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Syphilis is a chronic infectious disease, which dates back to the XV century and is caused by the spirochete treponema pallidum, capable of invading the central nervous system in any of its stages- Its incidence has increased in parallel to the HIV/AIDS pandemic, and the synergism between both pathologies is such. that it has become a public health problem in recent years. Here we present the case of a 31-year-old female patient, who consulted for headache associated with decreased visual acuity and provided an unenhanced head CT showing hypodense lesions in both thalamic regions, serological tests for syphilis were reactive and those for HIV were not reactive. The brain MRI with spectroscopy was reported in favor of cerebral toxoplasmosis, which was later ruled out with a study of cerebrospinal fluid. Management with penicillin G sodium IV for 6 weeks was indicated, achieving complete imaging resolution of her lesions.

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We evaluated the diagnostic clinical performance characteristics (DCPC) of cerebrospinal fluid (CSF) total protein (TP), white blood cell count (WBC), and lactate (LA) with different cutoff points as adjunct biomarkers of confirmed or presumptive symptomatic neurosyphilis (NS) and the impact of HIV infection. From 5,640 participants who underwent lumbar punctures, 236 participants were included, and classified as either people with HIV (PWH) or people without HIV (PWoH) according to the CDC criteria for confirmed NS (n = 42), presumptive NS (n = 74), systemic syphilis (SS) (n = 38), serological diagnosis of syphilis (n = 18), PWH without SS and NS (n = 10), and negative control (n = 72). In PWoH, for presumptive NS, the combination of CSF TP > 45 mg/dL and/or WBC > 5.0 cells/mm3 is valuable for screening, whereas in PWH, it is not recommended for either screening or case-finding NS, however the DCPC were better in the suppressed group. In PWoH, the value of CSF TP > 45 mg/dL is adequate for both screening and confirmation of presumptive NS, subject to prevalence. For WBC count > 20 cell/mm3, the positive predictive value (PPV) of the test is almost perfect, suggesting a confirmatory test. In PWH, CSF TP is an inadequate marker of NS. The WBC count, with cutoffs of > 10 or > 20 cells/mm3, was moderately applicable for screening.As conclusions: CSF WBC count and TP showed distinct DCPC in confirmed or presumptive NS, better in the former. These biomarkers could be included for presumptive NS diagnosis. DCPC of these biomarkers for the diagnosis of NS is greatly affected by HIV co-infection.

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Background: Neurosyphilis is the most severe presentation of acquired and congenital syphilis, it occurs when Treponema pallidum penetrates the central nervous system. This development can occur at any time during the evolution of the disease phases. In Brazil in 2021, 2,343 children born with congenital syphilis were diagnosed with neurosyphilis, representing 9.3% of the total. The objective of this study was to analyze the scientific evidence on the medical manifestations presented by pediatric patients affected by neurosyphilis. Methods: In February 2023, PubMed, VHL, Scopus, Lilacs and Bdenf databases were researched for published case reports of patients aged zero to less than 18 years with T. pallidum infection. The data analysis period covered 55 years. Results: Nine articles were found in the period of publication from 1967 to 2022. There were two cases in females and only one with manifestation in an adolescent of acquired neurosyphilis. The adolescent's case was the only one with a favorable outcome after adequate treatment. Other cases resulted in impaired quality of life for patients and family members involved in child care. Conclusion: The reported cases of neurosyphilis were mostly related to late diagnosis. Evidencing the fragility of prenatal care, which is crucial for prevention and intervention by T. pallidum infection causes serious consequences for child development. Therefore, control measures should focus on mandatory prenatal screening during the first trimester of pregnancy, partner notification, prompt treatment and postnatal follow-up of the newborn.

Introdução: A neurossífilis é a apresentação mais grave da sífilis adquirida e congênita, ocorre quando o Treponema pallidum penetra no sistema nervoso central. Esse desenvolvimento pode ocorrer a qualquer momento durante a evolução das fases da doença. No Brasil, em 2021, 2.343 crianças nascidas com sífilis congênita foram diagnosticadas com neurossífilis, representando 9,3% do total. O objetivo deste estudo foi analisar as evidências científicas sobre as manifestações clínicas apresentadas por pacientes pediátricos acometidos por neurossífilis. Métodos: Em fevereiro de 2023, os bancos de dados PubMed, BVS, Scopus, Lilacs e Bdenf foram pesquisados para relatos de casos publicados de pacientes de zero a menos de 18 anos com infecção por T. pallidum. O período de análise dos dados abrangeu 55 anos. Resultados: Foram encontrados nove artigos no período de publicação de 1967 a 2022. Houve dois casos no sexo feminino e apenas um com manifestação em adolescente de neurossífilis adquirida. O caso da adolescente foi o único com evolução favorável após tratamento adequado. Outros casos resultaram em comprometimento da qualidade de vida dos pacientes e familiares envolvidos no cuidado da criança. Conclusão: Os casos notificados de neurossífilis foram, em sua maioria, relacionados ao diagnóstico tardio. Evidenciando a fragilidade do pré-natal, fundamental para a prevenção e intervenção da infecção pelo T. pallidum, trazendo sérias consequências para o desenvolvimento infantil. Portanto, as medidas de controle devem se concentrar na triagem pré-natal obrigatória durante o primeiro trimestre de gravidez, notificação do parceiro, tratamento imediato e acompanhamento pós-natal do recém-nascido.

