We present a case of a 33 year old Bulgarian male who attended a Neurological Clinic at University Hospital Alexandrovska. He attended the clinic because of progressive attention and memory impairments as well as apathy, anxiety and irritability reported by family members. Eighteen months earlier his brother noticed that he was confused, forgetful and unable to manage his professional activities as a construction worker. He became apathetic, irritable and more verbally aggressive. Our patient has a low level of education with poor written language and simple arithmetic abilities; however he was a good worker who was able to carry out everyday activities.
Neuropsychological assessments were performed using a general cognitive functioning scale (Mini Mental State Examination, MMSE), and tests of attention, memory, language and executive functions (see Table
). Our patient was not fully orientated (he did not know the year, season, month, day and date), however, he was relatively orientated to place. Assessment of memory revealed a severe verbal learning impairment with an extremely low ability to retain new information. He also demonstrated difficulty with remembering autobiographical and personal information. His verbal communication was relatively spare; however he did have a mild anomia and poor categorical fluency. A severe dysexecutive syndrome was also documented (with notably poor coding test and letter fluency). Bearing in mind the patient’s premorbid cognitive functioning, neuropsychological assessment revealed mild to moderate dementia (MMSE
The patient had no history of skin lesions or symptoms of Argyll-Robertson; his pupillary reflexes were preserved, and the pupils constricted in response to light and accommodation. Pyramidal and extrapyramidal signs, dysarthria, and impairment in coordination were documented.
Laboratory workups, including a complete and differential blood count, serum electrolytes and glucose, liver and renal function tests, thyroid function tests, serum B12 and folate levels, were normal. In addition, cerebrospinal fluid (CSF) analysis showed pleocytosis, elevated protein levels, and positive oligoclonal bands. Cerebrospinal fluid was clear with 1
/l erythrocytes, 39
/l leucocytes (82% lymphocytes, 16% monocytes) and a protein level of 0.88g/l. The diagnosis of active neurosyphilis was based on positive results of the Venereal Disease Research Laboratory test/Treponema pallidum
hemagglutination assay (VDRL/TPHA) reactions in blood and CSF samples (serum-VDRL 1:128, serum-TPHA 1:2560, CSF-VDRL 1:64, CSF-TPHA 1:640). The serum and CSF test for HIV was negative. Magnetic resonance imaging (MRI) of the brain demonstrated moderate cortical and marked hippocampal atrophy (Figure
Figure 1 Magnetic Resonance Imaging (MRI) of the brain. A/ Axial fluid attenuated inversion recovery (FLAIR). B/ Sagittal fluid attenuated inversion recovery (FLAIR). C/ Coronal 3D -T1-TFE. D/Coronal T2WI – TSE. All images are showing marked diffuse loss (more ...)
No adverse reactions were observed upon receiving a course of intravenous Penicillin G 5x5000000 IU /daily for 20 days.
At the 6 month follow up examination, clinical signs and neuropsychological findings showed slight improvement in general cognitive functioning. Six months after treatment the patient’s MMSE score was 19/30 (see Table
). Improvement was also noted on the activities of daily living and behavioural disturbances assessments. The patient’s CSF protein level was 0.55 g/L, with 1
/l leucocytes. The VDRL test of CSF indicated positive results.