A case of neurosyphilis presenting as parkinsonism

A 47 year old male presented with a history of progressive gait disturbance, amimia, rigidity and cognitive decline for the past two years. He had been previsouly diagnosed, by a neurologist, with Parkinson's disease and treated with Ldopo with minimal improvement in rigidity.On admission to our department neurological examination showed akinetic parkinsonism and cognitive impairment of the subcortical type. Routine blood tests were normal; examination of the serum showed a positive TPHA. Evaluation of the CSF resulted in elevated cell count and protein concentration (270 GB/mmS, 2.2 gr/L) and positive CSF VDRL, TPHA-FTA (IgG-IgM), fulfilling the criteria for diagnosis of neurosiphylis (NS). Encephalic MRI showed multiple foci of increased signal intensity on T2 weighted images. EEG showed a mild generalized slowing of the background activity. Neuropsycological testing confermed subcortical dementia.Treatment consisted of three 10-days cycles high dose penicillin G (24 million unit daily) over one year.During this period, the patient was examined at day 15 and at 3, 6, and 12 months, following the baseline evaluation. Improvement occurred in all parameters: CSF, CSF VDRL-TPHA, EEG, clinical and neuropsycological evaluations. The dramatic clinical improvement following antibiotic therapy, demonstrated the correlation between extrapyramidal symptoms and NS. NS presenting as parkinsonism is very unusual.This case suggests that neurosyphilis should be considered as a cause of extrapyrimidal sindrome, particularly in relatively young patient exibiting atypical symptoms.