<i>Status Epilepticus Presenting in a Patient with Neurosyphilis and a Previously Asymptomatic Arachnoid Cyst</i>

To the Editor: Primavera et al. (1) described a series of four patients with neurosyphilis with status epilepticus (SE) as the first manifestation of their infection. We report a similar presentation in a man with a previously asymptomatic arachnoid cyst. A 44-year-old man had been previously healthy. For two months prior to his admission, relatives noted mild word-finding difficulties with a slight deterioration in verbal fluency. The evening before his admission he had loss of dexterity in his right hand while using chopsticks at a restaurant. Several hours later, he was found convulsing by his wife. There was no history of previous seizures, head trauma, or serious infections (including syphilis-associated skin lesions). On arrival to the emergency department, he had been unconscious with right-arm clonic movements for the previous 30 min. He was given lorazepam (LZP), phenytoin (PHT), and phenobarbitol (PB) with no cessation of seizure activity. EEG showed pseudo-periodic epileptic discharge in the left posterior quadrant. Repetitive electrographic seizures were observed arising from this quadrant. He was intubated and started on propofol to attain a burst-suppression pattern. Computed tomography and magnetic resonance imaging (MRI) revealed a large left-sylvian region arachnoid cyst without mass effect or parenchymal changes (Figure 1). A cerebrospinal fluid (CSF) analysis indicated a pleocytosis (WBC count, 22/mm3, 15/mm3 mononuclear cells) and elevated protein (1.2 g/L). The patient continued on PHT, and later, carbamazepin (CBZ) and clobazam (CLB) were added while attempting to wean him from propofol. T1-weighted magnetic resonance image from a 44-year-old man in status epilepticus, showing a large left-sylvian region arachnoid cyst without significant mass effect. Later the patient also was found to have neurosyphilis. Eventually focal right arm seizures became better controlled, and he was able to be extubated after 10 days. A repeated MRI showed no change from the initial examination. Serologic tests for syphilis were positive, including blood VDRL and FTA-ABS as well as CSF VDRL. Human immunodeficiency virus (HIV) testing was negative. He was treated with a 14-day course of penicillin G and then penicillin V weekly for 3 weeks. After his intensive care unit stay, no further seizures were noted, and his motor function improved rapidly. However, language function evolved much more slowly, and at his 6-month follow-up visit, he still had a moderate global aphasia with some short-term memory problems. At the time of this visit, he had been maintained with both CBZ and PHT with no recurrence of seizures. Similar to other case reports of neurosyphilis in SE, this patient had focal epileptiform activity. In this case, however, the location of this activity conformed to a cystic area. This patient's large arachnoid cyst had remained quiescent throughout his life before neurosyphilis developed. It is possible that the combination of these two factors explains why his seizures remained initially refractory to standard antiepileptic drug treatment. This case demonstrates how double pathology must be considered in a patient in SE with a previously asymptomatic arachnoid cyst. Suggestive CSF results ultimately led to a diagnosis of neurosyphilis.

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