Introducción: La neurosífilis es la presentación más grave de la sífilis adquirida y congénita, se presenta cuando Treponema pallidum penetra al sistema nervioso central. Este desarrollo puede ocurrir en cualquier momento durante la evolución de las fases de la enfermedad. En Brasil, en 2021, 2.343 niños nacidos con sífilis congénita fueron diagnosticados con neurosífilis, lo que representa el 9,3% del total. El objetivo de este estudio fue analizar la evidencia científica sobre las manifestaciones médicas que presentan los pacientes pediátricos afectados por neurosífilis. Métodos: en febrero de 2023, se investigaron las bases de datos PubMed, VHL, Scopus, Lilacs y Bdenf para obtener informes de casos publicados de pacientes de cero a menos de 18 años con infección por T. pallidum. El período de análisis de los datos abarcó 55 años. Resultados: Se encontraron nueve artículos en el período de publicación de 1967 a 2022. Hubo dos casos en el sexo femenino y solo uno con manifestación en un adolescente de neurosífilis adquirida. El caso de la adolescente fue el único con evolución favorable luego de un tratamiento adecuado. Otros casos resultaron en deterioro de la calidad de vida de los pacientes y familiares involucrados en el cuidado de niños. Conclusión: Los casos notificados de neurosífilis se relacionaron en su mayoría con un diagnóstico tardío. Evidenciando la fragilidad del control prenatal, que es fundamental para la prevención e intervención de la infección por T. pallidum que provoca graves consecuencias para el desarrollo infantil. Por lo tanto, las medidas de control deben centrarse en el tamizaje prenatal obligatorio durante el primer trimestre del embarazo, la notificación a la pareja, el tratamiento oportuno y el seguimiento posnatal del lactante.

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Uncommon forms of syphilis exist, among which neurosyphilis, otosyphilis, and ocular syphilis are included. Neurosyphilis is the infection of the central nervous system caused by Treponema pallidum. The clinical manifestations of neurosyphilis are diverse and include early, late, and atypical forms. Syphilis can affect virtually any ocular structure and can occur at any stage of the disease, as well as otosyphilis. The diagnosis of these conditions is often challenging. However, it is important to consider them as a differential diagnosis, as most of these clinical manifestations are reversible with appropriate antibiotic treatment. A case series study of patients diagnosed with neurosyphilis, otosyphilis, and ocular syphilis, who were admitted to a tertiary-level hospital, is here presented: syphilitic meningitis with cranial nerve involvement, and seizures (case 1), ocular syphilis (case 2), general paresis (case 3), and tabes dorsalis (case 4). Half of the patients presented bilateral sensorineural hearing loss; and also half of the patients had reactive VDRL in cerebrospinal fluid. All were treated with aqueous penicillin G, and in two of these cases, ceftriaxone was chosen to complete ambulatory treatment. One patient had an unfavorable outcome and died (case 1); another was lost in follow-up (case 4); one completely resolved his symptoms (case 2); and another one experienced symptom relapse six months after treatment (case 3).

Existen formas de presentación poco frecuentes de sífilis, dentro de las cuales se incluyen la neurosífilis, otosífilis y sífilis ocular. La neurosífilis es la infección del sistema nervioso central por Treponema pallidum. Las manifestaciones clínicas de neurosífilis son variadas e incluyen formas tempranas, tardías y atípicas. Además, la sífilis puede comprometer prácticamente cualquier estructura ocular, en cualquier etapa de la enfermedad, como así también la otosífilis. El diagnóstico de estas entidades suele ser dificultoso. Sin embargo, resulta importante considerarlas como diagnósticos diferenciales, ya que la mayoría de estas manifestaciones son reversibles con tratamiento antibiótico adecuado. Se presenta una serie de casos de pacientes con diagnóstico de neurosífilis, otosífilis y sífilis ocular, que cursaron internación en un hospital de tercer nivel: meningitis sifilítica con compromiso de pares craneales y convulsiones (caso 1), sífilis ocular (caso 2), paresis general (caso 3) y tabes dorsalis (caso 4). La mitad de los pacientes presentó hipoacusia neurosensorial bilateral. El 50% presentó VDRL reactiva en líquido cefalorraquídeo. Todos fueron tratados con penicilina G sódica y en el 50% se optó por el uso de ceftriaxona como modalidad para finalizar el tratamiento en internación domiciliaria. Respecto a la evolución de los pacientes, uno de ellos falleció como consecuencia del cuadro de neurosífilis (caso 1), otro se perdió en el seguimiento (caso 4) mientras que, de los dos restantes, el caso 3 presentó recaída de su enfermedad a los 6 meses del tratamiento y el caso 2 resolvió ad integrum su sintomatología.

