Cerebrovascular complications of neurosyphilis: The return of an old problem

Neurosyphilis is increasing due to a rise in the number of cases of syphilis in cocaine/crack addicts and in patients with HIV infection. Neurosyphilis is an example of a unique group of chronic CNS diseases that may cause either a degenerative or a vasculitic process, where the main pathogenic event is “endarteritis obliterans” of terminal arterioles. In meningovascular neurosyphilis, the most commonly involved artery is the middle cerebral artery. It generally presents with a prodromic phase, weeks or months before the onset of identifiable vascular syndromes. When there is focal inflammation the clinical picture is characterized by hemiplegia, whereas in the case of multifocal involvement of small intracranial arteries, it presents with a slowly progressive loss of cognitive functioning and personality changes. Since neurological deficits once established may only slightly improve with treatment, the goal of therapy is to halt the progression of the disease. Intravenous aqueous crystallin penicillin G is the most accepted treatment. HIV-infected patients have shown accelerated development of neurosyphilis, and it is suggested that coinfection with HIV alters the course of Treponema pallidum infection. Atypical manifestations of neurosyphilis have been reported among HIV patients, including fulminant presentation, rapid progression, atypical serological findings, and failure of conventional doses of penicillin to eradicate infection.