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LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 1  |  Page : 89-91

Syphilitic myelitis: Magnetic resonance imaging features


1 Department of Neurology, BenQ Medical Center, Jianye District, Nanjing 210019, China
2 Department of Radiology, BenQ Medical Center, Jianye District, Nanjing 210019, China

Date of Submission25-Dec-2013
Date of Decision27-Dec-2013
Date of Acceptance26-Jan-2014
Date of Web Publication7-Mar-2014

Correspondence Address:
Dongmei He
Department of Neurology, BenQ Medical Center, Jianye District, Nanjing 210019
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.128347

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How to cite this article:
He D, Jiang B. Syphilitic myelitis: Magnetic resonance imaging features. Neurol India 2014;62:89-91

How to cite this URL:
He D, Jiang B. Syphilitic myelitis: Magnetic resonance imaging features. Neurol India [serial online] 2014 [cited 2019 Sep 17];62:89-91. Available from: http://www.neurologyindia.com/text.asp?2014/62/1/89/128347


Sir,

The incidence of syphilis has markedly declined in the post-penicillin era. However, cases of syphilis have been increasing with the emergence of human immunodeficiency virus (HIV) infection since mid-1980s world-wide. [1],[2] Although approximately one-third of patients with early syphilis have central nervous system involvement, symptomatic neurosyphilis, especially syphilitic myelitis is rare, [3] hence this report.

A 63-year-old male patient presented with a 12-day history of progressive lumbago and weakness of both lower extremities. Examination documented bilateral lower-limb weakness with motor power of 4-5, lower limb hyporeflexia. Cerebrospinal fluid (CSF) examination revealed 303 Χ 10 6 cells/L (84% were lymphocytes), 917 mg/L protein, normal glucose and chloride and positive rapid plasma regain test (RPR). The Treponema pallidum hemagglutination test was positive and the serum RPR was positive with 1:16. Serological test for other viral infections including HIV were negative. Spinal magnetic resonance imaging (MRI) revealed swelling and high signal intensity of the spinal cord parenchyma at level of T6 through to T11 on T2-weighted images and focal gadolinium enhancement [Figure 1]. Brain MRI was normal. Treatment with ceftriaxone (2 g twice a day for 30 days) and methylprednisolone (100 mg/day, 50 mg/day and 12.5 mg/day for 3 days each) was initiated. He had symptomatic improvement by day-5. CSF examination at 1 month showed 34 Χ 10 6 cells/L, 454 mg/L protein, negative RPR. Serum RPR was positive with 1:4. Spinal MRI showed decreased abnormal signal [Figure 2]. After 3 months, neurologic examination, CSF findings and spinal MRI were normal [Figure 3]. Serum RPR titer was 1:2, indicating cure.
Figure 1: (a) Sagittal T2-weighted image of the thoracic spinal cord shows long-segment diffuse high signal intensity from T6 to T11 with cord swelling. (b) Coronal T1-weighted image with contrast shows focal enhancement at T8/T9 level. (c) Sagittal T1-weighted image with contrast. (d) Axial T1-weighted image with contrast at T8/T9 level

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Figure 2: Follow-up magnetic resonance imaging performed 1 month after onset of treatment. (a) Sagittal and (b) axial gadolinium-enhanced T1-weighted images show residual focal enhancement in the thoracic cord at T8/T9 level

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Figure 3: Follow-up magnetic resonance imaging performed 3 months after onset of treatment. (a) Sagittal T2-weighted image and (b) sagittal gadolinium-enhanced T1-weighted image show normal spinal cord and the abnormal signals have disappeared

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Syphilis is a sexually transmitted infectious disease caused by spirochete T. pallidum. The incidence of neurosyphilis is estimated to be 4-10% in untreated cases and 1.5% of neurosyphilis will progress to syphilitic myelitis. [4],[5]

