Case Presentation: A 45 year-old man with no past medical history presented with recurrent nausea, vomiting, and abdominal pain. He had previously been admitted for nausea and vomiting and was diagnosed with gastritis and discharged home with pantoprazole. It initially improved but he began experiencing postprandial nausea and vomiting again 3-4 weeks ago. His intermittent vomiting was accompanied by severe, burning, epigastric abdominal pain and non-bloody and non-bilious emesis. He reported no recent NSAID use and moderate alcohol intake. He denied fever, diarrhea, constipation, bloody or black stools, rashes, and sick contacts. His vitals were within normal limits. His physical exam was significant for Argyl-Robertson pupils, a 2/6 systolic crescendo-decrescendo murmur best heard at the right upper sternal border, decreased symmetric lower extremity reflexes, and a positive Romberg sign. His abdominal exam was normal.
His RPR was positive with a titer of 1:16 and FTA-ABS was reactive. A spinal tap revealed a reactive VDRL with a titer of 1:2 and no other CSF abnormalities. He was HIV-negative. A gastric emptying study and EGD were unremarkable, and stomach biopsies were negative for H. pylori. Echocardiogram revealed a bicuspid aortic valve with moderate aortic stenosis, mild aortic regurgitation and a dilated ascending aorta. He received aqueous crystalline penicillin G 24 million units IV per day for 14 days. His GI symptoms resolved and he was scheduled for another spinal tap 6 months later to assess treatment success.
Discussion: Neurosyphilis refers to a CNS infection by T. pallidum and can occur at any stage of syphilis. Early neurosyphilis typically affects the meninges and vasculature while late neurosyphilis typically affects the brain and spinal cord parenchyma. Meningovascular manifestations can range from meningitis to stroke. In contrast, general paresis (a progressive dementing illness) and tabes dorsalis are more often seen with tertiary syphilis. Tabes dorsalis is a disease of the posterior columns which can present as lancinating pains, sensory ataxias, gastric crises, or bladder and bowel dysfunction. Common signs include pupillary abnormalities, diminished lower extremity reflexes, and impaired vibratory and position sense. Tabetic gastric crises present as paroxysms of nausea, vomiting, hyperacidity, and abdominal pain due to dysautonomia. To diagnose neurosyphilis, one must first establish a diagnosis of syphilis with reactive serum nontreponemal and treponemal tests. While a reactive CSF-VDRL establishes the diagnosis of neurosyphilis, a nonreactive test does not exclude the diagnosis especially in the setting of CSF pleocytosis and symptoms or signs consistent with neurosyphilis
Conclusions: This case is important because nausea and vomiting is a common chief complaint of hospitalized patients, but the diagnosis of neurosyphilis as the cause was completely unexpected. The patient had already been previously admitted and misdiagnosed. If a thorough exam was not done and a broad differential was not generated, then the diagnosis may have been missed again. This case also illustrates the importance of hospitalists being aware of the unusual manifestations of neurosyphilis and of the serious consequences that can manifest from failing to diagnose syphilis early on.