Neurosyphilis physical examination: Difference between revisions

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==Overview==
==Overview==
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
Patients with neurosyphilis may be asymptomatic. Physical examination of patients with neurosyphilis is usually remarkable for: [[Argyll Robertson pupil|Argyll-Robertson pupils]], impaired vibratory and [[proprioception]] sense, broad base and [[Sensory ataxia|sensory ataxic gait]] and positive [[romberg's test]].
 
OR
 
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
 
OR
 
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].


==Physical Examination==
==Physical Examination==
* Physical examination of patients with [disease name] is usually normal.
*Many manifestations of neurosyphilis usually develops 15-20 years after primary infection.
OR
*Physical examination of patients with neurosyphilis is usually remarkable for: [[Argyll Robertson pupil|Argyll-Robertson pupils]] (bilateral small pupils that constrict when the patient focuses on a near object, but do ''not'' constrict when exposed to bright light), Impaired vibratory and [[proprioception]] sense, broad base and [[Sensory ataxia|sensory ataxic gait]] and positive [[romberg's test]] (a test used for examination of neurological function for balance).
*Physical examination of patients with [disease name] is usually remarkable for:[finding 1], [finding 2], and [finding 3].
*The presence of [finding(s)] on physical examination is diagnostic of [disease name].
*The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
 
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].  


===Vital Signs===
===Vital Signs===


*High-grade / low-grade fever
*Usually [[vital signs]] of patients with neurosyphilis are normal.<ref name="pmid19148316">{{cite journal| author=Tso MK, Koo K, Tso GY| title=Neurosyphilis in a non-HIV patient: more than a psychiatric concern. | journal=Mcgill J Med | year= 2008 | volume= 11 | issue= 2 | pages= 160-3 | pmid=19148316 | doi= | pmc=2582679 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19148316  }} </ref>
*[[Hypothermia]] / hyperthermia may be present
===Skin===
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
Important cutanous findings in neurosyphilis include:
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
* Granulomatous [[Skin lesion|skin lesions]]:
*Tachypnea / bradypnea
** One of the late manifestations of [[tertiary syphilis]] called [[gumma]] may be present
*Kussmal respirations may be present in _____ (advanced disease state)
** [[Gumma]]<nowiki/>s are [[granulomatous]] reactions to long-term smoldering infection with [[Treponema pallidum]] and its residual [[Antigen|antigens]].<ref name="pmid21694502">{{cite journal| author=Carlson JA, Dabiri G, Cribier B, Sell S| title=The immunopathobiology of syphilis: the manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity. | journal=Am J Dermatopathol | year= 2011 | volume= 33 | issue= 5 | pages= 433-60 | pmid=21694502 | doi=10.1097/DAD.0b013e3181e8b587 | pmc=3690623 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21694502  }} </ref>
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]


===Skin===
* Skin examination of patients with [disease name] is usually normal.
OR
*[[Cyanosis]]
*[[Jaundice]]
*[[Jaundice]]
* [[Pallor]]
* Bruises


<gallery widths="150px">


UploadedImage-01.jpg | Description {{dermref}}
[[Image:Tertiary syphilis gumma.JPG|500px|thumb|center|Tertiary syphilis gumma <br> Source:By NearEMPTiness (Wie Schönes Wissen schafft im MUT) [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons, rID: 51340]]
UploadedImage-02.jpg | Description {{dermref}}


