A 38-year-old man was admitted to the hospital with a 3-year history of memory impairment. He had attended the psychiatric clinic with manic behavior, aggression, and delusions, and had been treated with antipsychotics and antidepressants. One year earlier, he had had speech difficulty, sometimes using words in other languages. Six months later, he developed pallilalia and episodes of laughing and crying. He reported no previous disease, and the family history was unremarkable. The physical examination showed no abnormality. On neurological examination, he was alert, disoriented, and had slight dysarthria; he was slow in response to commands. Pupils did not respond to light but contracted normally to accommodation and convergence (Argyll-Robertson pupils). The deep tendon reflexes were symmetric and brisk. The plantar responses were bilaterally extensor. Results of liver function tests, thyroid hormones, vitamin B12, folic acid, and other biochemical tests were normal. In serum testing, treponema pallidum hemagglutination assay (TPHA) and venereal disease research laboratory test (VDRL) were positive, at 1/5120 and 1/8 titers, respectively. CSF showed normal WBC count, protein 25 mg/dl, glucose 56 mg/dl, and the TPHA test was positive, at 1/320 titer. He was serologically negative for HIV infection. His Mini-Mental State Exam (MMSE) score was 8/30 because of to deficits in orientation, memory, attention, calculation, recall, and language. Cranial MRI study showed cerebral atrophy, particularly in the frontal lobe Figure 1).
FIGURE 1.Cerebral and Cerebellar Atrophy Seen in the Axial and Sagittal Sections on MRI
The patient was started on ceftriaxone (1.2g IM daily) for 14 days. He is currently being monitored by neurology and infectious disease departments, and syphilis serology will be performed regularly during that time.