Ardelean, Gavril - Buicu, Florin (szerk.): Satu Mare. Studii şi comunicări. Seria ştiinţele naturale 8. (2007)
Medicină
Satu Mare - Studii şi Comunicări Seria Ştiinţele Naturii Vo\. VIII (2007) motor deficit. The osteotendinous reflexes were diminished in the lower limbs. He had normal coordination, without sensory impairment, but he showed behavioral and mild memory impairment. There was also present an attention deficit (distruptability and inattention); without sleep disorders. The ophthalmogyc examination didn’t show any abnormalities. The positive diagnosis was established based on the serology, the modifications in the CSF (positive VDRL, TPHA and the increased celularity) and the neurological manifestations (the clinical manifestations are not mandatory for the diagnosis). The differential diagnosis included the various forms and stages of neurosyphilis. The differential diagnostic possibilities are broad. The first diagnosis that should be taken into consideration is CVA (all the causes of ischemic CVA). Other causes involved can be: meningitides (other basal meningitides should be considered if the presentation is that of cranial nerve paralysis), primary neoplasm’s , metastasis, or other space occupying lesions (if gummata are present), psychiatric symptoms (delirium, dementia, mania, psychosis, personality change etc.) especially in general paresis, multiple sclerosis [2], Adequate treatment of neurosyphilis is based largely on achieving treponemicidal levels of penicillin in die CSF. Treponema palädum is highly susceptible to penicillin, which is the drug of choice for all stages of syphilis. Penicillin acts by interfering with the synthesis of cell walls and is active only against organisms that, like Treponema palädum, synthesize their cell walls in growth and division. Penicillin has some ameliorative effect in every stage of neurosyphilis. Earlier forms of illness are better candidates for a response to antibiotic treatment. Meningovascular disease responds most dramatically. The etiologic treatment was realized according to the Ministry of Public Health’s Order 1070/25.08.2004 using Penicillin G at 3 million U/4 h, for 15 days achieving a total dose of 18 million U per day. During the hospitalization there was noticed an increase in the level of transaminases (SGPT= 89 UI/L and SGOT= 45UI/L) and a slight increase of potassium level (5.3 mmol/L). These modifications were interpreted in the context of penicillin treatment and did not pose special problems. Other antibiotics have not been studied sufficiently, and their routine use is not recommended. Still either of the following is acceptable: Procaine PCN-G at 2.4 million U/day intramuscularly plus probenecid at 500 mg orally 4 times per day for 10-14 days (the regimen is not recommended if the patient has a history of allergy to sulfonamides). Ceftriaxone can be attempted at 1-2 g/day im or iv, for 10-14 days; if patients are allergic to PCN doxycycline can be another alternative as it is effective at a dose of 100 mg, bid, for 28-30 days. The neurological treatment included Trileptal 600 mg, 2 tablets/day, Sermion 1 tablet/day and Piracetam 2 tablets/day. After the release from the hospital the patient received Benzathine PNC G at 2.4 million U intramuscularly once a week for 3 weeks. The treatment was evaluated monitoring the CSF. A CSF examination 6 months following treatment should demonstrate a normal blood cell count and decreasing protein content. CSF examinations should be repeated every 6 months for 3 years or until the CSF is normal. A lack in the decrease of the protein content after 6 months or an abnormal CSF after 2 years is an indication for re-treatment. Under the treatment the patient did not show an improvement of the neurological symptoms, the confusional syndrome was maintained, but the seizures did not appear anymore. Discussion Neurosyphilis is considered as positive diagnosis when the CSF WBC count is greater than 20 cells/mL or when CSF VDRL test gives a reactive result. Persons not treated for persistent CSF abnormalities are at risk of developing clinically apparent disease and are hereafter referred to as having contracted neurosyphilis. Neurosyphilis may occur at any stage of syphilis. Before the advent of antibiotics, it was typically seen in 25-35% of patients with syphilis. Neurosyphilis is now most common in patients with FIIV infection. In 1999, the World Health Organization estimated tit at worldwide, approximately 12 million new cases of syphilis occurred among adults. Some degree of acute or subacute aseptic meningitis is present even in primary syphilis; therefore, neurosyphilis, in a broad sense, begins eady. Approximately 35% to 40% of persons with secondary syphilis have asymptomatic central nervous system involvement. Syphilis is known as the great imitator, so the fact that symptoms of neurosyphilis are broad should come as no surprise. Symptoms of neurosyphilis include the following and are listed in order of frequency: personality change (including cognitive and/or behavioral impairment) 33%, ataxia 28%, stroke 23%, ophthalmic symptoms (e.g., blurred vision, reduced colour perception, impaired acuity, visual dimming, 73