</gallery>


===HEENT===
===HEENT===
* HEENT examination of patients with [disease name] is usually normal.
Abnormalities of the [[head]] in patients with neurosyphilis include:<ref name="pmid16845316">{{cite journal| author=Thompson HS, Kardon RH| title=The Argyll Robertson pupil. | journal=J Neuroophthalmol | year= 2006 | volume= 26 | issue= 2 | pages= 134-8 | pmid=16845316 | doi=10.1097/01.wno.0000222971.09745.91 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16845316  }} </ref><ref name="pmid1195972">{{cite journal| author=Nadol JB| title=Hearing loss of acquired syphilis: diagnosis confirmed by incudectomy. | journal=Laryngoscope | year= 1975 | volume= 85 | issue= 11 pt 1 | pages= 1888-97 | pmid=1195972 | doi=10.1288/00005537-197511000-00012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1195972  }} </ref><ref name="pmid655658">{{cite journal| author=Jordan K, Marino J, Damast M| title=Bilateral oculomotor paralysis due to neurosyphilis. | journal=Ann Neurol | year= 1978 | volume= 3 | issue= 1 | pages= 90-3 | pmid=655658 | doi=10.1002/ana.410030114 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=655658  }} </ref><ref name="pmid16397078">{{cite journal| author=Smith GT, Goldmeier D, Migdal C| title=Neurosyphilis with optic neuritis: an update. | journal=Postgrad Med J | year= 2006 | volume= 82 | issue= 963 | pages= 36-9 | pmid=16397078 | doi=10.1136/pgmj.2004.020875 | pmc=2563717 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16397078  }} </ref><ref name="pmid24315656">{{cite journal| author=Klein TA, Ridley MB| title=An old flame reignites: vagal neuropathy secondary to neurosyphilis. | journal=J Voice | year= 2014 | volume= 28 | issue= 2 | pages= 255-7 | pmid=24315656 | doi=10.1016/j.jvoice.2013.08.018 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24315656  }} </ref>
OR
* Icteric sclera
* Abnormalities of the head/hair may include ___
*[[Argyll Robertson pupil|Argyll Robertson pupils]]
* Evidence of trauma
*[[Cranial nerves|Cranial nerve]] dysfunction symptoms:
* Icteric sclera
** [[Diplopia]]
* [[Nystagmus]]  
**[[Impaired vision]]
* Extra-ocular movements may be abnormal
**[[Hearing loss]]
*Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
**Voice changes
*Ophthalmoscopic exam may be abnormal with findings of ___
===Neck===
* Hearing acuity may be reduced
* [[Neck stiffness]]
*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
* [[Brudzinski's sign]]
*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
* [[Kernig's sign]]
* [[Exudate]] from the ear canal
* Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
*Inflamed nares / congested nares
* [[Purulent]] exudate from the nares
* Facial tenderness
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae


===Neck===
*Cervical [[lymphadenopathy]]
* Neck examination of patients with [disease name] is usually normal.
OR
*[[Jugular venous distension]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]


===Lungs===
===Lungs===
* Pulmonary examination of patients with [disease name] is usually normal.
* <nowiki/>Bilaterally coarse [[crackles]]<ref name="pmid14931376">{{cite journal| author=MORGAN AD, LLOYD WE, PRICE-THOMAS C| title=Tertiary syphilis of the lung and its diagnosis. | journal=Thorax | year= 1952 | volume= 7 | issue= 2 | pages= 125-33 | pmid=14931376 | doi= | pmc=1019150 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14931376  }} </ref><nowiki/>
OR
* Asymmetric chest expansion / Decreased chest expansion
*Lungs are hypo/hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Vesicular breath sounds / Distant breath sounds
*Expiratory/inspiratory wheezing with normal / delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]
 
===Heart===
* Cardiovascular examination of patients with [disease name] is usually normal.
OR
*Chest tenderness upon palpation
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*[[Heave]] / [[thrill]]
*[[Friction rub]]
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the otoscope
 
===Abdomen===
Abdominal examination of patients with [disease name] is usually normal.
 
OR
*[[Abdominal distention]]
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Rebound tenderness]] (positive Blumberg sign)
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
 
===Back===
* Back examination of patients with [disease name] is usually normal.
OR
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump
 
===Genitourinary===
* Genitourinary examination of patients with [disease name] is usually normal.
OR
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge


