J Korean Neurosurg Soc.  2013 Mar;53(3):197-200. 10.3340/jkns.2013.53.3.197.

Cerebral Syphilitic Gumma Mimicking a Brain Tumor in the Relapse of Secondary Syphilis in a Human Immunodeficiency Virus-Negative Patient

• Yoon YK
• Kim MJ
• Chae YS
• Kang SH

• KMID: 2190766
• DOI: http://doi.org/10.3340/jkns.2013.53.3.197

Abstract

Diagnosis of cerebral syphilitic gumma is frequently determined at the time of surgery, because imaging and laboratory findings demonstrate the elusive results. A 59-year-old woman presenting dysarthria showed a mass on her brain computed tomography. She was first suspected of brain tumor, but histological results from surgical resection revealed cerebral gumma due to neurosyphilis. After operation, she presented fever and rash with an infiltration on a chest X-ray. Histological assessment of skin was consistent with syphilis. Fluorescent treponemal antibody absorbed test IgG in cerebrospinal fluid was positive. She was successfully treated with ceftriaxone for 14 days.

Keyword

Gummatous neurosyphilis; Latent syphilis; HIV negative; Ceftriaxone

MeSH Terms

Brain
Brain Neoplasms
Ceftriaxone
Dysarthria
Exanthema
Female
Fever
Humans
Immunoglobulin G
Neurosyphilis
Recurrence
Skin
Syphilis
Syphilis, Latent
Thorax
Ceftriaxone
Immunoglobulin G
Syphilis

Figure

• 

  Fig. 1 Brain magnetic resonance imaging (MRI) scans of the patient. A : The preoperative T1-weighted images showed a round mass-like lesion with isointensity in the peripheral and hypointensity in the central portion of the left frontal region. B : Non-contrast-enhanced, T1-weighted image demonstrated severe cerebral edema around the enhancing mass. C : Sagittal sections revealed a mass adjacent to the enhanced dura over the cerebral convexity. D, E and F : Three months after operation, the postoperative MRI scans showed that the rim enhancing mass in the left frontal region had disappeared with a small amount of remaining extraaxial fluid collection.

• 

  Fig. 2 Intraoperative and histopathological findings of a central nervous system gumma. A : The cerebral parenchyma was severely adhesive to the dura. B : The lesion had a rubbery appearance and was yellowish in color. En bloc resection was performed. C : High-power view of the mass showing occlusion of small arterioles as endoarteritis obliterans, and spirochetes were not detected on Warthin-Starry staining of this region (hematoxylin and eosin stain, ×400). D : The portion immediately below the meninges containing necrotic material infiltrated with predominantly plasma cells (×100). E : The peri-vascular region with fibrosis contained lymphocytes and plasma cells (×400). F : Parenchymal infiltration of lymphocytes and plasma cells in the gumma of the brain (×400).

• 

  Fig. 3 A and B : The rash was reddish-brown, non-itchy maculopapular and widespread over the whole body including the palms of the hands and soles of the feet. C : Chest computed tomograpic images show centrilobular nodules and infiltration with an interstitial pattern in both lower lung fields.

Reference

1. Ances BM, Danish SF, Kolson DL, Judy KD, Liebeskind DS. Cerebral gumma mimicking glioblastoma multiforme. Neurocrit Care. 2005; 2:300–302. PMID: 16159080.

2. Berger JR, Waskin H, Pall L, Hensley G, Ihmedian I, Post MJ. Syphilitic cerebral gumma with HIV infection. Neurology. 1992; 42:1282–1287. PMID: 1620334.

3. Brightbill TC, Ihmeidan IH, Post MJ, Berger JR, Katz DA. Neurosyphilis in HIV-positive and HIV-negative patients : neuroimaging findings. AJNR Am J Neuroradiol. 1995; 16:703–711. PMID: 7611026.

4. Clark EG, Danbolt N. The Oslo study of the natural history of untreated syphilis; an epidemiologic investigation based on a restudy of the Boeck-Bruusgaard material; a review and appraisal. J Chronic Dis. 1955; 2:311–344. PMID: 13252075.

