Page 38 - Delaware Medical Journal - July-August 2018
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Introduction
Syphilis is a chronic infection involving multiple organ systems,
involvement of the central nervous system with this bacterium.
Case Presentation
This is a 54-year-old gentleman with a history of alcohol use who presented to the hospital with acute change in mental status. He had two weeks of confusion and nonsensical speech, with visual and auditory hallucinations. He denied any constitutional symptoms, suicidal, or homicidal ideation. Social history included drinking
six cans of beers daily and multiple sexual partners. Polydipsia
was observed. Laboratory studies showed sodium of 110 mmol/L and positive blood alcohol level. CT and MRI of the head were unremarkable. Initial evaluation also included serum RPR, B12, folate, Lyme titer, and urine toxicology screen, all of which were within normal limits. Hyponatremia corrected appropriately CSF WBC 10, elevated protein of 97 mg/dL, and CSF glucose of 42mg/dL, which was noted by the primary team to be abnormal
but not diagnostic for any particular condition. CSF VDRL was negative. Psychiatry was consulted for persistent psychosis, but the mental health providers doubted the working diagnosis of primary psychosis due to the rarity of this condition presenting in the sixth decade of life. Repeat serum RPR was found to be positive at 1:32 penicillin G therapy for a total of 10 days to treat neurosyphilis, followed by three weekly IM Bicillin LA injections for syphilis of unknown duration. His mental status ultimately improved.
Discussion
This case illustrates the challenge of diagnosing neurosyphilis: Despite appropriate clinical suspicion and the use of diagnostic testing, the ultimate diagnosis was delayed by confounding variables. It is agreed that serum RPR has outstanding sensitivity However, a well-documented cause for a false negative result is acute alcohol intoxication. This detail of testing is often forgotten. Further, acute psychosis complicated by acute hyponatremia and psychogenic polydipsia has been previously described in cases of caused by T.pallidum, the diagnosis of neurosyphilis is very abnormality or positive CSF VDRL. This study well illustrates
the following conclusions: Firstly, the general internist should be reminded that acute psychosis typically presents in the second and third decade of life. Secondly, neurosyphilis can develop at any stage of the disease. Lastly, neurosyphilis should be considered
in the diagnosis of acute psychosis and the internist should be vigilant in his efforts to exclude this protean illness.
RESIDENT POSTER: FIRST PLACE PRIZE
Determining a Difficult Diagnosis of Disseminated Histoplasmosis
By Shawn Naqvi, DO; Pamela Bailey, DO; Nealanjon Das, DO and Alfred Bacon, MD
Case Presentation
A 44-year-old male smoker was admitted to the hospital with three weeks of intermittent fevers, weight loss, headaches, dyspnea, abdominal pain, back pain, and myalgias. Physical examination was notable for splenomegaly and a diffuse raised hyperpigmented maculopapular rash to the trunk and extremities sparing the
palms and soles. Autoimmune and infectious work-up, including blood and urinary antigens for Histoplasma capsulatum, was negative. Echocardiography showed no valvular vegetations. Contrast-enhanced CT scanning of the chest, abdomen, and pelvis demonstrated multiple bilateral pulmonary nodules, mediastinal lymphadenopathy, and splenomegaly. Video-assisted thoracoscopic surgical wedge resections of the right lung upper, middle, and lower lobes yielded many necrotizing granulomatas, and silver staining demonstrated numerous spores that were morphologically compatible with Histoplasma capsulatum. He received treatment with intravenous liposomal amphotericin B, followed by outpatient oral itraconazole. He was re-hospitalized with recurrence of fevers,
of a new pericardial effusion, which was concerning a diagnosis of acute, progressive, disseminated histoplasmosis complicated by granulomatous mediastinitis, and this required re-treatment with intravenous liposomal amphotericin.
Discussion
and urinary antigen testing, as mediastinal disease in particular
has been noted to lead to falsely negative antigen testing. It is the Histoplasma antigen detected in the blood and urine for testing
via enzyme immunoassay. Host immune status is important to consider when interpreting histoplasmosis testing, as it affects Urinary Histoplasma antigen detection is marginally more sensitive than hematologic detection. Although antigen detection is rapid, noninvasive and highly sensitive, the gold standard for the diagnosis of Histoplasma infection remains tissue biopsy showing yeast on pathology of tissue and isolation of spores in culture.
There is also the possibility that this patient had a prozone reaction. The prozone effect is well documented in immunoassays that are run frequently, most notably in HIV or syphilis testing. Prozone reactions are false negative antigen tests where an excess antibody present in the blood interferes with agglutination due
to antigen-antibody complexes. A lack of agglutination causes a false negative test. As these are immunoassays, the potential false
210 Del Med J | July/August 2018 | Vol. 90 | No. 6
