Syphilis is a sexually transmitted disease caused by Treponema pallidum, with human beings as the only host. With the advent of antibiotics, the classical skin and mucosal manifestations have become rare but presentations now can mimic any psychiatric disorders, from mood disorders, psychosis, delirium, and cognitive impairment. Here, the authors present a case of tertiary syphilis that presented with psychiatric symptoms.
Mr. HA, a 58-year old Muslim married male from the rural parts of Assam first presented to our hospital with bilateral hearing difficulties about 4 years ago without any psychiatric complaints. He was referred for an ENT opinion and asked to review later. He was brought after a gap of 3 years with complaints of suspiciousness against his wife and subsequent aggressive behavior with gradual and insidious onset from the previous 2 years. His mental status examination revealed increased psychomotor activity, irritable affect, delusion of infidelity and persecution, impaired judgment, and poor insight. His physical examination revealed bilateral sensori-neural hearing loss and absent bilateral ankle jerks. There was no skin or mucosal lesions. His initial brief psychiatric rating scale (BPRS) score was 70. He was admitted in our hospital with an initial diagnosis of persistent delusional disorder and treated with olanzapine on adequate dose and duration without any response, subsequently changed over to risperidone for optimal dosage but he failed to show much response as his BPRS score remained 68. His initial investigation reports had shown venereal disease research laboratory test reactive which was subsequently confirmed to be tertiary syphilis when his fluorescent treponemal antibody absorption (came positive. His diagnosis was revised to Organic delusional disorder with late syphilis and he was started on Injection Benzathine penicillin (2.4 million units) and Tablet Probenecid 500 mg QID for 2 weeks along with Tablet Pimozide 1 mg and referred for neurological opinion. His family members reported improvement in behavioral symptoms within a few weeks which continued to improve over the months.
Syphilis starts with primary syphilis presenting as a single ulcer, which if remain untreated can progress to secondary syphilis consistent with fever, maculopapular rash following which the infection enters a latency period lasting for many years following which the untreated individual enters tertiary syphilis phase. As many individuals may not be able to provide a reliable history of initial infection, it is important to consider syphilis a possibility in individuals presenting with late-onset psychiatric symptoms.
Our patient failed to respond to multiple trials of antipsychotics and showed improvement on antibiotics. Hence, when a patient fails to respond to conventional treatment, other causes should be ruled out, particularly syphilis.
Syphilis has often been nicknamed as the Great Mimicker or the Great Imitator. Infection rates have fallen through the latter half of the twentieth century till the late 1990s when it started emerging concurrently along with HIV infection. However, in HIV-negative individuals, psychiatric symptoms can still be the primary manifestation of the disease. In conclusion, syphilis should be considered a differential diagnosis in HIV-negative patients with late-onset psychiatric manifestations who fail to respond to usual treatment.
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