Delirium and stroke-like symptoms led to psych labels. Neurosyphilis was treatable.

A sudden disorientation

A 38-year-old male, recently diagnosed with Graves’ disease and taking carbimazole and propranolol, presented to the emergency department with a five-day history of sudden vertigo. He described a sensation of the surroundings spinning and an unsteady gait, swaying to the right. Though he appeared alert with a Glasgow Coma Scale score of 15/15, he was oriented to person but not to place or time.

A generalized, pruritic maculopapular rash was noted over his body, including his palms and forearms. Despite his confusion and disorientation, a neurological examination found his cranial nerves, motor function, and coordination to be within normal limits.

The stroke protocol

The patient was admitted with a working diagnosis of stroke. Initial laboratory tests for blood count, renal function, and liver function were normal. A noncontrast CT of the brain and a chest X-ray showed no acute abnormalities. On the second day, an MRI revealed multiple small foci of diffusion restriction in the deep periventricular white matter, suggestive of acute ischemic lesions. Based on these findings, he was started on aspirin, clopidogrel, and atorvastatin for ischemic stroke.

The psychiatric turn

By the second day of admission, the patient’s condition shifted. He became increasingly confused and disoriented, exhibiting inappropriate behavior and delirium. Because of the generalized rash, doctors expanded the workup beyond standard stroke protocols. While autoimmune screenings were negative, serological testing for syphilis returned a high rapid plasma reagin (RPR) titer of 1:256 and positive T. pallidum antibodies.

A lumbar puncture was performed to check for central nervous system involvement. The analysis showed an elevated white cell count and an increased IgG index, indicating the body was producing antibodies within the spinal fluid. Notably, the CSF VDRL—the specific test often used to confirm neurosyphilis—was negative. Despite this, the clinical picture of multifocal infarcts and positive blood serology led to a revised diagnosis of meningovascular neurosyphilis.

Recovery and rehabilitation

The patient was started on intravenous penicillin G, receiving 4 million units every four hours. By day 6, he remained in a state of delirium with a decreased Glasgow Coma Scale score of 12/14. However, after the medical team extended the penicillin therapy to three weeks, his mental status began to improve. He started following simple commands and regained the ability to participate in physiotherapy.

At the start of his recovery, his Mini-Mental State Examination (MMSE) score was just 9 out of 30, showing significant deficits in orientation, attention, and recall. Following five weeks of intensive inpatient rehabilitation, his cognitive function improved markedly. By the time of discharge, his MMSE score had risen to 21/30 and his Montreal Cognitive Assessment score was 25/30. He was discharged home, oriented and able to perform self-care with minimal supervision.