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Syphilis is an infectious disease caused by the spirochete Treponema pallidum. It can cause ocular compromise at any stage, in immunocompetent or immunocompromised patients. Even though the ocular form is not frequent, due to the increase in the incidence of syphilis in recent years, it is mandatory to take it into consideration as a differential diagnosis in visual disorders. The most common clinical presentation is uveitis. Diagnosis is based on the presence of clinical signs and symptoms consistent with ophthalmologic involvement in a patient with syphilis. The CSF study should be performed on a clinical basis, to rule out concomitant neurological involvement. We present 5 cases of ocular syphilis, its clinical manifestations, treatment and evolution.

La sífilis es una enfermedad infecciosa causada por la espiroqueta Treponema pallidum. Puede producir compromiso ocular en cualquier estadio, en pacientes inmunocompetentes o inmunocomprometidos. Si bien la frecuencia de presentación de la forma ocular no es alta, debido al aumento de la incidencia de sífilis en los últimos años, es necesario tenerla en cuenta como diagnóstico diferencial en los trastornos visuales. La presentación clínica más frecuente es la uveítis. Se objetiva ante la presencia de signos y síntomas clínicos consistentes con afectación oftalmológica en un paciente con sífilis. El estudio del LCR debe realizarse ante la sospecha clínica, para descartar compromiso neurológico concomitante. Comunicamos 5 casos de sífilis ocular, sus manifestaciones clínicas, tratamiento y evolución.

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Resumen La sífilis es una enfermedad infecciosa causada por la espiroqueta Treponema pallidum. Puede producir com promiso ocular en cualquier estadio, en pacientes in munocompetentes o inmunocomprometidos. Si bien la frecuencia de presentación de la forma ocular no es alta, debido al aumento de la incidencia de sífilis en los últimos años, es necesario tenerla en cuenta como diagnóstico diferencial en los trastornos visuales. La presentación clínica más frecuente es la uveítis. Se objetiva ante la presencia de signos y síntomas clínicos consistentes con afectación oftalmológica en un pacien te con sífilis. El estudio del LCR debe realizarse ante la sospecha clínica, para descartar compromiso neurológi co concomitante. Comunicamos 5 casos de sífilis ocular, sus manifestaciones clínicas, tratamiento y evolución.

Abstract Syphilis is an infectious disease caused by the spi rochete Treponema pallidum. It can cause ocular compro mise at any stage, in immunocompetent or immunocom promised patients. Even though the ocular form is not frequent, due to the increase in the incidence of syphilis in recent years, it is mandatory to take it into consider ation as a differential diagnosis in visual disorders. The most common clinical presentation is uveitis. Diagnosis is based on the presence of clinical signs and symptoms consistent with ophthalmologic involvement in a patient with syphilis. The CSF study should be performed on a clinical basis, to rule out concomitant neurological involvement. We present 5 cases of ocular syphilis, its clinical manifestations, treatment and evolution.

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Resumen Existen formas de presentación poco frecuentes de sífilis, dentro de las cuales se incluyen la neurosífilis, otosífilis y sífilis ocular. La neurosífilis es la infección del sistema nervioso central por Treponema pallidum. Las manifestaciones clínicas de neurosífilis son variadas e incluyen formas tempranas, tardías y atípicas. Además, la sífilis puede comprometer prácticamente cualquier estructura ocular, en cualquier etapa de la enfermedad, como así también la otosífilis. El diagnóstico de estas en tidades suele ser dificultoso. Sin embargo, resulta impor tante considerarlas como diagnósticos diferenciales, ya que la mayoría de estas manifestaciones son reversibles con tratamiento antibiótico adecuado. Se presenta una serie de casos de pacientes con diagnóstico de neurosí filis, otosífilis y sífilis ocular, que cursaron internación en un hospital de tercer nivel: meningitis sifilítica con compromiso de pares craneales y convulsiones (caso 1), sífilis ocular (caso 2), paresis general (caso 3) y tabes dorsalis (caso 4). La mitad de los pacientes presentó hipoacusia neurosensorial bilateral. El 50% presentó VDRL reactiva en líquido cefalorraquídeo. Todos fueron tratados con penicilina G sódica y en el 50% se optó por el uso de ceftriaxona como modalidad para finalizar el tratamiento en internación domiciliaria. Respecto a la evolución de los pacientes, uno de ellos falleció como consecuencia del cuadro de neurosífilis (caso 1), otro se perdió en el seguimiento (caso 4) mientras que, de los dos restantes, el caso 3 presentó recaída de su enferme dad a los 6 meses del tratamiento y el caso 2 resolvió ad integrum su sintomatología.

