Case Presentation: A 57-year-old female presented with a three-month history of confusion and weight loss secondary to decreased oral intake, with three weeks of new onset paranoia. Family reported she exhibited disorganized behavior and hallucinations, associated with urinary incontinence, unsteadiness, dysphagia, and odynophagia. Medical history was negative for psychiatric illness or STI. Her family history was significant for schizophrenia in her brother. Physical exam was remarkable for reactive, miotic pupils, lower limb hypotonia and hyperalgesia. Her urine drug screen and urinalysis were negative. Her labs were notable for minimally decreased vitamin B12 of 174pg/ml (reference range: 213-816pg/ml). Syphilis antibody cascading reflex was positive and RPR titer was 1:512. HIV was negative. CT head non-contrast revealed dilation of the entire ventricular system. Empiric treatment with IV penicillin G 4 million units every 4 hours, was begun for, prior to receiving the results of the lumbar puncture. VRDL of the CSF was reactive with a titer of 1:16 and the FTA antibody was reactive. The CSF culture and gram stain were positive for pseudomonas putida with resistance to Bactrim. Herpes simplex 1 and 2 PCR on CSF were negative. Uveitis was not found by ophthalmology. Infectious disease recommended a fourteen-day course of IV penicillin G every 4 hours, for neurosyphilis, and three weeks of IV cefepime 2g every eight hours, for CSF infection with Pseudomonas putida. Prior to discharge, the patient was alert and oriented times two. She was discharged with a PICC line for continued antibiotic treatment at a SNF. However, the patient did not receive her antibiotics at the SNF and re-presented to an outside hospital with worsened mental status.

Discussion: Rapidly progressive cognitive and behavioral decline is present in both the meningovascular and parenchymal stages of neurosyphilis. In the meningovascular neurosyphilis stage, cognitive impairment is the result of ischemic strokes presenting as vascular dementia or hydrocephalus due to blockage of cerebrospinal fluid flow[3]. The paretic stage neurosyphilis involves direct spirochete invasion into the parenchyma, leading to lymphocytic infiltration[3]. It can affect the patient’s personality, affect, reflexes, eye, sensation, intellect, and speech[5]. Our patient presented with three months of rapidly progressing cognitive impairment that progressed to paranoia, hallucinations, gait disturbances, and urinary incontinence prior to presentation. Pseudomonas putida, a gram negative aerobe, typically causes nosocomial infections[7,8]. Acute bacterial meningitis caused by non-aeruginosa pseudomonas infections are rarely reported[7.] It is likely that a combination of neurosyphilis and pseudomonas meningitis contributed to this patient’s neuropsychiatric symptoms.

Conclusions: The case presented here is an advanced stage of neurosyphilis. This patient’s cognitive impairment and new onset psychiatric symptoms are congruent with the presentation of paretic neurosyphilis. Even though the neuroimaging findings are somewhat consistent with meningovascular neurosyphilis, this case likely progressed to the late paretic stage. There was improvement in the cognitive and psychiatric symptoms with continuation of antibiotics. This patient case has clinical and diagnostic findings from both the meningovascular and paretic stages of neurosyphilis in the setting of a concomitant pseudomonas putida meningitis.

IMAGE 1: MRI with and without contrast depicting moderate ventriculomegaly and mild microvascular ischemia