A peculiar case of neurosyphilis presenting with general paresis of the insane with concurrent untreated HIV infection

Abstract

General paresis of insane or dementia paralytica is a rare conventional manifestation of neurosyphilis. In the era of penicillin and HIV it is a challenge to observe and diagnose typical presentations of neurosyphilis.42-year-old single male presented with an acute behavioural disturbance with hearing voices in a background of rapidly progressing forgetfulness and functional deterioration to the extent of needing support for his activities of daily living with urine incontinence for nine months duration. His beha-vioural change had first started with distressing insomnia leading to consumption of alcohol 30 units a day. Gradually displayed disorganised and dis-inhibited behaviour with some overactivity and was treated as a mood disorder with poor response and rapid deterioration of functioning.Investigations revealed marked impairment of frontal lobe and dominant parietal lobe functions in extended cognitive assessment. Blood investigations revealed normocytic normochromic anaemia with raised inflammatory markers: CRP, ESR, CPK with normal thyroid function. Syphilis serology was positive. Subsequently the examination carried out by an eye surgeon detected ocular syphilis. CSF analysis was negative for syphilis and the changes were most likely related to the untreated HIV infection with a CD4 count of 104 cells/μL. Neuroimaging showed generalized cortical atrophy with enlarged ventricles. He was treated for neurosyphilis as well as and treatment for HIV was initiated, but there was minimal improvement.Conclusions: Neurosyphilis remains as an important aetiology to be considered in rapidly progressing dementia in young patients. Comorbid HIV infection worsens the severity and prognosis.