Abstract Uncommon forms of syphilis exist, among which neurosyphilis, otosyphilis, and ocular syphilis are included. Neurosyphilis is the infection of the central nervous system caused by Treponema pallidum. The clinical manifestations of neurosyphilis are diverse and include early, late, and atypical forms. Syphilis can affect virtually any ocular structure and can oc cur at any stage of the disease, as well as otosyphilis. The diagnosis of these conditions is often challeng ing. However, it is important to consider them as a differential diagnosis, as most of these clinical mani festations are reversible with appropriate antibiotic treatment. A case series study of patients diagnosed with neurosyphilis, otosyphilis, and ocular syphilis, who were admitted to a tertiary-level hospital, is here presented: syphilitic meningitis with cranial nerve in volvement, and seizures (case 1), ocular syphilis (case 2), general paresis (case 3), and tabes dorsalis (case 4). Half of the patients presented bilateral sensori neural hearing loss; and also half of the patients had reactive VDRL in cerebrospinal fluid. All were treated with aqueous penicillin G, and in two of these cases, ceftriaxone was chosen to complete ambulatory treat ment. One patient had an unfavorable outcome and died (case 1); another was lost in follow-up (case 4); one completely resolved his symptoms (case 2); and another one experienced symptom relapse six months after treatment (case 3).

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INTRODUCCIÓN: La neurosífilis representa la infección del sistema nervioso central por la bacteria Treponema pallidum. Se han descrito complicaciones parenquimatosas y meningovasculares. La enfermedad cerebrovascular isquémica, puede ser la única manifestación de la neurosífilis y puede ocurrir en cualquier fase de la enfermedad. Un tratamiento oportuno lleva a una adecuada recuperación y prevención de complicaciones potencialmente mortales e incapacitantes. OBJETIVO: proporcionar una fuente de información actualizada como medio de consulta rápida para personal médico que trata a pacientes con neurosífilis. METODOLOGÍA: Estudio de revisión de 44 artículos y selección de 33 encontradas en la base de datos del motor PUBMED, Biblioteca Cochrane, portal BVS Ecuador, datos publicados en tesis de la Universidad Central del Ecuador y Pontificia Universidad Católica del Ecuador, cuyas fechas de publicación corresponden en su mayoría a los últimos 5 años, y pocos artículos de años previos que por su relevancia se mantuvieron, el criterio de búsqueda empleado consistió en documentos que contenían datos sobre epidemiología, fisiopatología, clínica, diagnóstico y tratamiento de enfermedad cerebrovascular isquémica como presentación de neurosífilis. CONCLUSIÓN: La sospecha clínica de neurosífilis en pacientes jóvenes con antecedente epidemiológico orienta a un diagnóstico oportuno y disminuye la mortalidad y complicaciones secundarias a un infarto cerebral.

INTRODUCTION: Neurosyphilis represents the infection of the central nervous system by the bacterium Treponema pallidum. Parenchymal and meningovascular complications have been described. Ischemic cerebrovascular disease can be the only manifestation of neurosyphilis and can occur at any stage of the disease. Timely treatment leads to adequate recovery and prevention of life-threatening and disabling complications. OBJECTIVE: To provide an up-to-date source information as a means of quick consultation for medical personnel treating patients with neurosyphilis. METHODOLOGY: Review study of 44 articles and selection of 33 found in the database of the PUBMED engine, Cochrane Library, BVS Ecuador portal, data published in theses of the Universidad Central del Ecuador and Pontificia Universidad Católica del Ecuador, whose publication dates they correspond mostly to the last 5 years, and few articles from previous years that due to their relevance remained, the search criteria used consisted of documents that contained data on the epidemiology, pathophysiology, clinic, diagnosis and treatment of ischemic cerebrovascular disease as a presentation of neurosyphilis. CONCLUSION: The clinical suspicion of neurosyphilis in young patients with an epidemiological history leads to a timely diagnosis and reduces mortality and complications secondary to a cerebral infarction.

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We documented two stages of bone involvement due to syphilis in two adult patients infected with human immunodeficiency virus. Bony lesions of secondary versus tertiary syphilis cannot be differentiated on clinical or radiologic grounds alone. Given the rarity of this clinical presentation, there is no consensus on treatment duration and related outcomes.

Se describen dos etapas de compromiso óseo por sífilis en dos pacientes adultos infectados por el virus de la inmunodeficiencia humana. Las lesiones óseas de la sífilis secundaria y de la sífilis terciaria no se pueden diferenciar únicamente por características clínicas o radiológicas. Dada la rareza de esta presentación clínica, no hay consenso sobre la duración del tratamiento y los resultados relacionados.

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We documented two stages of bone involvement due to syphilis in two adult patients infected with human immunodeficiency virus. Bony lesions of secondary versus tertiary syphilis cannot be differentiated on clinical or radiologic grounds alone. Given the rarity of this clinical presentation, there is no consensus on treatment duration and related outcomes.

