Neurosyphilis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]Tarek Nafee, M.D. [3]

Overview

Neurosyphilis must be differentiated from other diseases that cause abnormal gait, Blindness, confusion and depression, such as multiple sclerosis, Brain tumours, Wernicke’s encephalopathy, CNS abscess, electrolyte disturbance, Subdural empyema, subarachnoid hemorrhage, brain stroke, Conversion disorder and Drug toxicity.

Differentiating X from other Diseases

  • Neuroyphilis has an extensive differential diagnosis.
Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
Na+, K+, Ca2+ CT /MRI CSF Findings Gold standard test Neck stiffness Motor or Sensory deficit Papilledema Bulging fontanelle Cranial nerves Headache Fever Altered mental status
Neurosyphilis[3][4] Leukocytes and protein
  • CSF FTA-Ab -sensitive[5]
  • Unprotected sexual intercourse, STIs
  • History of multiple sexual partners.
Multiple sclerosis Oligoclonal bands of IgG on electrophoresis of cerebrospinal fluid MRI
Brain tumour[1][2] Cancer cells[7] MRI Cachexia, gradual progression of symptoms
Wernicke’s encephalopathy Normal History of alcohal abuse Ophthalmoplegia, confusion
CNS abscess leukocytes >100,000/ul, glucose and protien, red blood cells, lactic acid >500mg Contrast enhanced MRI is more sensitive and specific,

Histopathological examination of brain tissue

History of drug abuse, endocarditis, immune status High grade fever, fatigue,nausea, vomiting
Electrolyte disturbance or Depends on the cause Confusion, seizures
Subdural empyema Clinical assesment and MRI History of relapses and remissions Blurry vision, urinary incontinence, fatigue
Delirium tremens Clinical diagnosis Alcohol intake, sudden witdrawl or reduction in consumption Tachycardia, diaphoresis, hypertension, tremors, mydriasis, positional nystagmus,
Subarachnoid hemorrhage[8] Xanthochromia[9] CT scan without contrast[11][6] Trauma/fall Confusion, dizziness, nausea, vomiting
Stroke Normal CT scan without contrast TIAs, hypertension, diabetes mellitus Speech difficulty, gait abnormality
Viral encephalitis Increased RBCS or xanthochromia, mononuclear lymphocytosis, high protein content, normal glucose Clinical assesment Tick bite/mosquito bite/ viral prodome for several days Extreme lethargy, rash hepatosplenomegaly, lymphadenopathy, behavioural changes
Herpes simplex encephalitis Clinical assesment History of hypertension Delirium, cortical blindness, cerebral edema, seizure
Drug toxicity Lithium, Sedatives, phenytoin, carbamazepine
Conversion disorder Diagnosis of exclusion Tremors, blindness, difficulty swallowing
Febrile convulsion Not performed in first simple febrile seizures Clinical diagnosis and EEG Family history of febrile seizures, viral illness or gastroenteritis Age > 1 month,
Hypoglycemia ↓ or Serum blood glucose

HbA1c

History of diabetes Palpitations, sweating, dizziness, low serum, glucose

References

  1. 1.0 1.1 Soffer D (1976) Brain tumors simulating purulent meningitis. Eur Neurol 14 (3):192-7. PMID: 1278192
  2. 2.0 2.1
  3. 3.0 3.1 Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.
  4. 4.0 4.1 Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
  5. 5.0 5.1 Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.
  6. 6.0 6.1 DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
  7. 7.0 7.1 Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions". Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.
  8. 8.0 8.1 Yeh ST, Lee WJ, Lin HJ, Chen CY, Te AL, Lin HJ (2003) Nonaneurysmal subarachnoid hemorrhage secondary to tuberculous meningitis: report of two cases. J Emerg Med 25 (3):265-70. PMID: 14585453
  9. 9.0 9.1 Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.
  10. Goldenberg MM (2012). "Multiple sclerosis review". P T. 37 (3): 175–84. PMC 3351877. PMID 22605909.
  11. Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.

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