Psychosomatics 47:538-539, December 2006
doi: 10.1176/appi.psy.47.6.538
© 2006 Academy of Psychosomatic Medicine
Neurosyphilis Presenting as Rhabdomyolysis and Acute Renal Failure With Subsequent Irreversible Psychosis and Dementia
Ryan F. Estévez, M.D., Ph.D., Univ. of Texas Southwestern Medical Center at Dallas, Dallas, TX
TO THE EDITOR: There has recently been a resurgence of syphilis in relation to the human immunodeficiency virus (HIV) epidemic, the decreased use of condoms for contraception, and the lack of routine serology testing. Because of its atypical presentation and relatively low incidence, neurosyphilis is often overlooked in diagnosis.1 This case report describes such an instance of a man with neurosyphilis who atypically presented with rhabdomyolysis and renal failure.
"Mr. M," a 56-year-old black man with no earlier psychiatric history saw his primary-care doctor at his wife’s urging as she noticed increasingly bizarre behavior and paranoid thoughts over the previous 6 months. Over the next 3 days, he was seen twice by his physician’s assistant and a psychiatric nurse-practitioner, who diagnosed him with "marital problems, not otherwise specified." He was not able to find his way home from his first appointment, and he was brought into the ER by the police, who found him agitated, confused, dirty, and wandering around the VA site. His wife, who was called, said that he had been missing for the past 2 days. She stated that he had been increasingly accusatory of her, responding to voices, and "paranoid."
Except for the fact that he was disheveled, the patient had an unremarkable physical and neurological exam. His pupils (1 mm) were constricted and minimally reactive. A psychiatrist was consulted, who noted bizarre and uncooperative behavior consistent with psychosis, confusion, and paranoia. We ordered a full "altered-mental-status" work-up. Laboratory results showed a BUN of 49 mg/dl, creatinine of 1.6 mg/dl, anion gap of 21.4 mmol/liter (osmolality=323 mosm/kg), and elevated CBC (15.6 K/mm3), AST=404 U/liter, AST=132 U/liter, CPK=19,195 U/liter; urinalysis and toxicology were negative. A head CT showed an age-inappropriate increased global atrophy. Rapid plasma reagin (RPR) was positive, with a titer of 1:16, and the MHA-TP was positive, with +HCV (hepatitis C virus) and –HIV. A lumbar puncture showed lymphocyte predominance and a positive VDRL titer of 8 DILS). The patient was admitted to the medical service for rhabdomyolysis, acute renal insufficiency with anuria, and an anion-gap metabolic acidosis. He was given intravenous fluids and penicillin G, as well as several prn doses of risperidone for bizarre behavior, failure to follow instructions, and inability to remain in bed. His acid/base status and renal insufficiency gradually resolved, as did his mental status, although he remained paranoid and delusional. After 12 days, he was transferred to the psychiatric ward, where, over the next 10 days, his mental status improved dramatically, and his paranoia and psychosis diminished significantly.
Two weeks after discharge, he returned to the ER and was again admitted to the psychiatric service for confusion, wandering, paranoia, and delusional thinking. The patient’s compliance with 4 mg of daily risperidone was suspect, given that he experienced several dystonic reactions while at home. A repeat serum RPR titer had decreased to 1:32. We felt that the patient’s cognitive status had deteriorated to the point where he needed 24-hour care, and he was placed in a nursing home. After 6 months, the patient’s paranoia was greatly diminished, although his level of dementia had increased dramatically. His psychosis and behavior were managed well with antipsychotics.
Discussion
Neurosyphilis, developing 5 to 15 years after initial infection, may present as virtually any psychiatric disorder.2,3 Changes in personality, affect, sensorium, and intellect are cardinal findings on psychiatric examination.4 Cranial nerve dysfunction, paresis, and pupillary changes can sometimes be found on physical examination, but are not always evident.
This case demonstrates a complex diagnostic problem for the clinician because obtaining a history from the neurosyphilitic patient can be difficult, if not impossible. Providers must always be suspicious and consider neurosyphilis in the differential diagnosis of any new-onset psychosis or behavioral change in middle-aged or elderly patients.
Obtaining collateral information is essential. This patient was erroneously diagnosed three times with marital problems and sent away. His mental conditioned deteriorated to such a poor state that he was not able to find his way home, became dehydrated, and developed rhabdomyolysis and renal failure.
Appropriate antibiotic treatment for neurosyphilis often leads to complete remission of psychiatric symptoms, although, if the patient also presents with dementia, this is typically irreversible. Unfortunately for this patient, neither his psychotic symptoms nor dementia resolved after antibiotic treatment.
REFERENCES
- Kohler CG, Pickholtz J, Ballas C: Neurosyphilis presenting as schizophrenia-like psychosis. Neuropsychiatry Neuropsychol Behav Neurol 2000; 13:297–302[Medline]
- Rundell JR, Wise MG: Neurosyphilis: a psychiatric perspective. Psychosomatics 1985; 26:287–295[Abstract/Free Full Text]
- Sirota P, Eviatar J, Spivak B: Neurosyphilis presenting as psychiatric disorders. Br J Psychiatry 1989; 155:559–561[Abstract/Free Full Text]
- Hoffman BF: Neurosyphilis in a young man. Can J Psychiatry 1981; 26:68–70[Medline]
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