The first descriptions of MRI findings in syphilitic myelitis were short-segment high signal intensity in the thoracic cord on T2-weighted images and abnormal peripheral enhancement. [6] Since the only a few cases have been documented in the literature. [7],[8],[9],[10] The high-signal lesions of the spinal cord parenchyma extending over multiple levels on T2-weighted imaging and the abnormal enhancement on gadolinium-enhanced T1-weighted images have been validated [Table 1]. The classic appearance on contrast studies, candle guttering appearance, was seen in our patient, but not the flip-flop sign, low signal intensity on T2-weighted imaging and high intensity on gadolinium-enhanced T1-weighted imaging. [9] The gadolinium-enhancement seen on T1-weighted images resolve with the treatment with penicillin G and prednisolone and might represent spinal cord ischemia or edema secondary to meningovascular syphilis. [6],[7],[8],[9],[10] However, the inflammatory nature of the MRI findings has been implied. [11] This patient had surgical resection of the lesion as the pre-operative diagnosis being spinal cord tumor and on histopathology the lesion consisted of a core of Microspironema pallidum and peripheral lymphocytic infiltrate with gliosis. The "candle guttering appearance" on MRI suggests that the pathological process of neurosyphilis involves invasion of the spinal cord from its surface. Furthermore, the high intensity area of the spinal cord on T2-weighted images may represent a spinal cord edema or ischemia secondary to inflammatory process. In fact, all abnormally enhanced areas on T1-weighted images locate in the central parts of the high intensity areas on T2-weighted images. In our patient, the enhanced nodule on T1-weighted images at level of T8/T9 located centrally in high intensity area on T2-weighted images at T6-T11 level. If the lesion on gadolinium-enhanced T1-weighted images is large enough, the flip-flop sign may be observed. However, the diagnosis of syphilitic myelitis must be based on serum and CSF tests because the MR imaging features are non-specific, [12] Guidelines recommend treatment of neurosyphilis with 18-24 million units of aqueous penicillin IV per day for 10-14 days. Prednisolone may be added to prevent cord edema, ischemia, or Jarisch-Herxheimer reactions. [13] Ceftriaxone is acceptable alternative in patients who are allergic to penicillin, such as our patient.
Table 1: Cases of syphilitic myelitis reported previously

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The characteristics MRI findings may suggest the diagnostic possibility of syphilitic myelitis and help in confirming the diagnosis of neurosyphilis by serological tests.

 
 » References Top

1.Hook EW 3 rd , Marra CM. Acquired syphilis in adults. N Engl J Med 1992;326:1060-9.  Back to cited text no. 1
    
2.Fenton KA, Breban R, Vardavas R, Okano JT, Martin T, Aral S, et al. Infectious syphilis in high-income settings in the 21 st century. Lancet Infect Dis 2008;8:244-53.  Back to cited text no. 2
    
3.O′donnell JA, Emery CL. Neurosyphilis: A current review. Curr Infect Dis Rep 2005;7:277-84.  Back to cited text no. 3
    
4.Conde-Sendín MA, Amela-Peris R, Aladro-Benito Y, Maroto AA. Current clinical spectrum of neurosyphilis in immunocompetent patients. Eur Neurol 2004;52:29-35.  Back to cited text no. 4
    
5.Adams RD, Merritt HH. Meningeal and vascular syphilis of the spinal cord. Med (Baltimore) 1944;23:181-214.  Back to cited text no. 5
    
6.Tashiro K, Moriwaka F, Sudo K, Akino M, Abe H. Syphilitic myelitis with its magnetic resonance imaging (MRI) verification and successful treatment. Jpn J Psychiatry Neurol 1987;41:269-71.  Back to cited text no. 6
    
7.Nabatame H, Nakamura K, Matuda M, Fujimoto N, Dodo Y, Imura T. MRI of syphilitic myelitis. Neuroradiology 1992;34:105-6.  Back to cited text no. 7
    
8.Tsui EY, Ng SH, Chow L, Lai KF, Fong D, Chan JH. Syphilitic myelitis with diffuse spinal cord abnormality on MR imaging. Eur Radiol 2002;12:2973-6.  Back to cited text no. 8
    
9.Kikuchi S, Shinpo K, Niino M, Tashiro K. Subacute syphilitic meningomyelitis with characteristic spinal MRI findings. J Neurol 2003;250:106-7.  Back to cited text no. 9
    
10.Chilver-Stainer L, Fischer U, Hauf M, Fux CA, Sturzenegger M. Syphilitic myelitis: Rare, nonspecific, but treatable. Neurology 2009;72:673-5.  Back to cited text no. 10
    
11.Wu M, Qian RB, Wei XP. A case of syphilitic myelitis. Shandong Med 2011;51:101.  Back to cited text no. 11
    
12.Nagappa M, Sinha S, Taly AB, Rao SL, Nagarathna S, Bindu PS, et al. Neurosyphilis: MRI features and their phenotypic correlation in a cohort of 35 patients from a tertiary care university hospital. Neuroradiology 2013;55:379-88.  Back to cited text no. 12
    
13.Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006;55:1-94.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]

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