==== Front IDCasesIDCasesIDCases2214-2509Elsevier S2214-2509(18)30120-310.1016/j.idcr.2018.e00423e00423ArticleAcute syphilitic meningitis in an HIV-infected patient Wagemakers Alex A.wagemakers@vumc.nla⁎Hepp Dagmar bKillestein Joep bPeferoen Laura cAng Wim aa Department of Medical Microbiology and Infection Prevention, VU medical center, Amsterdam, The Netherlandsb Department of Neurology, VU medical Center, Amsterdam, The Netherlandsc Department of Pathology, VU medical Center, Amsterdam, The Netherlands⁎ Corresponding author at: Department of Medical Microbiology and Infection Prevention, VU medical center, Postbus 7057, 1081HV, Amsterdam, The Netherlands. A.wagemakers@vumc.nl07 7 2018 2018 07 7 2018 13 4 4 14 6 2018 5 7 2018 5 7 2018 © 2018 The Authors2018This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).We present a case of acute syphilitic meningitis in a 28-year old HIV-infected patient, presenting with a seizure. MRI revealed a meningeal lesion with cortical involvement, and the patient described previous treatment for syphilis. Final diagnosis was established by PCR and spirochete staining on a brain biopsy, upon which the patient was successfully treated with benzylpenicillin. Keywords SyphilisTreponema pallidumMeningitisAbbreviations MSM, men who have sex with men ==== Body A 28-year old MSM patient presented with a generalized seizure six days after a previous episode for which he was already treated with valproic acid. Besides a headache, the patient did not describe any symptoms and had a low CRP (10 mg/L, reference value: <8 mg/L). Ten months previous to presentation in our hospital, he was diagnosed with HIV in a different hospital where treatment was not yet started according to the local guideline at the time, with a CD4 count of 660 cells/μl. In the month previous to presentation, he had a CD4 count of 500 cells/μl and a viral load of 2,7 × 104 copies/ml. He was treated for syphilis, chlamydia and gonorrhea in the past year. Physical examination revealed generalized lymphadenopathy without neurologic abnormalities. MRI showed a solitary non-homogenous and irregularly intense meningeal lesion with cortical involvement, consisting of multiple nodular lesions (Fig. 1A).Fig. 1 A. T1-weighed MRI with contrast reveals a solitary non-homogenous and irregularly intense meningeal lesion with cortical involvement approximately 29 × 17 mm in diameter, consisting of multiple nodular lesions. B. Biopsy of the process in the right frontal lobe showing extensive leukocyte infiltration, predominantly CD8+ T-cells and the presence of spirochetes (in brown, one of which is indicated by a yellow arrow). Fig. 1 Serum VDRL was negative but TPPA was positive, confirmed by T. pallidum EIA and western blot. Lumbar puncture revealed CSF with a mild leukocytosis (12 leukocytes/μl) with normal glucose and protein level, while the IgG index was elevated (7.76) and TPPA was positive with negative VDRL (supplemental data). A brain biopsy was performed, which was PCR-positive for T. pallidum. Pathology revealed encephalitis with predominantly CD8+ T-cells without characteristics of a gumma and immunohistochemic spirochete staining demonstrated the presence of spirochetes (Fig. 1B). The clinical picture was categorized as acute syphilitic meningitis with unusual parenchymatous involvement, and the patient was successfully treated with benzylpenicillin 12 million units/day IV for 2 weeks. Acute syphilitic meningitis is a rare presentation of neurosyphilis, usually occurring within one year after initial infection. It became extremely rare since the introduction of penicillin, but re-emerged since the HIV epidemic [1]. Among HIV-infected MSM with early syphilis, the incidence of symptomatic early neurosyphilis was estimated to be 1.7%, 12% of which was found to present as acute syphilitic meningitis [2]. Besides treatment failure due to his HIV status, a recent reinfection might have also occurred in our patient. Physicians should be alert for treatment failure of syphilis in HIV-infected patients, and acute syphilitic meningitis in these patients can present with an unusual encephalitic component. Contributors DH and JK treated the patient, provided clinical data and revised the report. LP performed the pathology and spirochete stain. AW and WA collected, assessed and interpreted data and wrote the report. Declaration of interest We declare no competing interests Author statement Conceptualization and Data curation: AW and WA Investigation: all authors Methodology: all authors Visualization: LP Roles/Writing – original draft: AW and WA Writing – review & editing: all authors Appendix A Supplementary data The following is Supplementary data to this article: Appendix A Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.idcr.2018.e00423. ==== Refs References 1 Ghanem K.G. REVIEW: neurosyphilis: a historical perspective and review CNS Neurosci Ther 16 5 2010 e157 e168 20626434 2 Centers for Disease, C. and Prevention Symptomatic early neurosyphilis among HIV-positive men who have sex with men–four cities, United States, January 2002-June 2004 MMWR Morb Mortal Wkly Rep 56 25 2007 625 628 17597693