A 48 y.o. male presents with inability to walk
He had a hx of uveitis diagnosed 1/23 and frequent falls since that time with the gradual development of leg numbness and weakness. He was seen 10/23 after a fall and diagnosed with neuropathy in an ED.
what do you notice on the MRI?
Hint: you also note a lesion on the leg.. What is the cause?
Our patient has longitudinal transverse myelitis from syphilitic gummas. He also has a gumma on his leg.
Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum. The signs and symptoms depend on which of the four stages it presents in (primary, secondary, latent, and tertiary).
the stages of syphilis
Our patient had secondary syphilis when he presented and tertiary when he presented with neurosyphilis and gummas. Gummas are usually found in the skin, mucocutaneous tissue , bones and liver. Usually in the gumma stage of tertiary syphilis the lesions are not contagious. Syphilis is often misdiagnosed in the early stages as it was in our patient. He presented in January and was paralyzed by October when an RPR was sent confirming the diagnosis.
The disease itself began around 3000 BC in South-Western Asia. It was initially a mild disese but grew in virulence due to mutations at the end of the 15th century. It was not isolated as a bacterium until 1905. Reported cases of syphilis have inreased 74 percent since 2017. Congenital syphilis increased 203 persent in the past five years.
Hutchinson’s triad of deafness, dental malformations and keratitis can occur in congenital syphilis
FUN FACTS
The first person to call the illness syphilis was Giralamo Fracastoro in 1530. Syphilis was a character in his poem. He was the sheperd of a king who was cursed by Apollo with a terrible disease which was eventually known as syphilis.
The disease was known by the Italians as the French disease, the Russians called it the Polish disease, the Turks called it the Christian disease and Muslims blamed it on Hindus.
The family of Treponema also is responsible for three other diseases: yaws, bejel and pinta.
Our patient was treated with 34 million units of of PCN q 4 and then benzathine penicilln . He remains paraplegic but is able to ambulate with assistance and a walker.
De Melo FL, De Mello JCM, Fraga AM. Syphilis at the Crossroad of Phylogenetics and Paleopathology. PLoS Negl Trop Dis. 2010;4:575.
Worku D, Houston A, Cosgrove C, et al. Spinal syphilitic gumma: a rare presentation of an old disease. Case Reports in Infectious Diseases Vol 2021 Article ID 5533686 https://doi.org/10.1155/2021/5533686
Asselin C, Ekindi N, Carignan A, Richard P. Gummatous penile syphilis ID Cases 2019;18:e00589. PMID 31406680