Commentary

Neurosyphilis and brain magnetic resonance imaging Monika Czarnowska-Cubała, MD, PhD Department of Radiology, Medical University of Gda nsk, Gda nsk, Poland E-mail: [email protected]

I read with great interest the recent paper by Khamaysi et al.1 on tertiary syphilis with invasion of the central nervous system. The diagnostic process included brain magnetic resonance imaging (MRI), which revealed abnormalities with hyperintense signal changes that were misinterpreted as infarcts, mild atrophy, and mild enlargement of the celebral sulci. Neuropsychiatric symptomatology is now recognized as representing the most common clinical manifestations of neurosyphilis.2 The diagnosis of neurosyphilis is complex, and no reference standard exists. Given that standard laboratory findings are unremarkable, serum analysis for syphilis with nonspecific lipoidal tests (rapid plasma reagin [RPR] and Venereal Disease Research Laboratory [VDRL] tests) and treponemal-specific tests (fluorescent treponemal antibody absorption [FTA-Abs] test) should be considered routine in patients presenting with or hospitalized for psychiatric disorders. However, it should be noted that an ultimate serology test with cerebrospinal fluid analysis for venereal disease is found to be non-reactive in 43% of cases.2 Brain MRI findings in neurosyphilis are not specific, and no radiologic pathognomonic findings have been identified to date.2,3 However, generalized cerebral atrophy and foci of increased signal intensity are commonly seen in populations of patients with neurosyphilis. Moreover, the identification of the most common radiologic manifestations of cerebral infectious vasculitis can be

helpful. In neurosyphilis, the most frequently reported abnormalities refer to the middle cerebral artery and branches of the basilar artery. There is also some evidence that ischemic changes in MRI on medium contrast enhancement, and atrophy, white matter lesions, and edema are indicative of neurosyphilis. In addition, multiple areas of infarction in different vascular territories and of different ages in young patients seem to be indicative of cerebral vasculitis. However, normal findings are also frequently seen.3 The complexity of the diagnostic process in neurosyphilis, which is associated with a range of false negative tests, points to brain MRI as an auxiliary tool in the differential diagnosis of the insidious disease of neurosyphilis. References 1 Khamaysi Z, Bergman R, Telman G, et al. Clinical and imaging findings in patients with neurosyphilis: a study of a cohort and review of the literature. Int J Dermatol 2014; 53: 812–819. 2 Patel MV, Shelby J, Yekkirala L. Neurosyphilis in patients with psychotic symptoms: clinical presentation in the modern era. Carle Selected Papers 2011; 54: 33–36. 3 Czarnowska-Cubała M, Wiglusz MS, Cubała WJ, et al. MR findings in neurosyphilis – a literature review with a focus on a practical approach to neuroimaging. Psychiatr Danub 2013; 25(Suppl.): 153–157.

863 ª 2015 The International Society of Dermatology

International Journal of Dermatology 2015, 54, 863

Neurosyphilis and brain magnetic resonance imaging.

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