Associate Program director Schwab Rehabilitation Hospital Chicago, Illinois, United States
Case Diagnosis: Non-traumatic spinal cord injury due to combined neurosyphillis and VZV myelitis
Case Description: 30-year old male w/ no PMH presented to ED with BLE weakness and paresthesias. MRI thoracic and lumbar spine showed changes throughout the entire cord with diffuse enhancement into the subarachnoid space and leptomeningeal enhancement along the conus. CSF returned positive for varicella and syphilis. Other workup returned positive for AIDS, mycobacterium avium pulmonary nodules, and rectal chlamydia. Physical exam consistent with T11 ASIA B: 1 strength at bilateral hip flexors, 0 strength in bilateral L3-S1 myotomes, and no sensation below T11. He was discharged from acute care at a MaxA level for transfers and bed mobility.
Discussions: This is a rare case of transverse myelitis in the setting of AIDS, neurosyphilis, and disseminated varicella. Neurodiagnostic imaging and labs were consistent with syphilitic meningocele myelitis and VZV myelitis. Longitudinally extensive transverse myelitis refers to complete or incomplete spinal cord dysfunction with MRI lesion extending beyond 3 vertebral segments as was present in this patient.
Conclusions: Neurosyphillis and VZV are rare causes for transverse myelitis, with few cases published in literature and especially of both. End-stage presentations of these disease processes are less commonly seen with improved treatment for AIDs. Reported cases of syphilis in 2018 reached their highest since 1991 while rates of HIV have remained stagnant. Physiatrists should remain vigilant for transverse myelitis associated with STIs as well as management of associated infections. Rehabilitation goals should be targeted for deficits corresponding to spinal cord injury levels.