Matsubayashi Taiki, Muramatsu Ryoko, Fujiki Shuko, Furuki Misako, Obayashi Masato
Department of Neurology, National Hospital Organization Disaster Medical Center, Tokyo, JPN.
Cureus. 2025 Feb 14;17(2):e78984. doi: 10.7759/cureus.78984. eCollection 2025 Feb.
Syphilis cases are increasing worldwide, raising concerns about a potential rise in neurosyphilis. However, neurosyphilis presenting with cranial nerve palsy as the initial symptom remains rare. A 45-year-old man presented with fever, right-sided headache, and numbness localized to the first branch of the right trigeminal nerve for eight days. Initial brain magnetic resonance imaging (MRI), performed on day eight after symptom onset, revealed enlargement of the right trigeminal nerve. A follow-up MRI on day 15 later demonstrated a hyperintense lesion on the T2-weighted image in the pontine region adjacent to the swollen nerve. The lesion in the pons had an iso-intensity on diffusion-weighted imaging and elevated apparent diffusion coefficient (ADC) values. Cerebrospinal fluid analysis showed an elevated cell count, a positive fluorescent treponemal antibody absorption test, and increased rapid plasma reagin levels, leading to a diagnosis of neurosyphilis. Intravenous penicillin G treatment was initiated on day 15, resulting in an improvement of the patient's fever, headache, and numbness. Additionally, a follow-up brain MRI on day 44 showed reduced trigeminal nerve swelling and resolution of signal changes in the brain parenchyma. The chronological progression observed on MRI, with signal changes in the adjacent brain parenchyma appearing after trigeminal nerve swelling, and the signal changes in the brain parenchyma accompanied by elevated ADC values, suggest that the abnormal signal changes in neurosyphilis may be linked to angiogenic edema resulting from secondary inflammation. In this case, early diagnosis likely contributed to a favorable therapeutic response. This case further highlights the importance of considering neurosyphilis in the differential diagnosis of patients presenting with trigeminal nerve impairment.
梅毒病例在全球范围内呈上升趋势，引发了对神经梅毒潜在增加的担忧。然而，以颅神经麻痹为初始症状的神经梅毒仍然罕见。一名45岁男性出现发热、右侧头痛以及局限于右侧三叉神经第一支的麻木感，持续了8天。在症状出现后的第8天进行的初次脑磁共振成像（MRI）显示右侧三叉神经梅毒病例在全球范围内呈上升趋势，引发了对神经梅毒潜在增加的担忧。然而，以颅神经麻痹为初始症状的神经梅毒仍然罕见。一名45岁男性出现发热、右侧头痛以及局限于右侧三叉神经第一支的麻木感，持续了8天。在症状出现后的第8天进行的初次脑磁共振成像（MRI）显示右侧三叉神经增粗。15天后的随访MRI显示，在与肿胀神经相邻的脑桥区域的T2加权图像上有一个高强度病变。脑桥病变在扩散加权成像上呈等强度，表观扩散系数（ADC）值升高。脑脊液分析显示细胞计数升高、荧光密螺旋体抗体吸收试验呈阳性以及快速血浆反应素水平升高，从而诊断为神经梅毒。在第15天开始静脉注射青霉素G治疗，患者的发热、头痛和麻木症状得到改善。此外，在第44天进行的随访脑MRI显示三叉神经肿胀减轻，脑实质信号变化消失。MRI上观察到的按时间顺序发展的过程，即三叉神经肿胀后相邻脑实质出现信号变化，且脑实质信号变化伴有ADC值升高，表明神经梅毒中的异常信号变化可能与继发性炎症导致的血管生成性水肿有关。在这个病例中，早期诊断可能促成了良好的治疗反应。该病例进一步凸显了在对出现三叉神经损伤的患者进行鉴别诊断时考虑神经梅毒的重要性。 显示右侧三叉神经增粗。15天后的随访MRI显示，在与肿胀神经相邻的脑桥区域的T2加权图像上有一个高强度病变。脑桥病变在扩散加权成像上呈等强度，表观扩散系数（ADC）值升高。脑脊液分析显示细胞计数升高、荧光密螺旋体抗体吸收试验呈阳性以及快速血浆反应素水平升高，从而诊断为神经梅毒。在第15天开始静脉注射青霉素G治疗，患者的发热、头痛和麻木症状得到改善。此外，在第44天进行的随访脑MRI显示三叉神经肿胀减轻，脑实质信号变化消失。MRI上观察到的按时间顺序发展的过程，即三叉神经肿胀后相邻脑实质出现信号变化，且脑实质信号变化伴有ADC值升高，表明神经梅毒中的异常信号变化可能与继发性炎症导致的血管生成性水肿有关。在这个病例中，早期诊断可能促成了良好的治疗反应。该病例进一步凸显了在对出现三叉神经损伤的患者进行鉴别诊断时考虑神经梅毒的重要性。
