Neurosyphilis Presenting with Anxiety: A Case Report

The number of cases of late and late latent syphilis in the United States is on the rise. This diagnosis is often forgotten when an elderly patient is being worked up for altered mental status. Rarely does a 70-year-old male with neurosyphilis present simply with anxiety. Due to the decreased severity of the presentation, this patient was sent home from the emergency department multiple times until the anxiety progressed to psychosis. He was finally admitted with delirium, suicidal ideation, and paranoia. A routine Treponema pallidum antibody test returned positive and a further workup of confirmatory lab work, a thorough neurological exam, and magnetic resonance imaging (MRI) revealed a chronic syphilis infection. This case study explores signs in the history and physical examination that should quickly prompt a provider to consider neurosyphilis in their differential. This patient presented with Argyll-Robertson pupils and significant risk factors. The goal of this discussion is to bring awareness to this infrequent presentation and share simple examination techniques that could have been used to diagnose and treat this patient's symptoms more promptly. In doing so, the hope is to raise awareness for the diagnosis of neurosyphilis, especially in the elderly patient presenting with psychiatric symptoms.