1. A 29-year-old HIV infected man with right eye-lid ptosis and diplopia
Teaching Neuroimages
NEUROLOGY
Resident and Fellow section
© 2017 American Academy of Neurology

2. Vignette
A 29-year-old HIV infected man on antiretroviral treatment with negative viral load and CD4+ T cell count low at 344/mm3;
Presented with right eye-lid ptosis and diplopia;
On examination, right pupil was dilated, without reaction to light or accommodation;
Extra-ocular movements were impaired in all directions, except abduction.
Serum VDRL and TPHA were positive (titer of 1/512 and 1/10240 respectively)
Additionally confirmed in CSF - VDRL positive, TPHA titer of 1/320 with 92/µl mononuclear cells, 55mg/dL of protein and normal glucose.
Sá e Silva et al
© 2017 American Academy of Neurology

3. Imaging Sá e Silva et al A B C D © 2017 American Academy of Neurology
Fig. 1 MRI features of gummatous neurosyphilis pre and post-treatment.
(A) Axial T2 MRI shows diffuse thickening of the cisternal portion of the right oculomotor nerve. (B) Contrasted T1 MRI exhibits strong enhancement of the lesion. (C) Axial T2 MRI and (D) contrasted T1 MRI demonstrate complete radiographic resolution 4 months after treatment.  
Sá e Silva et al
© 2017 American Academy of Neurology

4. Gummatous neurosyphilis
Although very rare, neurosyphilis can affect the cranial nerves and should be suspected in a co-infected HIV patient.
1. Seeley WW, Venna N. Neurosyphilis presenting with gummatous oculomotor nerve palsy. J Neurol Neurosurg Psychiatry May;75(5):789.
2. Hess CW, Rosenfeld SS, Resor SR Jr. Oculomotor nerve palsy as the presentingsymptom of gummatous neurosyphilis and human immunodeficiency virus infection:clinical response to treatment. JAMA Neurol Dec;70(12):
Sá e Silva et al
© 2017 American Academy of Neurology