===Neuromuscular===
===Neuromuscular===
* Neuromuscular examination of patients with [disease name] is usually normal.
*Positive [[Romberg's test|romberg test]] <ref name="pmid17235095">{{cite journal| author=French P| title=Syphilis. | journal=BMJ | year= 2007 | volume= 334 | issue= 7585 | pages= 143-7 | pmid=17235095 | doi=10.1136/bmj.39085.518148.BE | pmc=1779891 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17235095  }} </ref>
OR
* [[Hyporeflexia]] or [[areflexia]]<ref name="pmid22330117">{{cite journal| author=Pandey S| title=Magnetic resonance imaging of the spinal cord in a man with tabes dorsalis. | journal=J Spinal Cord Med | year= 2011 | volume= 34 | issue= 6 | pages= 609-11 | pmid=22330117 | doi=10.1179/2045772311Y.0000000041 | pmc=3237288 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22330117  }} </ref>
*Patient is usually oriented to persons, place, and time
* Bilateral [[Babinski's Reflex]]<ref name="pmid22334859">{{cite journal| author=Ahamed S, Varghese M, El Agib el N, Ganesa VS, Aysha M| title=Case of neurosyphilis presented as recurrent stroke. | journal=Oman Med J | year= 2009 | volume= 24 | issue= 2 | pages= 134-6 | pmid=22334859 | doi=10.5001/omj.2009.29 | pmc=3273935 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22334859  }} </ref>
* Altered mental status
* Bilateral [[muscle weakness]] in [[lower limbs]]<ref name="pmid16778468">{{cite journal| author=Matijosaitis V, Vaitkus A, Pauza V, Valiukeviciene S, Gleizniene R| title=Neurosyphilis manifesting as spinal transverse myelitis. | journal=Medicina (Kaunas) | year= 2006 | volume= 42 | issue= 5 | pages= 401-5 | pmid=16778468 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16778468  }} </ref><ref name="pmid16845316">{{cite journal| author=Thompson HS, Kardon RH| title=The Argyll Robertson pupil. | journal=J Neuroophthalmol | year= 2006 | volume= 26 | issue= 2 | pages= 134-8 | pmid=16845316 | doi=10.1097/01.wno.0000222971.09745.91 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16845316  }} </ref>
* Glasgow coma scale is ___ / 15
*Bilateral [[sensory loss]] in lower extremities<ref name="pmid19148316">{{cite journal| author=Tso MK, Koo K, Tso GY| title=Neurosyphilis in a non-HIV patient: more than a psychiatric concern. | journal=Mcgill J Med | year= 2008 | volume= 11 | issue= 2 | pages= 160-3 | pmid=19148316 | doi= | pmc=2582679 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19148316  }} </ref>
* Clonus may be present
*[[Sensory ataxia|Sensory ataxic gait]]<ref name="pmid19148316">{{cite journal| author=Tso MK, Koo K, Tso GY| title=Neurosyphilis in a non-HIV patient: more than a psychiatric concern. | journal=Mcgill J Med | year= 2008 | volume= 11 | issue= 2 | pages= 160-3 | pmid=19148316 | doi= | pmc=2582679 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19148316  }} </ref>
* Hyperreflexia / hyporeflexia / areflexia
*[[Cranial nerve palsy]] ([[Diplopia|diplopia,]] [[mydriasis]])<ref name="pmid8279327">{{cite journal| author=Vogl T, Dresel S, Lochmüller H, Bergman C, Reimers C, Lissner J| title=Third cranial nerve palsy caused by gummatous neurosyphilis: MR findings. | journal=AJNR Am J Neuroradiol | year= 1993 | volume= 14 | issue= 6 | pages= 1329-31 | pmid=8279327 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8279327  }} </ref>
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
*Abnormal finger-to-nose test <ref name="pmid19918420">{{cite journal| author=Mehrabian S, Raycheva MR, Petrova EP, Tsankov NK, Traykov LD| title=Neurosyphilis presenting with dementia, chronic chorioretinitis and adverse reactions to treatment: a case report. | journal=Cases J | year= 2009 | volume= 2 | issue=  | pages= 8334 | pmid=19918420 | doi=10.4076/1757-1626-2-8334 | pmc=2769430 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19918420  }} </ref>
* Muscle rigidity
===Extremities===
* Proximal/distal muscle weakness unilaterally/bilaterally
* [[Charcot joint|Charcot arthropathy]]<ref name="pmid23919113">{{cite journal| author=Kaynak G, Birsel O, Güven MF, Oğüt T| title=An overview of the Charcot foot pathophysiology. | journal=Diabet Foot Ankle | year= 2013 | volume= 4 | issue=  | pages=  | pmid=23919113 | doi=10.3402/dfa.v4i0.21117 | pmc=3733015 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23919113  }} </ref>
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Positive straight leg raise test
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Positive/negative Trendelenburg sign
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Normal finger-to-nose test / Dysmetria
*Absent/present dysdiadochokinesia (palm tapping test)


===Extremities===
* Extremities examination of patients with [disease name] is usually normal.
OR
*[[Clubbing]]
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Muscle atrophy
*Fasciculations in the upper/lower extremity


==References==
==References==

Latest revision as of 21:57, 5 April 2018

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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]

Overview

Patients with neurosyphilis may be asymptomatic. Physical examination of patients with neurosyphilis is usually remarkable for: Argyll-Robertson pupils, impaired vibratory and proprioception sense, broad base and sensory ataxic gait and positive romberg's test.

Physical Examination

  • Many manifestations of neurosyphilis usually develops 15-20 years after primary infection.
  • Physical examination of patients with neurosyphilis is usually remarkable for: Argyll-Robertson pupils (bilateral small pupils that constrict when the patient focuses on a near object, but do not constrict when exposed to bright light), Impaired vibratory and proprioception sense, broad base and sensory ataxic gait and positive romberg's test (a test used for examination of neurological function for balance).