Se describen dos etapas de compromiso óseo por sífilis en dos pacientes adultos infectados por el virus de la inmunodeficiencia humana. Las lesiones óseas de la sífilis secundaria y de la sífilis terciaria no se pueden diferenciar únicamente por características clínicas o radiológicas. Dada la rareza de esta presentación clínica, no hay consenso sobre la duración del tratamiento y los resultados relacionados.

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Introducción: La sífilis es una enfermedad de transmisión sexual causada por el Treponema pallidum. Reportes recientes de diferentes regiones del mundo sugieren que la sífilis ocular está reemergiendo en paralelo con el incremento de la incidencia de la infección sistémica a nivel global. Objetivo: Profundizar en el conocimiento sobre la sífilis, especialmente, en la sífilis ocular, que se encuentra en la bibliografía especializada. Métodos: Fundamentalmente se consultaron artículos de los últimos 5 años, en idioma español e inglés, disponibles en textos completos. Las bases de datos consultadas fueron: PubMed, SciELO y Google académico. Conclusiones: La sífilis ocular puede presentarse en cualquier estadío de la enfermedad e imitar diferentes afecciones inflamatorias oculares, por lo que debe tenerse presente en el diagnóstico diferencial de toda uveítis. El tratamiento oportuno de estos pacientes puede minimizar el daño visual, pero su diagnóstico es a menudo un desafío para el oftalmólogo(AU)

Introduction: Syphilis is a sexually transmitted disease caused by Treponema pallidum. Recent reports from different regions of the world suggest that ocular syphilis is re-emerging, in parallel with the increasing incidence of systemic infection globally. Objective: To deepen the knowledge on syphilis and especially ocular syphilis found in the specialized literature. Methods: The articles consulted were mainly from the last 5 years, in Spanish and English, available in full text. The databases consulted were PubMed, SciELO and Google academic. Conclusions: Ocular syphilis can present at any stage of the disease and mimic different ocular inflammatory conditions, so it should be taken into account in the differential diagnosis of any uveitis. Prompt treatment of these patients can minimize visual damage but its diagnosis is often a challenge for the ophthalmologist(AU)

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ABSTRACT BACKGROUND: Syphilis is a major public health issue worldwide. In people living with human immunodeficiency virus (PLHIV), there are higher incidences of both syphilis and neurosyphilis. The criteria for referring PLHIV with syphilis for lumbar puncture is controversial, and the diagnosis of neurosyphilis is challenging. OBJECTIVE: To describe the knowledge, attitudes, and practices of infectious disease specialists and residents in the context of care for asymptomatic HIV-syphilis coinfection using close-ended questions and case vignettes. DESIGN AND SETTING: Cross-sectional study conducted in three public health institutions in São Paulo (SP), Brazil. METHODS: In this cross-sectional study, we invited infectious disease specialists and residents at three academic healthcare institutions to answer a self-completion questionnaire available online or in paper form. RESULTS: Of 98 participants, only 23.5% provided answers that were in line with the current Brazilian recommendation. Most participants believed that the criteria for lumbar puncture should be extended for people living with HIV with low CD4+ cell counts (52.0%); in addition, participants also believed that late latent syphilis (29.6%) and Venereal Disease Research Laboratory (VDRL) titers ≥ 1:32 (22.4%) should be conditions for lumbar puncture in PLHIV with no neurologic symptoms. CONCLUSION: This study highlights heterogeneities in the clinical management of HIV-syphilis coinfection. Most infectious disease specialists still consider syphilis stage, VDRL titers and CD4+ cell counts as important parameters when deciding which patients need lumbar puncture for investigating neurosyphilis.

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Introduction: Previous retrospective studies have demonstrated that the concentration of chemokine ligand CXCL13 in cerebrospinal fluid (CSF-CXCL13) is a promising biomarker in the diagnosis of neurosyphilis and, additionally, in the monitoring of therapeutic efficacy. Objective: To describe three cases of patients with neurosyphilis (NS) treated at Hospital Universitário Gaffrée e Guinle, in Rio de Janeiro, Brazil, with suspected active syphilis with neurological symptoms. Case report: Three patients from Rio de Janeiro, Brazil, were investigated for symptomatic NS. The concentration of CSF-CXCL13 was prospectively performed by enzyme-linked immunosorbent assay (ELISA) in all participants at baseline and in follow-up visits at 3 months after therapy. CSF-CXCL13 concentrations were significantly higher in all three patients with established NS. The CSF-CXCL13 concentrations decreased after 3 months of therapy compared to baseline in all cases reported. The added high concentration of CSF-CXCL13 plus CSF-TPHA reactivity above 1:40 titer agreed with the diagnosis of NS in 100% of the cases. Conclusion: In this case series, we present three cases of NS diagnosed using CXCL13 in CSF as a complementary test. These case series suggest that the clinical use of CSF-CXCL13 is useful as a supplementary biomarker for NS and for monitoring the effectiveness of NS therapy, especially in patients with nonreactive CSF-VDRL, excluding other neurologic diseases

