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Neurosyphilis presenting with gummatous oculomotor nerve palsy

Although epidemiological studies suggest that the incidence of primary syphilis is rising,1 neurosyphilis remains an uncommon manifestation of Treponema pallidum infection. In addition, the MRI appearances of this treatable neurological condition are not well known. Many patients with neurosyphilis are asymptomatic, but manifestations include subacute basal meningitis, a meningovascular syndrome of small deep cerebral and cranial nerve infarctions, chronic gummatous inflammation with focal intracranial mass lesions, chronic comportmental dementia of general paresis, and chronic sensory-ataxic myelopathy of tabes dorsalis. We report a case in which a meningeal form of neurosyphilis presented with rapid evolution of a pupil-involving oculomotor nerve palsy to highlight the clinical, CSF, and MRI features and good response to treatment.

The patient was a 54 year old right handed homosexual man with a history of syphilis of unknown stage, treated with penicillin 25 years previously. He was well until 6 weeks prior to evaluation when he sustained minor head trauma in an automobile accident, followed by intermittent headaches, fatigue, photophobia, and anorexia. Four days before …