Neurosyphilis masquerading as hemiparesis and Jacksonian epilepsy in an HIV positive patient: a case report

Neurosyphilis is a common but often missed disease worldwide, mainly because it has many manifestations making its diagnosis difficult. It is often missed among HIV patients as the search for other co-infections such as toxoplasmosis often overshadows its consideration.

To describe one of our cases of neurosyphilis in HIV, raise awareness about the reality of neurosyphilis in Africa and share our experiences in diagnosis and management of the disease.

A 40 year old, HIV positive female was admitted with a 2 month history of left sided facial and limb weakness followed by delirium, aphasia and Jacksonian epilepsy. She underwent clinical and laboratory evaluation.

On examination she had a maculo-papular rash and left sided paresis. Rapid Plasma Reagin(RPR) was reactive(titre 1:16). Treponema Pallidum Haemoaggluttination Assay(TPHA) was also reactive. Cerebrospinal fluid (CSF) analysis revealed: protein 56 mg per dl, glucose 71 mg per dl, cells 14 per high power field (predominantly lymphocytes). The VDRL on the CSF was positive. The CD4 cell count was 320 per ml. She was treated with intravenous penicillin G, 4 mega-units 6 hourly for 14 days, with a very good response.

Neurosyphilis still occurs in Uganda. It should be considered in all patients with neurological/ophthalmic illness, including those with HIV. Most cases respond well to intravenous penicillin G.