Neurosyphilis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]Tarek Nafee, M.D. [3]

Overview

Neurosyphilis must be differentiated from other diseases that cause abnormal gait, Blindness, confusion and depression, such as multiple sclerosis, Brain tumours, Wernicke’s encephalopathy, CNS abscess, electrolyte disturbance, Subdural empyema, subarachnoid hemorrhage, brain stroke, Conversion disorder and Drug toxicity.

Differentiating X from other Diseases

• Neuroyphilis has an extensive differential diagnosis.

• Neurosyphilis must be differentiated from other diseases that cause abnormal gait, Blindness, confusion and depression, such as Brain tumours, Wernicke’s encephalopathy, CNS abscess, electrolyte disturbance, Subdural empyema, subarachnoid hemorrhage, brain stroke, Conversion disorder and Drug toxicity.

Diseases	Diagnostic tests				Physical Examination					Symptoms			Past medical history	Other Findings
	Na+, K+, Ca2+	CT /MRI	CSF Findings	Gold standard test	Neck stiffness	Motor or Sensory deficit	Papilledema	Bulging fontanelle	Cranial nerves	Headache	Fever	Altered mental status
Neurosyphilis		✔	↑ Leukocytes and protein	CSF VDRL-specifc CSF FTA-Ab -sensitive	✔	✔	✔	✔	✔	✔	✔	✔	Unprotected sexual intercourse, STIs History of multiple sexual partners. History of genital ulcer (chancre), diffuse maculopapular rash.	Blindness confusion, depression, Abnormal gait
Multiple sclerosis			Oligoclonal bands of IgG on electrophoresis of cerebrospinal fluid	MRI	✔	✔			✔	✔		✔	History of fatigue Mood problems Spasticity Bowel and bladder dysfunction	Vision problems Balance problems Dizziness Areas of demyelination in CNS MRI
Brain tumour		✔	Cancer cells	MRI		✔	✔	✔	✔	✔		✔		Cachexia Gradual progression of symptoms
Wernicke’s encephalopathy			Normal				✔	✔			✔		History of alcohal abuse	Ophthalmoplegia confusion
CNS abscess		✔	↑ leukocytes >100,000/ul ↓ glucose and ↑ protien ↑ red blood cells lactic acid >500mg	Contrast enhanced MRI is more sensitive and specific Histopathological examination of brain tissue	✔	✔	✔		✔	✔	✔	✔	History of drug abuse endocarditis	High grade fever Fatigue Nausea vomiting
Electrolyte disturbance	↓ or ↑			Depends on the cause						✔		✔		Confusion Seizures
Subdural empyema		✔		Clinical assesment and MRI	✔	✔	✔	✔	✔			✔	History of relapses and remissions	Blurry vision urinary incontinence Fatigue
Delirium tremens		✔		Clinical diagnosis		✔	✔		✔	✔	✔	✔	Alcohol intake Sudden withdraw or reduction in consumption	Tachycardia diaphoresis hypertension tremors, mydriasis positional nystagmus,
Subarachnoid hemorrhage		✔	Xanthochromia	CT scan without contrast	✔	✔	✔	✔	✔	✔	✔	✔	Trauma/fall	Confusion dizziness Nausea Vomiting
Stroke		✔	Normal	CT scan without contrast		✔	✔		✔	✔		✔	TIAs, hypertension, diabetes mellitus	Speech difficulty Gait abnormality
Viral encephalitis		✔	Increased RBCS or xanthochromia Mononuclear lymphocytosis High protein content Normal glucose	Clinical assesment	✔	✔	✔		✔	✔	✔	✔	Tick bite Mosquito bite Viral prodome for several days	Extreme lethargy, rash hepatosplenomegaly, lymphadenopathy, behavioural changes
Herpes simplex encephalitis		✔		Clinical assesment			✔	✔	✔	✔	✔		History of hypertension	Delirium Cortical blindness cerebral edema seizure
Drug toxicity											✔	✔		Lithium Sedatives phenytoin carbamazepine
Conversion disorder				Diagnosis of exclusion		✔		✔		✔	✔	✔		Tremors, blindness, difficulty swallowing
Febrile convulsion			Not performed in first simple febrile seizures	Clinical diagnosis and EEG					✔	✔	✔	✔	Family history of febrile seizures, viral illness or gastroenteritis	Age > 1 month,
Hypoglycemia	↓ or ↑			Serum glucose HbA1c		✔				✔		✔	History of diabetes	Palpitations, sweating, dizziness, low serum, glucose