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Year : 2020  |  Volume : 18  |  Issue : 4  |  Page : 326-328

Beneath a behavioral change

1 Family Health Unit Viseu-Cidade, Viseu Health Center I, Viseu, Portugal
2 Primary Care Health Centre São Pedro do Sul, Viseu, Portugal

Date of Submission11-May-2020
Date of Decision25-May-2020
Date of Acceptance11-Jun-2020
Date of Web Publication19-Oct-2020

Correspondence Address:
Dr. Inês Ferreira Santos
Rua Do Navio Nr 50 Cabanões, 3500-885 Viseu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmi.cmi_79_20

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When approaching symptoms suggestive of cognitive decline or dementia, it is important to rule out possible conditions that can lead to the emergence of psychological/behavioral changes. Herein, we present the case of a 69-year-old male, whose wife complained of sudden behavior and memory changes. He was diagnosed with syphilis and treated with three doses of penicillin. We report this case to highlight the importance of considering syphilis in the differential diagnosis of a fast onset cognitive decline. It also demonstrates the value of family physician proximity to the different members of a family, often a determining factor in establishing a diagnostic hypothesis, especially when complaints are not spontaneously exposed by the patient.

Keywords: Cognitive dysfunction (MeSH), neurosyphilis (MeSH), syphilis (MeSH)

How to cite this article:
Santos IF, Vasconcelos PJ, Figueiredo RA. Beneath a behavioral change. Curr Med Issues 2020;18:326-8

How to cite this URL:
Santos IF, Vasconcelos PJ, Figueiredo RA. Beneath a behavioral change. Curr Med Issues [serial online] 2020 [cited 2022 Dec 5];18:326-8. Available from: https://www.cmijournal.org/text.asp?2020/18/4/326/298599

  Introduction Top

When dealing with neuropsychiatric symptoms of late onset in the elderly (anxiety, irritability, agitation, depression, apathy, disinhibition, and changes in sensory perception), it is important to keep in mind the wide variety of possible differential diagnoses, including infectious causes.[1]

Syphilis still represents a relevant public health problem, despite the notable decrease in its incidence with the introduction of penicillin.[2]

In Portugal, according to data from the 2015–2016 National Serological Survey, 2.4% of residents aged 18 and over have antibodies to Treponema pallidum, which means that they have or had syphilis. The detection of antibodies was higher in males and older individuals, a fact that can be explained by the high incidence of syphilis in Portugal in the sixties and seventies.[2]

This case aims to emphasize the role of family physician (FP) in the differential diagnosis of behavioral changes/dementia, sometimes facilitated, as we demonstrate, by the proximity to other family members.

To present this case report, we obtained written consent from the patient.

  Case Report Top

We present the case of a 69-year-old Caucasian male, retired, married, with three children, belonging to a nuclear family, in Duvall life cycle stage VIII, with the medical history of asymptomatic cholelithiasis, chronic alcoholism (treated in a rehab center, abstinent for the past 20 years), and insomnia, medicated with lorazepam 1 mg.

The consultation at our Family Health Unit, scheduled by the patient, was preceded by a telephone contact from his wife, who was concerned about her husband's verbal aggressiveness in the last month, denying any known precipitating factor. She also conveyed her suspicions that her husband was having extramarital relationships, as he did not seem to have any sexual interest in her.

The patient came alone, complaining of feeling tired legs and swelling of the lower limbs. When asked about his emotional/psychological state, he referred a deterioration in his antegrade memory, which he related to a car accident that occurred a month before. According to the description of the event, no significant traumatic brain injury occurred. He denied depressed mood and recent changes in sleep or appetite. He denied self- or heterophysical aggressiveness, confessing, however, a more aggressive speech with his wife. He admitted having extramarital unprotected sex for several years. Consumption of alcohol or other substances was denied. Objectively, he was hemodynamically stable, without cutaneous/genital lesions which he denied having previously; he had stigmas of venous insufficiency; mental state and neurological examination were normal, with a mini-mental state examination of 28.

An analytical study was requested, including serological markers (HIV, hepatitis B and C, and syphilis) and other parameters for the initial assessment of dementia. We also requested a cranial computed tomography (CT). Regarding his initial complaints, we recommended compression stockings and a venotropic. Counseling on risk and prevention of sexually transmitted infections was carried out.

We posteriorly contacted his wife, advising her to discuss the matter with her children and to complain at the competent authorities in the event of aggressiveness escalation.

