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Neurology India, Vol. 57, No. 6, November-December, 2009, pp. 837-838 Correspondence Neurosyphilis K. Srinivasan Emeritus Professor of Neurology, Madurai Medical College, 11-A, By Pass Road, Ponmeni Stop, SBI Colony, Madurai - 625 010, India. Date of Acceptance: 15-Dec-2009 Code Number: ni09246 PMID: 20139537 DOI: 10.4103/0028-3886.59506 Sir, I enjoyed reading the editorial l [1] and the two articles [2],[3] on neurosyphilis which appeared in the May-June issue of Neurology India 2009. We have published one of the largest series, 132 patients with neurosyphilis, from India [4] and also on neurosyphilis-related stroke. [5] In this context I would like to make some observations. Neurosyphilis is considered an 'arch simulator' and is to be considered in the differential diagnosis of any lesion involving any component of the neuroaxis. With the emergence of human immunodeficiency virus (HIV) infection, tertiary neurosyphilis is being diagnosed more in the younger ages. We need more diagnostic skills so as not to miss the diagnosis of any type of neurosyphilis; and our threshold for the diagnostic possibility should be low. Treatment of asymptomatic neurosyphilis (cerebrospinal fluid (CSF) pleocytosis and VDRL positive) can prevent all the forms of neurosyphilis. However, many patients may not agree for lumbar puncture. Venereal Disease Research Laboratory (VDRL) tests like rapid plasma regain tests (RPR) are non-treponemal and non-specific tests and biologically false positives occur in many conditions. Positive CSF VDRL in tuberculous meningitis could be due to the passive transfer of regain from blood as a result of blood brain-barrier disruption. High titers do reflect disease activity further supported by CSF pelocytosis. However, more reliable treponemal tests like treponema pallidum hemagglutination assay (TPHA), fluroscent treponemal antibody (FTA), and fluroscent treponemal antibody absorption test (FTA-Abs) are more specific and remain positive life long even after effective treatment. In our study of 130 patients, 100 patients were positive for blood and CSF VDRL and in the remaining the diagnosis was based on low titers and high cell count. Special tests TPHA, FTA, FTA-Abs were also done. All the tests were done at the Department of Venereology, Madras Medical College, Madras, the World Health Organization (WHO) reference center. [4] I would like to give a brief account of two interesting cases. Case 1: A 35-year-old woman was operated for recurrent abdominal pain with a suspected diagnosis of mesenteric tuberculous adenitis. She had small irregular pupils with sluggish light reflex and also bilateral absent ankle reflexes. Postoperatively, she died and postpartum confirmed spinal syphilis and abdominal tuberculosis. Her serology for syphilis was positive. Case 2 : A 40-year-old man had conus cauda syndrome with positive serology for syphilis, both blood and CSF. Myelogram showed a large mass lesion in the conus. The mass was confirmed as tuberculoma after laminectomy. References
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