Misdiagnosis of Neuromyelitis Optica as Neurosyphilis

Case Diagnosis: Misdiagnosis of Neuromyelitis Optica as Neurosyphilis

Case Description or Program Description: Neurosyphilis is the central nervous system infection in a patient with syphilis. Neurosyphilis may present as meningitis (most common presentation), late meningovascular syphilis, general paresis, or tabes dorsalis. Neuromyelitis Optica (NMO) is an inflammatory disorder of the central nervous system characterized by severe, immune-mediated demyelination and axonal damage predominantly affecting optic nerves and the spinal cord. Patients with NMO have progressive deterioration due to accumulating visual, motor, sensory, and bladder deficits from recurrent attacks.

Setting: Acute Inpatient Rehabilitation Hospital

Assessment/Results: We found distinguishing between neurosyphilis and NMO difficult because of their similar presentation and MRI findings. Although getting titers is vital for diagnosis, each case still poses challenges for diagnosis and administrating the appropriate treatment

Discussion (relevance): Lower extremity weakness has many differential diagnoses, from spinal cord compressions, inflammatory disease (multiple sclerosis, Gillian Barre Syndrome), and neuropathies to infection of the central nervous system. The differential diagnosis between the different neurological myelopathies can be difficult. They have overlapping features. In this case, the patient had a false positive treponema test in the serum. Providing education to the patient about the importance of tests and outcomes is imperative. This case highlights the importance of proper history taking, effective communication between providers, and educating patients on the importance of various tests.

Conclusions: As clinicians, it is imperative to keep a broad differential as many neurological conditions have similar presentations. Although our patient had a positive serum titer for syphilis and was treated appropriately for neurosyphilis, our suspicion for neuromyelitis optica allowed us to manage an acute attack, which is debilitating if untreated. Additionally, we pursued approval for biologic therapy for continued management.