Vital Signs

Skin

Important cutanous findings in neurosyphilis include:


Tertiary syphilis gumma
Source:By NearEMPTiness (Wie Schönes Wissen schafft im MUT) [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons, rID: 51340


HEENT

Abnormalities of the head in patients with neurosyphilis include:[3][4][5][6][7]

Neck

Lungs

Neuromuscular

Extremities

  • Muscle atrophy

References

  1. ↑ 1.0 1.1 1.2 Tso MK, Koo K, Tso GY (2008). "Neurosyphilis in a non-HIV patient: more than a psychiatric concern". Mcgill J Med. 11 (2): 160–3. PMC 2582679. PMID 19148316.
  2. ↑ Carlson JA, Dabiri G, Cribier B, Sell S (2011). "The immunopathobiology of syphilis: the manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity". Am J Dermatopathol. 33 (5): 433–60. doi:10.1097/DAD.0b013e3181e8b587. PMC 3690623. PMID 21694502.
  3. ↑ 3.0 3.1 Thompson HS, Kardon RH (2006). "The Argyll Robertson pupil". J Neuroophthalmol. 26 (2): 134–8. doi:10.1097/01.wno.0000222971.09745.91. PMID 16845316.
  4. ↑ Nadol JB (1975). "Hearing loss of acquired syphilis: diagnosis confirmed by incudectomy". Laryngoscope. 85 (11 pt 1): 1888–97. doi:10.1288/00005537-197511000-00012. PMID 1195972.
  5. ↑ Jordan K, Marino J, Damast M (1978). "Bilateral oculomotor paralysis due to neurosyphilis". Ann Neurol. 3 (1): 90–3. doi:10.1002/ana.410030114. PMID 655658.
  6. ↑ Smith GT, Goldmeier D, Migdal C (2006). "Neurosyphilis with optic neuritis: an update". Postgrad Med J. 82 (963): 36–9. doi:10.1136/pgmj.2004.020875. PMC 2563717. PMID 16397078.
  7. ↑ Klein TA, Ridley MB (2014). "An old flame reignites: vagal neuropathy secondary to neurosyphilis". J Voice. 28 (2): 255–7. doi:10.1016/j.jvoice.2013.08.018. PMID 24315656.
  8. ↑ MORGAN AD, LLOYD WE, PRICE-THOMAS C (1952). "Tertiary syphilis of the lung and its diagnosis". Thorax. 7 (2): 125–33. PMC 1019150. PMID 14931376.
  9. ↑ French P (2007). "Syphilis". BMJ. 334 (7585): 143–7. doi:10.1136/bmj.39085.518148.BE. PMC 1779891. PMID 17235095.
  10. ↑ Pandey S (2011). "Magnetic resonance imaging of the spinal cord in a man with tabes dorsalis". J Spinal Cord Med. 34 (6): 609–11. doi:10.1179/2045772311Y.0000000041. PMC 3237288. PMID 22330117.
  11. ↑ Ahamed S, Varghese M, El Agib el N, Ganesa VS, Aysha M (2009). "Case of neurosyphilis presented as recurrent stroke". Oman Med J. 24 (2): 134–6. doi:10.5001/omj.2009.29. PMC 3273935. PMID 22334859.
  12. ↑ Matijosaitis V, Vaitkus A, Pauza V, Valiukeviciene S, Gleizniene R (2006). "Neurosyphilis manifesting as spinal transverse myelitis". Medicina (Kaunas). 42 (5): 401–5. PMID 16778468.
  13. ↑ Vogl T, Dresel S, Lochmüller H, Bergman C, Reimers C, Lissner J (1993). "Third cranial nerve palsy caused by gummatous neurosyphilis: MR findings". AJNR Am J Neuroradiol. 14 (6): 1329–31. PMID 8279327.
  14. ↑ Mehrabian S, Raycheva MR, Petrova EP, Tsankov NK, Traykov LD (2009). "Neurosyphilis presenting with dementia, chronic chorioretinitis and adverse reactions to treatment: a case report". Cases J. 2: 8334. doi:10.4076/1757-1626-2-8334. PMC 2769430. PMID 19918420.
  15. ↑ Kaynak G, Birsel O, Güven MF, Oğüt T (2013). "An overview of the Charcot foot pathophysiology". Diabet Foot Ankle. 4. doi:10.3402/dfa.v4i0.21117. PMC 3733015. PMID 23919113.

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