Meningovascular Syphilis

A 54-year-old right-handed man with no traditional vascular risk factors presented with right-sided weakness and fluctuating expressive aphasia. Magnetic resonance imaging of the brain showed an acute infarct of the left basal ganglia and corona radiata in the left middle cerebral artery (MCA) territory (Figure 1A). Computed tomography angiography of the head showed critical stenosis to near occlusion in the left supraclinoid internal carotid artery and the lower-mid basilar artery (Figure 1B and C) later confirmed by diagnostic 4-vessel cerebral angiogram. Stroke workup revealed positive serum syphilis immunoglobulin G and reactive rapid plasma reagin titer of 1:64. Cerebrospinal fluid (CSF) analysis revealed lymphocytic pleocytosis and elevated protein. Venereal Disease Research Laboratory (VDRL) test was positive at titer of 1:4. Other vasculitis and infectious workup including human immunodeficiency virus were negative. The patient was treated with a course of intravenous penicillin for 2 weeks. Repeat CSF VDRL 6 months after treatment was nonreactive