This article reports a male patient，aged 31 years，who were admitted due to sudden-onset speech and language impairment and limb weakness at the right side for more than 7 hours and achieved successful revascularization after endovascular treatment. Etiological screening revealed positive treponema pallidum particle agglutination （1∶1 280） and positive HIV antibodies in serum，as well as an increase in white blood cell count and positive TPPA （1∶640） in cerebrospinal fluid （CSF）. High-resolution magnetic resonance imaging of the vessel wall showed inflammatory changes in the vessel wall of the M1 segment of the left middle cerebral artery. After multidisciplinary consultation，the patient was diagnosed with acute ischemic stroke secondary to cerebral arteritis caused by neurosyphilis and HIV infection and was given antiplatelet therapy，benzathine penicillin for syphilis，and antiviral therapy. After 6 months of follow-up，the patient had a modified Rankin Scale score of 0 and achieved clearance of syphilis-related indicators in serum and CSF，and CT angiography confirmed revascularization without new-onset stenosis. The literature review shows that acute ischemic stroke is a common manifestation of co-infection with HIV and neurosyphilis in young individuals，and early syphilis detection in serum and CSF，HIV screening，and timely combination therapy are of great significance for improving prognosis.
Neurosyphilis ; Arteritis

Neurosyphilis （NS） is a group of diseases with a series of nervous system symptoms when Treponema pallidum infects the central nervous system， with an unknown pathogenesis and significant heterogeneity in clinical manifestations. It is called the “universal imitator”， leading to a high misdiagnosis rate in clinical practice. Cognitive impairment is one of the most common clinical manifestations of NS， but delayed diagnosis may cause irreversible neuronal damage. Therefore， early identification of NS with the main manifestation of mild cognitive impairment is of great importance for achieving a good prognosis of patients. This article reports a case of NS with the main manifestation of mild cognitive impairment and reviews its clinical features， in order to improve the understanding of this disease among clinicians.
Neurosyphilis

OBJECTIVE

To describe the clinical presentation, management and outcome of a rare case of isolated oculomotor nerve palsy in an immunocompromised adult secondary to a central nervous system (CNS) tuberculoma.

This is a case report.

A Filipino male in his 30s developed severe throbbing headache followed by binocular diplopia and drooping of the right upper eyelid. Findings were compatible with a neurologically-isolated pupil-involving, complete oculomotor nerve palsy on the right. Brain magnetic resonance imaging demonstrated enlargement and contrast enhancement of the cisternal portion of the right oculomotor nerve. Serologic testing was positive for the human immunodeficiency virus (HIV) and syphilis. Cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis and elevated protein. CSF polymerase chain reaction was positive for Mycobacterium tuberculosis (TB). The patient was treated with penicillin, quadruple anti-Koch’s, and anti-retrovirals. Eyelid position and ocular motility improved after treatment. Aberrant regeneration of the right oculomotor nerve was observed with elevation of the right eyelid on downgaze (pseudo-Graefe sign).

CNS tuberculoma may present as a neurologically-isolated oculomotor nerve palsy, particularly in immunocompromised individuals. In TB-endemic countries, like the Philippines, it should be considered in the differential diagnosis. Early recognition and appropriate antimicrobial therapy can lead to neurologic improvement.

Essential alopecia syphilitica (AS) is a rare presentation of secondary syphilis, known to affect 3-7% of the population. To the best of our knowledge, this is the first reported case in the country. Herein we present a rare case of alopecia syphilitica in a 27-year-old MSM.

A 27-year-old male presented with a 3-week history of irregularly-shaped, moth-eaten appearing alopecia without any history or presence of mucosal ulcers and copper penny-looking macules and plaques on the palms and soles. History-taking revealed multiple casual unprotected sexual practices. Syphilis enzyme immunoassay and rapid plasma reagin titer were reactive. Biopsy was consistent with syphilitic alopecia.

Syphilis, a highly prevalent STI presents in different spectra. Patients usually present with copper penny-looking erythematous to hyperpigmented macules and plaques on palms and soles, condylomata lata, erythematous papules and plaques on the trunk, and rarely as moth-eaten alopecia. Atypical presentation might lead to a missed diagnosis and untreated disease. This may give rise to an infectious and potentially debilitating deadly disease.