In a posterior consultation, the patient maintained his mnesic complaints, which were interfering with his daily life activities. Analytically, he presented no changes in blood count, renal, liver, and thyroid function, normal B12 vitamin, and folic acid and a nontreponemal test (Venereal Disease Research Laboratory [VDRL]) positive for 1:4 dilutions. Treponemic test (in this case fluorescent treponemal antibody absorption) was requested, which turned out to be positive. The patient's wife had a negative VDRL. The requested CT revealed atheromatous calcifications in the cranial base arterial vessels and accentuation of cortical grooves in the cerebral convexity, without parenchyma density alterations suggestive of infectious, vascular, or space-occupying lesions.

We referred him to an infectious disease consultation. Due to the suspicion of neurosyphilis, we contacted the infectious disease physician, who recommended treatment with 4.2 million units of parenteral penicillin weekly for 3 weeks.

The subsequent serum VDRL, used to follow the course of illness, including the response to therapy, showed a change of 1 dilution (from 1:4 to 1:2).

At the infectious disease consultation, the cerebral spinal fluid (CSF) study revealed clear liquor, with mild lymphocytic pleocytosis (15 cells/μL), elevated protein content (60 mg/dL), a nonreactive VDRL, and a reactive Treponema pallidum hemagglutination assay (32).

Meanwhile, the patient got divorced and began to experience anxiety that was difficult to control. We medicated him with sertraline 50 mg and referred him to a psychiatric consultation.

His perception of cognitive dysfunction did not improve during this assessment period.

  Discussion Top

Syphilis is characterized by several clinical stages, with different symptoms (primary, secondary, and tertiary stages), which alternate with long periods of latency. The latent stage is further divided into recent and late latent. Patients with late latent syphilis, infected for more than a year, may develop benign late syphilis (about 50%), cardiovascular disease (about 25%), or neurological disease (about 25%).[3]

Neurosyphilis has a wide variety of clinical manifestations that can mimic many other central nervous system diseases (atherosclerotic cerebrovascular disease, psychiatric pathology, dementia, or other infectious meningitis). Parenchymal involvement occurs in late neurosyphilis, usually many years (18–25) after the primary infection. In early stages, there is a gradual loss of memory, decreased intellectual capacity, personality, and behavior changes. Structurally, there is brain atrophy and thickening of the meninges.[4] Diagnosis is confirmed with treponemal and nontreponemal tests and CSF analysis.[3],[4]

Clinical suspicion is the key to diagnosis. In this case, new onset aggressiveness and memory loss associated with risky sexual behaviors were suggestive. The patient had a history of alcoholism and recent trauma, which could also have contributed to cognitive and behavior changes. He denied consuming alcohol for the past 20 years, which was confirmed by his wife and analytically supported. The head trauma during the car accident was mild, without alarm signals and cranial CT revealed no acute lesions resulting from the trauma.

The patient was referenced to an infectiology appointment, to perform a CSF analysis, since the possibility of neurosyphilis could not be excluded.

The later the neurosyphilis is treated, the greater the cognitive and behavioral sequels. Precocious treatment is fundamental to stop the dementia process.[4]

Treatment monitoring should be performed serially by clinical and quantitative serological assessment (nontreponemal serological tests) at 6, 12, and 24 months after treatment initiation.[3]

This case points out that the privileged knowledge FP has of patient's personality and common behavior. The management of risk behaviors within the couple is also FP responsibility. Finally, FP must work with the couple on the impact that such a diagnosis can generate in their relationship.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Directorate-General for Health, Clinical Norm 053/2011: Therapeutic Approach of Cognitive Changes; 2011. Available from: https://www.dgs.pt/directrizes da dgs/normas e circulares normativas/norma n 0532011 de 27122011 jpg.aspx. [Last accessed on 2020 Apr 10].  Back to cited text no. 1
National Institute of Health Doutor Ricardo Jorge; National Serological Survey 2015/2016: Sexually trasmitted infections; October 2017; Available from: http://repositorio.insa.pt/bitstream/10400.18/5402/1/INSA_ISN 2015 2016 IST_web.pdf. [Last accessed on 2020 Apr 10].  Back to cited text no. 2
Center for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines – Syphilis. Center for Disease Control and Prevention; 2016. Available from: https://www.cdc.gov/std/tg2015/syphilis.htm. [Last accessed on 2020 Apr 10].  Back to cited text no. 3
Janier M, Hegyi V, Dupin N, Unemo M, Tiplica GS, Potočnik M, et al. European Guideline on the Management of Syphilis; 2014. Available from: https://www.iusti.org/regions/europe/pdf/2014/2014SyphilisguidelineEuropean.pdf. [Last accessed on 2020 Apr 10].  Back to cited text no. 4


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