5. Cnossen WM, Niekus H, Nielsen O, Vegt M, Blansjaar BA. Ceftriaxone treatment of penicillin resistant neurosyphilis in alcoholic patients. J Neurol Neurosurg Psychiatry. 1995; 59:194–195. PMID: 7629543.

6. Coleman DL, McPhee SJ, Ross TF, Naughton JL. Secondary syphilis with pulmonary involvement. West J Med. 1983; 138:875–878. PMID: 6613117.

7. Darwish BS, Fowler A, Ong M, Swaminothan A, Abraszko R. Intracranial syphilitic gumma resembling malignant brain tumour. J Clin Neurosci. 2008; 15:308–310. PMID: 18187326.

8. Fargen KM, Alvernia JE, Lin CS, Melgar M. Cerebral syphilitic gummata : a case presentation and analysis of 156 reported cases. Neurosurgery. 2009; 64:568–575. discussioin 575-576. PMID: 19240620.

9. Gentile JH, Viviani C, Sparo MD, Arduino RC. Syphilitic meningomyelitis treated with ceftriaxone : case report. Clin Infect Dis. 1998; 26:528. PMID: 9502500.

10. Holland BA, Perrett LV, Mills CM. Meningovascular syphilis : CT and MR findings. Radiology. 1986; 158:439–442. PMID: 3941870.

11. Horowitz HW, Valsamis MP, Wicher V, Abbruscato F, Larsen SA, Wormser GP, et al. Brief report : cerebral syphilitic gumma confirmed by the polymerase chain reaction in a man with human immunodeficiency virus infection. N Engl J Med. 1994; 331:1488–1491. PMID: 7969298.

12. Lee CW, Lim MJ, Son D, Lee JS, Cheong MH, Park IS, et al. A case of cerebral gumma presenting as brain tumor in a human immunodeficiency virus (HIV)-negative patient. Yonsei Med J. 2009; 50:284–288. PMID: 19430565.

13. Lee JP, Koo SH, Jin SY, Kim TH. Experience of meningovascular syphilis in human immunodeficiency virus infected patient. J Korean Neurosurg Soc. 2009; 46:413–416. PMID: 19893736.

14. Lukehart SA, Hook EW 3rd, Baker-Zander SA, Collier AC, Critchlow CW, Handsfield HH. Invasion of the central nervous system by Treponema pallidum : implications for diagnosis and treatment. Ann Intern Med. 1988; 109:855–862. PMID: 3056164.

15. Marra CM, Boutin P, McArthur JC, Hurwitz S, Simpson PA, Haslett JA, et al. A pilot study evaluating ceftriaxone and penicillin G as treatment agents for neurosyphilis in human immunodeficiency virus-infected individuals. Clin Infect Dis. 2000; 30:540–544. PMID: 10722441.

16. Marra CM, Maxwell CL, Smith SL, Lukehart SA, Rompalo AM, Eaton M, et al. Cerebrospinal fluid abnormalities in patients with syphilis : association with clinical and laboratory features. J Infect Dis. 2004; 189:369–376. PMID: 14745693.

17. Oblu N. Handbook of Clinical Neurology. 1975. New York: Elsevir.

18. Pall HS, Williams AC, Stockley RA. Intracranial gumma presenting as a cerebral tumour. J R Soc Med. 1988; 81:603–604. PMID: 3184093.

19. Rolfs RT, Joesoef MR, Hendershot EF, Rompalo AM, Augenbraun MH, Chiu M, et al. The Syphilis and HIV Study Group. A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. N Engl J Med. 1997; 337:307–314. PMID: 9235493.

20. Shann S, Wilson J. Treatment of neurosyphilis with ceftriaxone. Sex Transm Infect. 2003; 79:415–416. PMID: 14573840.

21. Simon RP. Neurosyphilis. Arch Neurol. 1985; 42:606–613. PMID: 3890813.

22. Uemura K, Yamada T, Tsukada A, Enomoto T, Yoshii Y, Nose T. Cerebral gumma mimicking glioblastoma on magnetic resonance images--case report. Neurol Med Chir (Tokyo). 1995; 35:462–466. PMID: 7477692.