And we have a different form of neurosyphilis
called parenchymatous neurosyphilis,
and that involves the parenchyma of either the brain or the spinal cord.
And here I'm showing you a photomicrograph of brain tissue
and I think you can see the spirochetes throughout this brain tissue.
And that can present as general paresis,
and these are the last of tertiary syphilis to occur,
but you can do something about it. These are treatable.
You may not resolve all the findings,
but you can certainly get improvement of these.
So lets talk about parenchymatous neurosyphilis, so called general paresis.
You can actually use the word paresis as its own acronym.
P standing for personality,
A standing for affect, meaning carelessness in appearance
R standing for hyperactive reflexes
EYE standing for the Argyll Robertson pupil,
which reacts to light, the pupils constrict,
but when you try to show accomodation, there's no constriction of the pupils.
S for sensorium,
where the patient has illusions or delusions, megalomania, hallucinations
or one thing that I've noticed is confabulation
and as you know confabulation means
you may walk in the room and the patient
says he recognizes you and met you before
when you've never seen him before.
I for intellect which is decreased recent memory
judgement changes or poor insight
and S for slurred speech.
All of those are signs of parenchymatous neurosyphilis of the brain.
So once again, general paresis would be slow onset of neuropsychiatric disturbances
progressive cognitive deterioration
and then finally, loss of motor control -- paralysis, bowel and bladder dysfunction.
And I wonder how many people who have been diagnosed with Alzheimer's disease
actually have had syphilis and were never evaluated for it.
Now another form of parenchymatous neurosyphilis
is something called tabes dorsalis or syphilitic myelopathy
What we've got here is a picture showing demyelination
of the posterior spinal cord.
These patients will present with an ataxic, wide-based gait
because they've lost proprioception,
and they have no sense of how they're standing,
so in order to stay sturdy,
they have to widen their gait.
You can demostrate that the posterior columns are affected
because the patient has the loss of position and vibratory sense
which reflects the posterior or dorsal columns.
The patient also has the loss of deep pain and temperature
which involves the spinothalamic tract.
and a very unusual manifestation of tabes dorsalis
is this lancinating, lightning-like pain
called tabetic crisis.
These are episodic.
They occur in about 75% of patients with tabes dorsalis.
They usually involve the lower extremities,
but there may be visceral pain,
and what I mean by that is that the patient has the sudden onset of
lightning-like, agonizing epigastric pain with nausea and vomiting.
And as an interesting aside, I saw a patient years ago at the VA
who had been admitted at least 20 previous times for so called
tabetic abdominal crisis with this lightning-like pain,
and when I interviewed the patient, he said to me,
"Doc, this pain I've got today,
this is exactly like all of my other episodes --
exactly like that."
So I was led down the primrose path and assumed this was yet another
tabetic abdominal crisis due to syphilis.
I was embarassed when the diagnosis of a ruptured appendix was made.
So even though a patient may describe the symptoms like syphilis
the antenna of the physician should be up for other possible causes.
In this particular case, you lose the reflexes
in parenchymatous syphilis involving the brain, the reflexes are increased,
but with tabes dorsalis, the patella and achilles tendon reflexes are reduced,
and they'll have a positive Romberg's sign.
And as you know, a positive Romberg
is a measure of how the posterior columns are working.
So you have the patient stand with feet together,
hands out in front, have them close their eyes,
and see if they can maintain that same posture.
If they tend to fall,
then they have a positive Romberg test.