We read with interest the article by Wang et al about a 50-year-old man with neurosyphilis
that manifested as paraparesis of the lower limbs and sensory disturbances of the
lower limbs due to meningomyelitis.[1] Syphilis was diagnosed by serologic (toluidine red unheated serum test [TRUST],
treponema pallidum particle agglutination [TPPA]) and cerebrospinal fluid tests (pleocytosis,
elevated proteins, TRUST, TPPA).[1] The patient received penicillin for 5 weeks and made a full recovery within 3 months.[1] The study is noteworthy, but several points should be discussed.
The first point is that meningomyelitis is not a rare complication of syphilis. Both
myelitis and meningomyelitis (myelitis associated with meningitis) have been repeatedly
reported as manifestations of neurosyphilis.[2]
[3] In a retrospective study from a single hospital in China, four patients with syphilitic
myelitis were reported within 5 years.[4]
The second point is that the description “flickering candle” may have been misinterpreted;
the original authors used the term “candle guttering appearance,” which refers to
the characteristic pattern of peripheral nodular enhancement. The use of the term
“flickering candle” may therefore be considered ambiguous, as static images may not
convey the intended dynamic impression that “guttering” implies. Clarification of
this terminology through references or comparable cases could improve readability.
Third, in view of the known association of neurosyphilis with human immunodeficiency
virus and tuberculosis,[5] it would be informative to know whether screening for these infections was performed
in this case. It would also be interesting to know how the patient became infected
with Treponema pallidum and whether there was any evidence of previous stages of Lues in his medical history.
The fourth point is that it was not reported whether the patient also manifested in
the brain or not. The early stage of neurosyphilis usually manifests as meningitis,
headache, or hemiparesis.[6] The late stage of neurosyphilis is characterized by vasculitis, encephalitis, meningitis,
and myelitis.[6] Did the patient also show personality changes, aggressive behavior, mania, auditory
and visual hallucinations, illusions, overt paranoia, progressive cognitive impairment,
delirium, paranoia, or dementia? Was there evidence of hemiparesis, extrapyramidal
manifestations, stroke, epilepsy, cranial nerve lesions, Argyll-Robertson sign, optic
neuritis, ocular syphilis, or otosyphilis? Was cerebral imaging with contrast normal
or was there evidence of cerebral syphilis? Cerebral involvement in syphilis can be
asymptomatic but still show up on cerebral imaging.[7]
In summary, this interesting study has limitations that affect the results and their
interpretation. Addressing these limitations could strengthen the conclusions and
support the message of the study. Syphilitic myelitis belongs to the late stage of
neurosyphilis and is often associated with cerebral manifestations such as vasculitis,
encephalitis, and meningitis. Given the frequent cooccurrence of cerebral involvement,
brain imaging should be considered in all cases of syphilitic myelitis.
