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|Year : 2000 | Volume
| Issue : 2 | Page : 196-7
MRI in syphilitic meningomyelitis.
Srivastava T, Thussu A
|How to cite this article:|
Srivastava T, Thussu A. MRI in syphilitic meningomyelitis. Neurol India 2000;48:196
MRI in Syphilitic Meningomyelitis
MRI studies in syphilitic meningomyelitis have been infrequently reported. The clinical presentation of neurosyphilis includes acute lymphocytic meningitis (acute syphilitic meningitis), stroke (meningovascular syphilis), dementia (general paresis) and/or myelopathy (tabes dorsalis, meningomyelitis, syringomyelia). The symptoms may start within few weeks as in syphilitic meningitis, but may be delayed by over three decades in tabes. Meningomyelitis due to neurosyphilis has been estimated to account for 3% of all cases of neurosyphilis, excluding tabes dorsalis.
The diagnosis of syphilitic meningomyelitis is made on the basis of symptoms and signs of spinal cord involvement and characteristic abnormality of cerebrospinal fluid. MRI spine is an essential investigation to exclude compression and to demonstrate spinal cord lesion, if any. However, the MRI findings in syphilitic meningomyelitis have been infrequently reported.
A 32 year male, taxi driver by profession, presented with progressive tingling and numbness of both lower limbs of 4 months duration and weakness of both lower limbs and urinary urgency of 2 months duration. He gave history of extramarital sexual contacts. Physical examination revealed pyramidal signs in both lower limbs with extensor plantars. Touch and pinprick was impaired upto D6 level. Romberg test was positive. Investigations revealed normal haemoglobin, total leukocyte count, ESR and peripheral blood film. Serum biochemical parameters were normal. Blood VDRL was positive in 1:16 and blood Treponoma pallidum haem-agglutination test (TPHA) was positive in 1:160. CSF examination showed 40 cells/mm 100% mononuclear), protein 40 mg/dL, glucose 50 mg/dL. CSF VDRL was positive. CSF for gram stain, culture and AFB examination was negative. HIV serology was negative by ELISA. Visual and brainstem auditory evoked response study was normal. MRI of thoracic spine was normal on T1 weighted image. There was hyperintense signals in the cord extending from T5-T12 on T2 weighted image. Patient was treated with 4 million units of aqueous penicillin intravenously every 4 hours for 14 days.
Syphilitic meningomyelitis is the second most common form of spinal cord syphilis after tabes dorsalis. The manifestation usually occurs within 6 years of infection. Typically the onset is gradual but may be abrupt. Serologic and CSF findings, and prompt response to penicillin support the diagnosis of neurosyphilis. Although MRI finding of brain in meningovascular syphilis have been reported and include foci of ischaemia, studies on spinal MRI in syphilitic meningomyelitis are lacking. Berger reported a case of spinal cord syphilis who presented with paraparesis associated with HIV infection, in which MRI of cervical and thoracic spine was normal. In the present case, there was hyperintense signal on T2 weighted image, as described by Nabatame. In a case report, Tashiro et al described a case of syphilitic myelitis, which showed discrete and wedge straped Gadolinium-DTPA- enhanced lesion on magnetic resonance imaging at the level of T 3/4. The neurological and MRI findings improved after 16 days course of penicillin and prednisolone. Abnormal MRI findings in a case of syphilitic meningovascular myelitis were also noted by Strom et al. MRI therefore, is a useful adjuvant in the diagnosis and treatment of syphilitic myelitis. The hyperintense signals on T2 weighted image are nonspecific and may be present in other forms of noncompressive myelopathies.
Syphilitic meningomyelitis is usually a result of the combined effects of parenchymatous infection and inflammation as well as leptomeningeal artheritis with subsequent cord infarction. The high intensity areas on T2 weighting observed in this case may indicate ischaemic changes, inflammation or post infectious demyelination.
|1.||Nabatame H, Nakamura K, Matuda M et al: MRI of syphilitic myelitis. Neuroradiology 1992; 34: 105-106. |
|2.||Berger JR: Spinal cord syphilis associated with HIV infection: a treatable myelopathy. Am J Med 1992; 92: 101-103. |
|3.||Tashiro K, Moniaka F, et al: Syphilitic myelitis with its magnetic resonance imaging (MRI) verification and successful treatment. Jpn J Psychiatry Neurol 1987; 41: 269-71. |
|4.||Strom T, Schnrke SA: Syphilitic myelitis. Neurology 1991; 41: 325-326. |
|5.||Harrigan EP, McLaughlin TJ, Feldman RG: Transverse myelitis due to meningovascular syphilis. Arch Neurol 1984; 41: 337-338. |