# Ocular Syphilis and Syphilitic Meningitis as the Initial Symptoms of Neurosyphilis in an HIV-Negative Patient: A Case Report

## TL;DR

A 43-year-old HIV-negative man presented with ocular syphilis and meningitis as the first signs of neurosyphilis, highlighting the disease's variable and deceptive symptoms.

## Contribution

This case report emphasizes the importance of considering syphilis in differential diagnoses despite negative initial screening tests.

## Key findings

- The patient exhibited ocular syphilis and syphilitic meningitis without prior syphilis symptoms.
- Positive treponemal antibodies confirmed the diagnosis despite negative rapid plasma reagin and CSF VDRL tests.
- MRI revealed facial nerve involvement consistent with cranial nerve VII involvement.

## Abstract

Syphilis is an infectious disease caused by the spirochete bacteria Treponema pallidum and is most commonly transmitted via contact of mucous membranes with infectious lesions during sexual intercourse. It is called the "great mimicker" due to its ability to infect a wide variety of organs and, as a result, produce a multitude of symptoms. Neurosyphilis, an infection of the central nervous system, can occur at any stage of infection. Cases of early neurosyphilis may not present with any prior history of syphilis infection or classical symptoms of primary or secondary infection. Homosexual men are disproportionately affected by the increasing rate of transmission.In this case, a 43-year-old man was diagnosed with neurosyphilis, initially presenting with bilateral papilledema concerning for idiopathic intracranial hypertension. A detailed social history revealed that the individual was sexually active with a male partner. Despite nonreactive results from the rapid plasma reagin and CSF Venereal Disease Research Laboratory tests, further serum workup yielded positive results for treponemal antibodies. Evidence of facial nerve involvement was also found on MRI. These findings were consistent with a diagnosis of ocular syphilis with syphilitic meningitis involving cranial nerve VII. This case demonstrates the importance of clinical suspicion for syphilis when indicated by social history, even when screening tests are negative, due to the potential for false negatives and highly variable clinical presentation.