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Mielopatia inflamatória ou mielite transversa é uma síndrome neurológica potencialmente incapacitante com uma variedade de etiologias. Episódios únicos ou recorrentes podem resultar em dependência de cadeira de rodas. O quadro clínico de fraqueza, alteração de sensibilidade e disfunção autonômica de início agudo ou subagudo é marca dessa síndrome. Esse cenário é comum às diferentes etiologias, que podem ser de natureza desmielinizante, por doença autoimune sistêmica, paraneoplásica ou infecciosa. A ressonância magnética de coluna é o exame de neuroimagem de escolha. Exames complementares como avaliação do líquido cefalorraquidiano, testes sorológicos e pesquisa de anticorpos dão suporte à investigação. A depender da etiologia, há tratamentos específicos a fim de reduzir incapacidade e chance de novos surtos, além de diferentes prognósticos. Este trabalho objetiva uma revisão de literatura sobre mielopatias inflamatórias e suas principais etiologias, a partir de dados obtidos na plataforma eletrônica PubMed. Para a discussão, foram revisadas as etiologias desmielinizantes (encefalomielite disseminada aguda, esclerose múltipla, doença do espectro, neuromielite óptica e neurite óptica, encefalite e mielite associadas ao MOG-IgG); doenças autoimunes (lúpus eritematoso sistêmico e síndrome de Sjögren); síndromes paraneoplásicas e mielopatias infecciosas (neuroesquistossomose, mielite por HIV e por HTLV-1 e neurossífilis). Concluiu-se com este estudo que a mielopatia inflamatória é uma condição de gravidade variável que produz potencial incapacidade, causada por diferentes etiologias, porém com quadro clínico comum entre elas. Por isso, é importante conhecer cada uma dessas causas, a fim de promover o melhor e mais precoce tratamento e reduzir sequelas.

Inflammatory myelopathy or transverse myelitis is a potentially disabling neurological syndrome with various etiologies. Single or recurrent episodes can result in wheelchair dependence. A clinical picture of weakness, altered sensitivity, and autonomic dysfunction with acute or subacute onset is characteristic of this syndrome. This scenario is common to different etiologies, which can be of a demyelinating nature, due to systemic, paraneoplastic, or infectious autoimmune disease. Spine MRI is the neuroimaging test of choice. Complementary tests such as cerebrospinal fluid evaluation, serological tests and antibody research support the investigation. Depending on the etiology, there are specific treatments to reduce disability and the chance of new episodes, and different prognoses. This study is a literature review on inflammatory myelopathies and their main etiologies, based on data obtained from the PubMed database. Demyelinating etiologies (acute disseminated encephalomyelitis, multiple sclerosis, neuromyelitis optic spectrum disease and optic neuritis, MOG-IgG-associated encephalitis and myelitis), autoimmune diseases (systemic lupus erythematosus and Sjögren's syndrome), paraneoplastic syndromes and infectious myelopathies (neuroschistosomiasis, HIV and HTLV-1 myelitis, and neurosyphilis) were reviewed for discussion. In conclusion, inflammatory myelopathy is a condition of variable severity that produces potential disability, caused by different etiologies, but with a common clinical picture between them. Thus, knowledge on each of these causes is important to promote the best and earliest treatment and reduce sequelae.

La mielopatía inflamatoria o mielitis transversa es un síndrome neurológico potencialmente incapacitante con una variedad de etiologías. Los episodios únicos o recurrentes pueden tener como consecuencia dependencia de silla de ruedas. El cuadro clínico de debilidad, sensibilidad alterada y disfunción autonómica de inicio agudo o subagudo es distintivo de este síndrome. Esto es común a diferentes etiologías, que pueden ser de naturaleza desmielinizante, debido a enfermedades autoinmunes sistémicas, paraneoplásicas o infecciosas. La resonancia magnética de columna es la prueba de neuroimagen de elección. Las pruebas complementarias, como la evaluación del líquido cefalorraquídeo, las pruebas serológicas y la investigación de anticuerpos respaldan la investigación. Dependiendo de la etiología, existen tratamientos específicos para reducir la discapacidad y la posibilidad de nuevos brotes, además de diferentes pronósticos. Este trabajo tiene como objetivo revisar la literatura sobre mielopatías inflamatorias y sus principales etiologías desde los datos obtenidos de la base de datos electrónica PubMed. Se revisaron las etiologías desmielinizantes (encefalomielitis aguda diseminada, esclerosis múltiple, enfermedad del espectro, neuromielitis óptico y neuritis óptica, encefalitis y mielitis asociadas a MOG-IgG), las enfermedades autoinmunes (lupus eritematoso sistémico y síndrome de Sjögren), los síndromes paraneoplásicos y mielopatías infecciosas (neurosquistosomiasis, mielitis por VIH y HTLV-1 y neurosífilis). Se concluyó que la mielopatía inflamatoria es una condición de severidad variable, que produce potencial discapacidad causada por diferentes etiologías, pero tiene un cuadro clínico común entre ellas. Por ello, es importante conocer cada una de las causas para promover el mejor y más precoz tratamiento, además de reducir las secuelas.

