURE In this study, we describe a case that initially presented as persistent headache and untreatable psychotic symptoms, which was subsequently diagnosed as neurosyphilis during the clinical evaluation. Case report Twelve months prior to admission to the hospital, a 33-year-old man with persistent headache for the last 5 years, but no prior psychiatric history, developed paranoid ideation (delusions of persecution), acoustic hallucinations of threatening content, social withdrawal, loss of body weight (> 15% in 1 year) and blunted affect. The patient initially received risperidone in doses up to 10 mg/day, which was replaced by haloperidol in doses up to 30 mg/day without significant 335 Downloaded from imr.sagepub.com by guest on June 15, 2016 E Kararizou, C Mitsonis, N Dimopoulos et al. Psychosis and neurosyphilis improvement of his symptoms. For the past 6 months the patient has been treated with clozapine (500 mg/day) with only minor subsequent improvement. The patient presented to our hospital complaining of persistent, severe, generalized headache, with no provoking factors and associated features, partially responding to commonly prescribed pain medication, and worsening of his psychotic symptoms. There were no pathological findings reported on physical examination. He scored 22/30 on the Mini-Mental State Examination (MMSE), with disturbances of recent memory, orientation in time and place, and attention deficit. Standard laboratory work-up was within the normal range. Electroencephalogram, computed tomography and magnetic resonance imaging brain scans were negative for pathological findings. Blood serum analyses demonstrated a negative human immunodeficiency virus (HIV) test, a positive rapid plasma reagin (RPR) test, a positive Venereal Disease Research Laboratories (VDRL) test and a positive fluorescent treponemal antibody absorption (FTA-Abs) test. A lumbar puncture was performed and cerebrospinal fluid (CSF) analysis revealed a protein level of 85 mg/dl, a white blood cell count of 27 cells/mm3 (21% polymorphs, 79% mononuclear cells), a positive FTA-Abs test and a positive VDRL test. These findings resulted in a diagnosis of neurosyphilis. The patient received 14 days of intravenous aqueous crystalline penicillin G (4 × 106 IU every 4 h), while continuing his antipsychotic medication. After 10 days of treatment, the patient began to recover, as indicated by complete recovery from headache, acoustic hallucinations and delusions, and by becoming aware of his medical condition and displaying psychomotor improvement. He performed better on the MMSE (27/30). Six months after treatment, a new lumbar puncture was performed and CSF analysis revealed a normal protein level (45 mg/dl) and a normal white blood cell count (4 cells/mm3). The FTA-Abs and VDRL tests remained positive. An appointment was made at this time for a new lumbar puncture and CSF analysis in 6 months’ time. His clinical picture showed improvements and there were no episodes of headache and no psychotic symptoms. Discussion In recent years, the use of antibiotics, especially penicillin, in the treatment of syphilis has caused a significant reduction in the prevalence of neurosyphilis in Greece.9 The inappropriate and excessive use of antibiotics for all kinds of infections, together with the inefficient treatment of syphilis in its early stages, appears to have altered the clinical pattern of neurosyphilis. The classic forms of the disorder (general paresis, tabes dorsalis) are rarely seen in everyday clinical practice, having been replaced by other atypical clinical forms, with few symptoms, in which the classical neurological signs of neurosyphilis are absent.1,3 Today mental disorders and cognitive impairment present the most common expressions of neurosyphilis in many countries of the European Union, including Greece, in contrast to other typical symptoms, such as those of the eyes (mainly Argyll Robertson pupil) and tabetic symptoms, which tend to disappear.2,3 Serum analysis for syphilis (VDRL test and FTA-Abs) is considered routine in all patients who present with certain mental disorders (mainly psychotic symptoms) and who are hospitalized for the first time in certain psychiatric settings.5 In several circumstances, however, patients who suffered from syphilis in the past, whether they received treatment or not, may relapse. Whenever patients develop mental/cognitive 336 Downloaded from imr.sagepub.com by guest on June 15, 2016 E Kararizou, C Mitsonis, N Dimopoulos et al. Psychosis and neurosyphilis disorders, even without neurological symptoms, a lumbar puncture and CSF analysis must be performed, regardless of the results of serum analyses for syphilis. The resurgence of syphilis in Greece and other countries of Western Europe during the last 20 years seems to be associated not only with the unsafe sexual behaviour of some members of certain populations (homosexuals, sex workers, psychiatric patients), the intravenous use of illicit drugs and the increased co-morbidity with HIV infection, but also with the increasing immigration into countries of Western Europe of people from countries where syphilis is endemic.6,10,11 From 1990 until the present day, Greece has received almost one million economic immigrants from Eastern Europe, Asia and Africa.8 This fact must alert us all to be more cautious regarding the diagnosis, treatment and screening of patients with syphilis in its early stages if we want to avoid an exacerbation of neurosyphilis, the diagnosis of which in recent years has become quite difficult because of the atypical way in which it is expressed. Neurosyphilis must always be included in the differential diagnosis of psychosis.12 Conflicts of interest No conflicts of interest were declared in relation to this article. • Received for publication 26 October 2005 • Accepted subject to revision 14 November 2005 • Revised accepted 10 January 2006 Copyright © 2006 Cambridge Medical Publications References 1 Timmermans M, Carr J: Neurosyphilis in the modern era. J Neurol Neurosurg Psychiatry 2004; 75: 1727 – 1730. 2 Marra CM: Neurosyphilis. Curr Neurol Neurosci Rep 2004; 4: 435 – 440. 3 Conde-Sendin MA, Hernandez-Fleta JL, Cardenes-Santana MA, Amela-Peris R: Neurosyphilis: forms of presentation and clinical management. Rev Neurol 2002; 35: 380 – 386. 4 Lair L, Naidech AM: Modern neuropsychiatric presentation of neurosyphilis. Neurology 2004; 63: 1331 – 1333. 5 Saik S, Kraus JE, McDonald A, Mann SG, Sheitman BB: Neurosyphilis in newly admitted psychiatric patients: three case reports. 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Neuropsychiatry Neuropsychol Behav Neurol 2000; 13: 297 – 302. Address for correspondence Dr E Kararizou Neurologic Clinic, Eginition Hospital, 72–74, Vass. Sofias Ave., 11528 Athens, Greece. E-mail: ekarariz@med.uoa.gr 337 Downloaded from imr.sagepub.com by guest on June 15, 2016