Tabes Dorsalis With Spinal Meningeal Involvement and Possible Concomitant Epstein-Barr Virus Reactivation

We report an exceptionally rare case of tabes dorsalis with concomitant hypertrophic spinal pachymeningitis and incidental qualitative detection of Epstein-Barr virus (EBV) DNA in the cerebrospinal fluid (CSF), highlighting the diagnostic challenges and potential systemic complications of late neurosyphilis. A 44-year-old immunocompetent man presented with a two-year history of progressive sensory ataxia. Thoracic spine magnetic resonance imaging demonstrated longitudinal posterior column T2 hyperintensity with diffuse dural thickening and enhancement. Initial multiplex polymerase chain reaction of the CSF detected EBV DNA, raising concern for viral myelitis and prompting consideration of antiviral therapy. However, serological testing confirmed syphilis (rapid plasma reagin (RPR) 1:16; Treponema pallidum hemagglutination assay (TPHA) 1:20,480), while HIV and Human T-lymphotropic virus-1 (HTLV-1) testing were negative. Although CSF-Venereal Disease Research Laboratory (VDRL) was unavailable, the diagnosis was revised to probable neurosyphilitic myelopathy with tabetic features based on the clinical presentation, serological findings, CSF profile, and characteristic neuroimaging abnormalities. Intravenous ceftriaxone was initiated, resulting in clinical improvement, reduced CSF pleocytosis, and clearance of EBV DNA on follow-up analysis, suggesting incidental viral reactivation rather than active EBV infection. The patient was discharged in stable neurological condition but died suddenly within 24 hours. Although the exact cause of death could not be established, a cardiovascular complication of late-stage syphilis was considered the most likely explanation. This case broadens the recognized imaging spectrum of neurosyphilis by demonstrating hypertrophic spinal pachymeningitis with incidental EBV DNA detection and highlights the importance of considering syphilis in patients with posterior column myelopathy. It also emphasizes the need for comprehensive cardiovascular assessment in patients with late-stage syphilis to identify potentially life-threatening systemic complications.