AS may be mistaken as any other alopecia. Keen clinical eye, high index of suspicion, thorough history-taking with emphasis on sexual history and complete physical exam are needed to prevent missed diagnoses in these cases. Prompt treatment, close follow-up and proper counselling are essential to completely diagnose and treat.

Congenital syphilis is a worldwide public health concern. This occurs when an infected mother transmits the infection to the fetus during pregnancy or at birth.

We present a case of a 6-day-old male, term, born to a mother with secondary syphilis, via normal spontaneous delivery. Upon birth, patient was well and not in cardiorespiratory distress. However, cutaneous examination revealed multiple, well-defined vesicles and pustules on an erythematous background, some topped with erosions and crusts on the scalp, face, extremities, and trunk. Laboratory work-up and imaging were done which revealed congenital syphilis. He was managed with intravenous Penicillin (100,000iu) 160,000 IV for ten days, and wound healing was hastened by use of a coconut-based cellulose wound dressing on the erosions. He was then referred to a multispecialty team to assess and co-manage possible complications. Regular interval follow-up and repeat laboratory tests were advised for observation and for monitoring.

Congenital syphilis is caused by the bacterium Treponema pallidum. Sequelae include preterm birth, low birth weight, skin lesions, bone deformities, hepatosplenomegaly, anemia, and neurological problems. Diagnosis can be made on clinical suspicion combined with Rapid Plasma Reagin (RPR) and Venereal Disease Research Laboratory (VDRL). Aside from Penicillin G, wound care, nutritional build up, and close monitoring of growth and development with regular follow-ups are essential aspects in the management of congenital syphilis. With timely and adequate treatment, infants have a higher likelihood of complete resolution of symptoms, prevention of long-term complications, and improved overall health outcomes.

Nodular syphilis with a granulomatous inflammatory histopathologic pattern is an uncommon cutaneous presentation of secondary syphilis which could pose a diagnostic challenge for clinicians and pathologists alike.

A 33-year-old male diagnosed with HIV presented with a 5-week history of asymptomatic generalized erythematous papules and nodules with overlying scales, with involvement of the palms and soles. Histopathologic examination of a nodule from the forearm revealed non-caseating granulomas in a background of a mixed cell inflammatory infiltrate composed of lymphocytes, epithelioid and foamy histiocytes, plasma cells, neutrophils, and multinucleated giant cells. Warthin-Starry Stain revealed spirochetal organisms, while Fite-Faraco and Periodic Acid-Schiff stains were negative for acid-fast bacilli and fungal elements, respectively. Rapid plasma reagin (RPR) was reactive (1:256). Patient was given a single dose of benzathine penicillin G 2.4 million units intramuscularly, with noted complete resolution of skin lesions as well as an 8-fold decrease in RPR titers.

Nodular lesions are an uncommon cutaneous manifestation of secondary syphilis, and the associated histopathologic finding of granulomatous inflammatory pattern is also unusual, posing a diagnostic challenge. With the increasing prevalence of syphilis, especially among HIV patients, dermatologists, dermatopathologists, internists, and infectious disease specialists should be aware of such presentations of syphilis.

Syphilis is one of the most common sexually transmitted diseases in the world. It is known as “the great mimicker” due to its varied cutaneous presentations, which can make it challenging to diagnose. We report a case of a 20‑year‑old female presenting with a nonhealing, pruritic, annular plaque on the left malar area of 3‑month duration. She was initially treated as a case of tinea faciei. The lesion was unresponsive to topical antifungals and steroids with continued increase in size and number. Skin biopsy revealed secondary syphilis with histopathologic features of granuloma annulare. Degenerated collagen, not a feature of secondary syphilis, was seen, prompting further studies to confirm the diagnosis of secondary syphilis. Alcian blue stain was negative, which helped rule out granuloma annulare. She was then given benzathine penicillin G 2.4 million U, which led to a significant decrease in the size of the lesion noted 1 week posttreatment. Only postinflammatory hyperpigmentation was noted after 1 month of treatment. Clinically, secondary syphilis may present as an annular lesion that can mimic tinea. This can also present with atypical histopathologic features and an in‑depth investigation is needed to further confirm the diagnosis.
Granuloma Annulare ; Syphilis

