Abstracts

Rationale: Rationale: Neurosyphilis is rather uncommonly encountered in the US except in immuno-compromised patients. Although seizures are relatively common in neurosyphilis, CPSE is rare. We report on complex partial status epilepticus (CPSE) as the initial manifestation of neurosyphilis in an immuno-competent patient.Methods: A 51 year old imuno-competent man presented with a three day history of brief episodic confusion that progressed to a state of continuous confusion, slurred speech and intermittent agitation one day before admission. On examination he was confused with no localizing or lateralizing neurological findings. Head MRI showed leptomeningeal enhancement over the right cerebral hemisphere. Non convulsive seizures were suspected and video/EEG monitoring showed bihemispheric delta slow waves with right hemispheric periodic epileptiform discharges (PLEDs) maximal in the mid-posterior temporal region, with frequent ictal discharges of right mid-posterior temporal onset (Fig.1). CSF analysis revealed 33 WBC/µL, protein 110 mg/dL, glucose 76 mg/dL and positive VDRL (1:4 titer). Serum serology was positive for FTA-ABS.Results: CPSE was aborted by intravenous phenytoin, valproic acid and levetiracetam four days after admission. Neurosyphilis was treated with intravenous penicillin G, 4 million units every 4 hours for 14 days. After penicillin treatment and seizure control, repeat head MRI showed extensive increased signal in the right temporal lobe (Fig. 2). The patient had some cognitive improvement following treatment but he remained with a major cognitive impairment on discharge.Conclusions: Neurosyphilis should be considered, even in immuno-competent patients with new onset complex partial seizures, especially those that progress to CPSE. Head MRI of these patients might show cerebral signal abnormalities, but it is unclear if these changes are related to the syphilitic infection or are caused by the CPSE.