Case Presentation:

A 65‐year‐old man with past medical history significant for diverticulosis and irritable bowel syndrome presents with complaints of decreased visual acuity. He reported that his vision had been deteriorating for several months, and sought attention from an ophthalmologist, who diagnosed the patient with optic nerve atrophy. The patient also states that he worked as a Translator and noticed he had developed hearing loss, prompting him to retire early. On further history, patient states that he was treated with 1 antibiotic shot in Cuba more than 30 years ago for syphilis. When asked about any other syphilitic sequelae, patient states that he has always had “bad skin“ and has been followed by dermatology for treatment of several nonspecific rashes that improved with topical creams. Patient denies any other neurological complaints, and no other focal deficits were elicited on exam. He subsequently underwent repeat fundoscopic exam and an audiogram, which revealed optic nerve atrophy and moderate sensorineural hearing loss, respectively. Serology obtained revealed RPR greater than 1:32, reactive VDRL, and a positive FTA‐ABS. Hospital medicine was consulted, and treatment was initiated immediately, with 4 million units of penicillin G every 4 hours for 14 days as inpatient therapy and benzathine PCN G at 2.4 million U intramuscularly once weekly for 3 additional weeks as an outpatient to fully complete the course of treatment.


As this case illustrates, in neurosyphilis, many manifestations are nonspecific, so the diagnosis relies heavily on a high index of clinical suspicion. ln late neurosyphilis, both vascular lesions and neuronal degeneration are possible. The clinical manifestations of neurosyphilis include seizures, ataxia, aphasia, paresis, hyperreflexia, personality and cognitive changes, visual changes, hearing loss, neuropathy, and loss of bladder function. Our patient presented with ocular atrophy, which is commonly accompanied by the syndrome of tabes dorsalis. At the onset of symptoms, serology and lumbar puncture could have quickly confirmed the diagnosis, and the extent of neurological deficits would have been avoided. In the case mentioned above, it is of paramount importance that CSF VDRL levels in addition to CSF pleocytosis be followed 3.6, and 12 months after anlibiotic therapy to ensure effective treatment.


ln the words of Sir William Osier, “He who knows syphilis, knows medicine.'' Neurosyphilis represents a continuum encompassing early invasion, months to years of asymptomatic involvement, and possibly the development of early or late neurologic manifestations. Symptomatic neurosyphilis particularly in the antibiotic era, often presents not as a classic picture, but as a subtle or incomplete syndrome. As hospitalists. we should not forget this disease and remember that the high morbidity associated with neurosyphilis obligates its inclusion in the differential diagnosis of patients presenting with vague neurologic symptoms.

Author Disclosure:

L. Luly‐Rivera, none; A. Jaffer, none.