The great imitator behind an ischemic stroke: a case of meningovascular syphilis

Neurosyphilis is a rare but reversible cause of ischemic stroke. We report a 41-year-old male with no cardiovascular risk factors initially diagnosed with Bell's palsy for left facial weakness. Four days later, he developed left-sided hemiparesis and dysarthria. Neuroimaging confirmed a right nucleocapsular ischemic stroke. Cerebrospinal fluid analysis revealed pleocytosis (39 cells/µL), elevated protein (191.9 mg/dL), and a reactive VDRL, confirming meningovascular neurosyphilis. Treatment with 14 days of intravenous Penicillin G led to complete clinical recovery after six months. This case highlights "the great imitator" during a global resurgence of syphilis. This clinical evolution highlights how isolated cranial nerve deficits can act as a deceptive precursor to a endarteritis obliterans, masking a systemic infection behind a seemingly benign presentation. In young patients with stroke and no vascular risk factors, neurosyphilis should be considered, particularly when preceded by cranial nerve deficits.