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Background/Objective: Neurosyphilis can be associated with a variety of clinical manifestations. There are only a few cases of neurosyphilis associated with parkinsonism-plus syndromes (PPSs) that have been reported in the literature. We describe a case of an elderly woman who presented with abnormal gait and progressive visual disturbance, probably secondary to neurosyphilis. Methods: Literature search was performed in Embase, Google Scholar, Medline, Scielo, and ScienceDirect using a set of terms that included parkinsonism, tremor, and syphilis. Case Report: A 64-year-old female was admitted because of vision problems, gait disturbances, and cognitive impairment. The neurological examination revealed bradykinesia, rigidity, and rest tremor. The pupils were bilaterally small and reacted in size to a near object but did not constrict when exposed to bright light. The conjugate eye movements showed a defective downward gaze. On neuropsychological examination, the mini-mental state exam showed a moderate cognitive impairment. Reduced phonemic fluency was observed. A positive serum venereal disease research laboratory (VDRL) test was noted. A cerebrospinal fluid analysis showed positive VDRL. Brain and cervical spine magnetic resonance imaging was normal. An electro-encephalogram showed diffused slow waves. Penicillin G was started. Six months after, the patient had a full recovery of her conjugate eye movements and cognitive functions. Upon further questioning, the patient reported no response with a levodopa attempt. Conclusions: To the authors' knowledge, two individuals developed progressive supra-nuclear palsy (PSP), and one presented corticobasal degeneration (CBD), probably associated with neurosyphilis. This is the second case to document the occurrence of a progressive supra-nuclear palsy because of syphilis.

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Introducción: a partir del año 2000, los médicos han asistido a un retorno de la sífilis vinculado a prácticas sexuales no protegidas y con parejas múltiples, en especial entre hombres que tienen sexo con hombres. La coinfección Treponema pallidum/virus de la inmunodeficiencia humana (VIH) modifica tanto la historia natural de la sífilis, incrementando la incidencia de neurosífilis temprana, como la respuesta al tratamiento con penicilina. Métodos: un paciente varón, peruano, de 36 años, seropositivo para VIH, consulta por dis-minución de la agudeza visual en ojo derecho, pérdida de la audición, tinnitus, mareos y vértigo. Refería antecedentes de sífilis en los 2 años previos. Resultados: el examen oftalmológico efectuado al paciente mostró células en el segmento anterior del ojo derecho. El fondo de ojo reveló la existencia de inflamación del nervio óptico asociada con panuveítis. En base a los hallazgos clínicos, los valores de VDRL en suero y líquido cefalorraquídeo (LCR) se diagnosticó neurosífilis (NS) con neuritis óptica, panuveítis y otosífilis en un paciente coinfectado por VIH. El paciente fue tratado con penicilina G sódica intravenosa, 4 millones de UI cada 4 horas, durante 2 semanas con buena respuesta clínica. Discusión: el compromiso de los pares craneales óptico y auditivo puede representar la manifestación de una NS temprana, en especial, en el contexto de un paciente VIH positivo. De acuerdo con nuestro conocimiento, este sería el segundo caso publicado de compromiso simultáneo del nervio óptico y del aparato vestíbulo-coclear en un paciente con NS.

Introduction: from the 2000s, the physicians experienced a return of syphilis, which may be related to unrestricted sexual behaviour with unprotected contact between multiple partners, especially in men who have sex with men. Concurrent infection with human immunodeficiency virus (HIV) alters the natural history of syphilis by increasing the frequency of early neurosyphilis and the response to penicillin. Methods: a 36-year-old Peruvian man, seropositive for HIV infection, was admitted to the hospital with decreased visual acuity in his right eye, hearing loss, tinnitus, buzzing, and vertigo. He referred history of syphilis in the previous two years. Results: oph-thalmological examination was performed. Ocular anterior segment examination of the right eye showed cells. Fundoscopy revealed swelling of the right optic disc with panuveitis. Diagnosis of neurosyphilis (NS) with optic and ear neuritis, and concurrent HIV infection was made, based on the clinical manifestations and serum and cerebrospinal VDRL titers. The patient was treated with intravenous penicillin (four million units every four hours for two weeks) with an excellent clinical response. Discussion: simultaneous optic and auditive cranial nerve involvement can manifest early neurosyphilis (NS) and HIV coinfection. This is the second report to describe the simultaneous occurrence of syphilitic optic neuritis with vestibulocochlear nerve involvement.

