CUTANEOUS TERTIARY SYPHILIS WITH NEUROLOG ICAL SYMPTOMS

Introduction. The tertiary cutaneous syphilis is now extremly rare. We report a case of tubercular cutaneous syphilis associated with neurol ogical dysfunction. We emphasize the difficulties to interpret serolog ic and CSF tests for the diagnosis of neurosyphilis. Case report. A 63 year-old-woman had nodular, purplish and painless cutaneous lesions o n forhead and forearm for 6 months. The biopsy showed a dermohypodermi c lymphoplasmocytic granuloma, without necrosis, with endothelitis. Sy philis serologic tests were positive: VDRL = 512 U; TPHA = 40,960 U; F TA abs: IgG = 72,000 U; IgM = 1,350 U; Nelson test = 100 p. 100 (1,200 U). HIV test was negative. There was a past history of a positive syp hilis serologic test when the patient was 20-year-old. The patient com plained of shaking and her family spoke of gradual mental deterioratio n and behaviour troubles. The neurological examination showed a major frontal syndrome, cerebellar dysfunction with dysarthria and a major l abial and lingual tremor. There is no lymphocytosis nor increased prot ein in the CSF; VDRL test was negative, TPHA test was positive, FTA ab s = 4,000 U (IgG), and TPHA was increased. Penicillin G 16 millions un its/day was given intravenously for 20 days; a slow increase was made in association with steroids at the beginning. The cutaneous lesions r egressed in 14 days, but the neurologic state did not change. Six mont hs later, there was still no IgM, TPHA decreased and VDRL was unchange d. Discussion. While the diagnosis of tertiary cutaneous syphilis was correct, the neurological abnormalities are difficult to classify. The symptoms were those of general paresis, but there is no argument favo uring biological CSF activity (no increase in protein or lymphocytosis , negative VDRL). Nevertheless, in the context of very positive serolo gic tests and tertiary cutaneous syphilis, we treated this case as a n eurological syphilis. The treatment regimen and the need of current cu res are still under discussion.