Berger Joseph I, Vernon Kasun, Abdo Farid, Gulati Sandeep, Hariharan Radhika
Internal Medicine, St. John's Riverside Hospital, Yonkers, USA.
Radiology, St. John's Riverside Hospital, Yonkers, USA.
Cureus. 2022 Jun 25;14(6):e26318. doi: 10.7759/cureus.26318. eCollection 2022 Jun.
We present a 51-year-old male, with a past medical history of type 2 insulin-dependent diabetes mellitus (T2IDDM) without neuropathy, coronavirus disease 2019 (COVID-19) in April 2020 without residual symptoms, Raynaud's, and recent occupational outdoor exposure to insects as a construction manager who came to the emergency room complaining of a three-week history of bilateral progressive numbness and weakness beginning in his lower extremities and ascending toward his pelvis. Notably, he received the second dose of his Moderna COVID-19 vaccine one week prior to symptom onset and four weeks prior to admission. He also reported a recent appearance of a maculopapular rash on his upper extremities and flanks. Physical exam was remarkable for bilateral distal motor weakness in the upper and lower extremities with associated paresthesia and decreased reflexes in the lower extremities. The patient had slight ataxia and difficulty with heel walk and toe walk. Notably, the cranial nerve exam was normal, and the patient was afebrile. Intravenous immune globulin (IVIG) was started empirically for the treatment of Guillain-Barre syndrome (GBS), and doxycycline 100mg intravenous twice a day and ceftriaxone 2g intravenous daily were started for possible tick-borne disease. Subsequently, rapid plasma reagin (RPR) returned reactive at 1:64, and cerebral spinal fluid (CSF) venereal disease research laboratory (VDRL) test was reactive at 1:2 with markedly elevated protein and pleocytosis. Human immunodeficiency virus (HIV) testing was negative. Lyme disease testing was negative. Nerve conduction studies (NCS) and electromyography (EMG) showed a sensorimotor polyneuropathy with mixed demyelinating and axonal features. IVIG was continued for a total of five days, and antibiotics were changed to penicillin G (PCN G) for a total of 14 days for definitive treatment of early neurosyphilis (NS). While both clinical and laboratory findings confirm a positive diagnosis of NS, the patient's CSF composition showed very elevated total protein levels and pleocytosis. Additionally, his early peripheral neuropathy and EMG findings are not characteristics of a single disease and, instead, suggested a mixed pathology. We postulate that this patient had confirmed secondary syphilis with early NS associated with, and possibly correlated with, a simultaneous episode of acute inflammatory demyelinating polyneuropathy (AIDP) and/or a vaccine-related phenomenon.
我们报告一名51岁男性，既往有2型胰岛素依赖型糖尿病（T2IDDM）病史但无神经病变，2020年4月感染新型冠状病毒肺炎（COVID-19）且无残留症状，有雷诺现象，近期作为建筑经理在户外工作时接触过昆虫。他因双下肢渐进性麻木和无力3周，症状自下肢开始并向骨盆蔓延，前来急诊室就诊。值得注意的是，他在症状出现前一周、入院前四周接种了第二剂Moderna COVID-19疫苗。他还报告近期上肢和侧腹出现了斑丘疹。体格检查显示上下肢双侧远端运动无力，伴有感觉异常，下肢反射减弱。患者有轻度共济失调，足跟行走和足尖行走困难。值得注意的是，颅神经检查正常，患者无发热。经验性使用静脉注射免疫球蛋白（IVIG）治疗吉兰-巴雷综合征（GBS），并开始每天两次静脉注射100mg强力霉素以及每天静脉注射2g头孢曲松，以治疗可能的蜱传疾病。随后，快速血浆反应素（RPR）检测结果为1:64呈阳性，脑脊液（CSF）性病研究实验室（VDRL）检测结果为1:2呈阳性，蛋白明显升高且有细胞增多。人类免疫缺陷病毒（HIV）检测为阴性。莱姆病检测为阴性。神经传导研究（NCS）和肌电图（EMG）显示为感觉运动性多发性神经病，具有脱髓鞘和轴索性混合特征。IVIG持续使用了5天，抗生素改为青霉素G（PCN G）共使用14天，以明确治疗早期神经梅毒（NS）。虽然临床和实验室检查结果均确诊为NS，但患者的脑脊液成分显示总蛋白水平和细胞增多非常明显。此外，他早期的周围神经病变和EMG表现并非单一疾病的特征，而是提示存在混合性病理改变。我们推测该患者确诊为二期梅毒合并早期NS，可能与同时发生的急性炎症性脱髓鞘性多发性神经病（AIDP）发作和/或疫苗相关现象有关且可能存在关联。