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ABSTRACT Cerebrospinal fluid (CSF) analysis is an important diagnostic tool for many conditions affecting the central nervous system (CNS), especially CNS infectious diseases. Despite its low specificity, CSF white blood cell counts, CSF protein levels, CSF serum glucose ratio and CSF lactate measurement are useful in differentiating infections caused by distinct groups of pathogens. CSF direct examination and cultures can identify causative organisms and antibiotic sensitivities as well. Adjunctive tests such as latex agglutination, different immunological assays and molecular reactions have great specificities and increasing sensitivities. In this article, some recent diagnostic methods applied to CSF analysis for frequent CNS infections are presented.

RESUMO A análise do líquido cefalorraquiano (LCR) é uma importante ferramenta diagnóstica para muitas condições que afetam o sistema nervoso central (SNC), especialmente as doenças infecciosas. Apesar da baixa especificidade, a contagem de leucócitos no LCR, a determinação dos níveis de proteína, glicose e lactato podem ser úteis na diferenciação de infecções causadas por diferentes grupos de patógenos. O exame direto e as culturas podem identificar organismos causadores de infecções bem como suas sensibilidades a antibióticos. Testes adjuvantes como aglutinação em látex, diferentes ensaios imunológicos e reações moleculares têm taxas de sensibilidades e especificidades crescentes. Neste artigo, são apresentados alguns métodos diagnósticos mais recentemente aplicados à análise do LCR no diagnóstico das infecções do SNC.

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ABSTRACT Syphilis is a reemerging and potentially serious disease. Owing to its ubiquity and pleomorphism, it is called "the great imitator". We report the case of a young woman with secondary syphilis who presented with bilateral acute syphilitic posterior placoid chorioretinopathy along with a syphilitic skull periostitis. A pachymeningeal enhancement was observed on magnetic resonance imaging, but we believe it was an extension of the bone process rather than a meningitis itself on the basis of the normal cerebrospinal fluid analysis results. Treatment with intravenous crystalline penicillin resulted in complete resolution of the signs, symptoms, and imaging findings. Secondary syphilis is the stage with the highest bacteremia and the highest transmissibility, presenting mainly with mucocutaneous disorders and, less frequently, with involvement of other organs. High suspicion and a pragmatic approach are essential to the diagnosis because this disease can affect several organs, as in the present case, in which the eyes, bones, and skin were affected.

RESUMO A sífilis é uma doença reemergente e potencialmente grave. Por sua onipresença e pleomorfismo, é denominada "grande imitadora". Relatamos caso de paciente jovem com sífilis secundária, que se apresentou com coriorretinopatia placóide sifilítica posterior aguda bilateral, simultaneamente a periostite craniana sifilítica. A despeito de realce paquimeníngeo observado na ressonância magnética, acreditamos que este tenha sido uma extensão do processo ósseo e não, uma meningite em si, uma vez que o exame do líquido cefalorraquidiano estava completamente normal. Tratamento com penicilina cristalina intravenosa resultou em completa resolução dos sinais, sintomas e achados de imagem. A sífilis secundária é o estágio de maior bacteremia e maior transmissibilidade da doença, apresentando-se principalmente com quadros mucocutâneos, mas também, menos frequentemente, com envolvimento de outros órgãos. Elevada suspeição e uma abordagem pragmática são necessárias para o diagnóstico, uma vez que essa doença pode afetar vários órgãos, como no caso relatado, em que foram acometidos olhos, ossos e pele.

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OBJECTIVE: Our objective was to describe and compare the occurrence of neurological outcomes and neurosyphilis in people living with HIV with incident syphilis and no neurological symptoms who underwent early screening for asymptomatic neurosyphilis (ANS) or regular clinical management without a lumbar puncture. METHODS: This was a retrospective cohort study in a single referral centre of Sao Paulo, Brazil. Patients with incident syphilis diagnosed between January 2000 and August 2016 and meeting the adapted criteria for ANS investigation suggested by Marra et al. (CD4+ T-cell counts ≤350 cells/mm³ and/or venereal disease research laboratory test results ≥1:16) were identified. Those with no neurological symptoms and immediately referred for lumbar puncture were categorized as group 1, and those not referred for cerebrospinal fluid collection were categorized as group 2. We compared the occurrence of neurological symptoms and neurosyphilis diagnoses between the groups using incidence rates and Kaplan-Meier curves. RESULTS: We included 425 participants with a median follow-up of 6 years. The incidence rate of neurological symptoms was 36.5/1000 person-years in group 1 and 40.6/1000 person-years in group 2 (incidence rate ratio [IRR] 0.90; 95% confidence interval [CI] 0.57-1.39; p = 0.62). The incidence rate of neurosyphilis was 15.0 cases/1000 person-years in group 1 and 6.7 cases/1000 person-years in group 2 (IRR 2.26; 95% CI 0.93-5.68; p = 0.05). CONCLUSIONS: We found no statistically significant differences between groups in the incidence rates of neurological symptoms and neurosyphilis. Our findings support the current guidelines, which suggest a less invasive approach regarding ANS investigation among people living with HIV with incident syphilis.

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