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.