220 - Lost for Words: Multidisciplinary management of atypical neurosyphilis presenting with transcortical sensory aphasia

Case Diagnosis: A 49 y.o man with a history of alcohol use disorder and hyperlipidemia was diagnosed with atypical neurosyphilis after presenting with acute confusion, seizures, and aphasia. MRI showed abnormal signals in both temporal lobes. A lumbar puncture confirmed neurosyphilis.

Case Description:

The patient presented with altered mental status and recurrent seizures. Initial brain MRI demonstrated bilateral temporal lobe T2/FLAIR hyperintensities, progressing to involve the insular, frontal, and parietal cortices. Extensive workup ruled HSV, HIV, fungal, and AFB infections. Lumbar puncture confirmed neurosyphilis with positive CSF VDRL (1:4), elevated serum RPR (1:28), and T. pallidum IgM positivity. He was treated with a 14-day course of high-dose IV penicillin G and adjunctive IV methylprednisolone, alongside dual anti-epileptic medications to control ongoing status epilepticus.

Due to persistent aphasia, speech therapy was initiated focusing on compensatory communication strategies, auditory and verbal comprehension, verbal expression, and family education to improve functional communication. Physical therapy also evaluated and supported the patient’s mobility and endurance, ensuring safe ambulation and activity tolerance during recovery. Patient was ultimately discharged home with family. He will continue SLP in outpatient setting.

 

Discussions:

Neurosyphilis remains a diagnostic challenge due to its ability to mimic viral, autoimmune, and other neurodegenerative conditions. In this case, the overlap of neuroinfectious and inflammatory processes complicated early diagnosis and management. From a rehabilitation perspective, aphasia and cognitive impairment significantly impact a patient’s ability to engage in therapy, requiring specialized speech-language interventions alongside physical therapy to address mobility and endurance. Early multidisciplinary involvement was crucial in tailoring treatment plans and preventing functional decline. This case underscores the value of an integrated physiatric approach to facilitate neurological recovery and optimize patient outcomes.

Conclusions: Physiatrists should consider neurosyphilis in patients with unexplained cognitive and language deficits. Timely diagnosis and coordinated rehab can lead to meaningful recovery, even in complex, rare conditions like this one.