Neurosyphilis (NS) is an infectious disease caused by Treponema pallidum invading the central nervous system. It can manifest at any stage of syphilis, and is often misdiagnosed due to its atypical and progressive symptoms. The increasing incidence of NS underscores the necessity for early and accurate diagnosis. Here, we present a case where routine cerebrospinal fluid metagenomic next-generation sequencing (mNGS) was used to diagnose a patient with neurosyphilis. The patient exhibited cognitive impairment and was initially diagnosed with cerebral infarction due to syphilitic cerebral arteritis. Thus, the patient was treated with dual antiplatelet therapy (aspirin and clopidogrel) and statins to stabilize the plaques. Neurosyphilis was treated with penicillin sodium injections, resulting in significant improvement in the patient's mental state. This case is a rare instance of neurosyphilis associated with cerebral infarction. These findings suggest that mNGS is a valuable tool in diagnosing neurosyphilis, potentially improving diagnostic accuracy and patient outcomes.
Humans ; Anti-Bacterial Agents/therapeutic use* ; Cognitive Dysfunction/etiology* ; High-Throughput Nucleotide Sequencing ; Neurosyphilis/drug therapy* ; Treponema pallidum/isolation & purification*

We report two infants with neonatal cholestasis and hepatosplenomegaly secondary to congenital syphilis. The onset of jaundice of the first infant was at six weeks of life and the second case on the 28th hour of life with associated neurologic and bone involvement. The diagnosis was suspected based on a maternal history of untreated syphilis, clinical findings, and a reactive rapid plasma reagin. Early recognition and treatment can lead to clinical improvement but prevention by mandatory testing and treatment of maternal syphilis is a more effective strategy
Congenital syphilis ; neonatal cholestasis

Objective: To analyze the association between different treatment timings and adverse neonatal outcomes (premature birth, death, congenital syphilis) in syphilis-infected pregnant women. Methods: The National Management Information System for Prevention of HIV, Syphilis and HBV Mother-to-Child Transmission was used to collect information on the detection and treatment of syphilis-infected pregnant women and their newborns in Guangdong Province from October 2011 to December 2021. According to the gestational weeks of syphilis-infected pregnant women receiving penicillin treatment for the first time, they were divided into four groups: treatment in the first trimester, treatment in the second trimester, treatment in the third trimester, and no treatment during pregnancy. Multivariate logistic regression was used to analyze the association between different treatment timings and adverse neonatal outcomes in syphilis-infected pregnant women. Results: A total of 22 483 syphilis-infected pregnant women were included. The number of pregnant women who started treatment in the first trimester, second trimester, and third trimester and did not receive treatment during pregnancy were 4 549 (20.23%), 8 719 (38.78%), 2 235 (9.94%) and 6 980 (31.05%), respectively. Compared with pregnant women who started treatment in the first trimester, pregnant women who did not receive anti-syphilis treatment during pregnancy had increased risks of neonatal preterm birth (OR=1.42, 95%CI: 1.24-1.62), death (OR=4.27, 95%CI: 1.64-14.69) and congenital syphilis (OR=12.26, 95%CI: 6.35-27.45). At the same time, the risk of congenital syphilis in the newborns of pregnant women who started anti-syphilis treatment in the second trimester (OR=2.68, 95%CI: 1.34-6.16) and third trimester (OR=6.27, 95%CI: 2.99-14.80) also increased. Conclusion: Early initiation of anti-syphilis treatment during pregnancy in patients with syphilis can improve neonatal outcomes.
Pregnancy ; Female ; Infant, Newborn ; Humans ; Pregnant Women ; Syphilis/diagnosis* ; Pregnancy Complications, Infectious/drug therapy* ; Syphilis, Congenital/drug therapy* ; Premature Birth ; Infectious Disease Transmission, Vertical/prevention & control*