Case Presentation: A 60 year old woman with a history of substance abuse and unclassified dementia presented to the emergency department following 2 weeks of acute functional decline and being found unresponsive at home. She had experienced progressive cognitive decline over the prior 2 years, becoming increasingly forgetful and less talkative. She was diagnosed with an unclassified dementia 6 months prior to presentation. Over the preceding 2 weeks, she had become less responsive and could no longer ambulate or complete her own ADLs. On admission, patient was febrile, tachycardic, and hypertensive with a glasgow coma score of 10. Patient was responsive only to noxious stimuli. Physical exam was notable for left gaze preference, right-sided facial droop and increased tone in all extremities with intermittent posturing. A stat CT head was negative for acute infarct or hemorrhage. CTA of the neck demonstrated bead-like appearance and segmental narrowing of the left cervical ICA concerning for vasculopathy. EEG was concerning for seizure activity. Lorazepam was administered and patient was loaded with levetiracetam. She was intubated and started on broad spectrum antibiotics. MRI of the brain was notable for periventricular white matter hyperintensities with scattered microhemorrhages in cerebellum, left hippocampus and left thalamus. CBC was notable for leukocytosis with neutrophilic predominance. Metabolic studies including BMP, LFTs and thyroid studies were within normal limits. Urine toxicology screen was negative. Blood and urine cultures were negative. HIV screen was negative. Serum RPR was positive with a titer of 1:128 and serum treponemal antibody was positive. CSF studies were notable for leukocytosis with lymphocytic pleocytosis and elevated protein. CSF VDRL was positive with a titer of 1:8 and CSF FTA antibody was positive. Patient was diagnosed with neurosyphilis and was started on IV penicillin G. She was extubated, alert and oriented x 2 and following commands after 4 days of treatment. Patient had significant functional improvement and was discharged to a SNF to continue PT and complete a 14-day course of IV penicillin G.

Discussion: This case is a rare presentation of neurosyphilis in an HIV-negative individual and illustrates that neurosyphilis can present as an acute meningovasculitis with clinical features similar to an acute ischemic stroke. This patient’s CTA and MRI findings are consistent with vascular inflammation, which likely provoked this patient’s seizure activity and focal neurological deficits.

Conclusions: This case highlights the importance of screening for treatable causes of dementia in the inpatient setting. It is likely this patient had been infected with T. palladium for months to years prior to presentation. Routine evaluation for treatable causes of dementia includes obtaining a serum RPR, which would have detected syphilis infection in this patient and could have prevented her current presentation.