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The awesome burden of treatable yet untreated neurologic disease in the developing world presents a humanitarian crisis to those of us with neurologic expertise from more privileged situations. Although increased economic resources are critically needed, a shortage of personnel to care for these patients is as great a problem. It is neither feasible nor desirable to propose training neurologists to work in these regions. However, COs could be selected to receive additional training and return to their home regions to serve as resources for referrals and as community educators. Such a training program would not require massive financial commitments. A handful of dedicated neurologists could conceivably accomplish this in 6- to 8-week training sessions. Ideally, educational materials, such as posters and pamphlets in both English and the native language of the various regions, would be provided at no cost. Existing textbooks in neurology are written for physicians and often focus on diagnostic evaluations and therapies far beyond the services available in developing countries. A text for practical use by COs and community health workers that discusses the application of available medicines and therapies for common neurologic problems would be invaluable. Similar books exist that address general medical and obstetrical problems (for example, Where There Is No Doctor: A Village Health Care Handbook). Where There Is No Neurologist could be developed as a primary teaching tool and a valuable reference for COs with neurologic expertise. Neuroscience researchers, clinical neurologists, and neurology residents from industrialized countries have much to offer and to gain by working in the Third World. Research to monitor the incidence and resource utilization of emerging problems such as stroke is needed to influence public policy. The economic burden and lost productivity caused by neurologic disease in this part of the world has not been appreciated or explored. Disease beyond the scope of Western experience manifests daily in places like Chikankata. Entities such as tabes neurosyphilis, which previous generations of neurologists used as the basis for their training, still abound in Zambia. Much personal satisfaction can be gained in providing care to this vulnerable and underserved population.
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PMID:Barriers to care for patients with neurologic disease in rural Zambia. 1071 73

The questions most often asked of my residents and myself are the following: (1) How do you interpret the cerebrospinal fluid white blood cell count and polymerase chain reaction results when the lumbar puncture has been traumatic? (2) Does the older adult with a serum sample that tests positive by the Venereal Disease Research Laboratory test need spinal fluid analysis for neurosyphilis, and which of those syphilis tests can become nonreactive even though the patient is never treated? (3) Do you give steroids to patients with bacterial meningitis? (4) What do you do for the patient with cryptococcal meningitis who develops a spastic gait? (5) Are all cases of transverse myelitis "idiopathic"? and (6) When does the patient who has had a stroke need spinal fluid analysis to rule out an infectious etiology? This is how we answer these questions.
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PMID:What I have learned about infectious diseases with my sleeves rolled up. 1217 Mar 89

In split of a dramatic increase of syphilis incidence over the last time, neurosyphilis cases are reported relatively rare. The data on ischemic stroke of syphilis origin in 5 patients (3 males and 2 females, aged 35-43 years) are presented. A diagnosis was verified on the basis of clinical and MRT data and the results of blood and spinal fluid serological reactions. The patients had mild and moderate headache (5), movement (5) and sensitivity (3) disorders, membrane syndrome (2), hemianopsia (2), coma (1). Because of the absence of anamnesis data on syphilis survived, recognition of stroke origin was delayed and established only after positive serum and liquor tests. One patient died of multifocal brain lesion, 4 patients discharged from the hospital had differently pronounced movement disorders.
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PMID:[Cerebral ischemic strokes in young patients with neurosyphilis]. 1274 98

The history of vascular dementia can be traced back to cases of dementia postapoplexy described by Thomas Willis in 1672. During most of the 18th and early 19th century, "brain congestion" (due in all likelihood to the effects of untreated hypertension) was the most frequent diagnosis for conditions ranging from stroke to anxiety and to cognitive decline, and bloodletting became the commonplace therapy. The modern history of vascular dementia began in 1894 with the contributions of Otto Binswanger and Alois Alzheimer, who separated vascular dementia from dementia paralytica caused by neurosyphilis. In the 1960s, the seminal neuropathological and clinical studies of the New Castle school in England inaugurated the modern era of vascular dementia.
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PMID:Vascular dementia: a historical background. 1619 Dec 11

In 2001, the incidence of primary and secondary syphilis increased in the United States for the first time in a decade. Increasing rates of early syphilis among men who have sex with men have been reported in many American cities, with similar outbreaks noted in Canada and Europe. In San Francisco, the increase has been particularly sharp and accompanied by an increase in the incidence of neurosyphilis. Early neurosyphilis develops within weeks to years of primary infection and primarily involves the meninges. Syndromes include syphilitic meningitis (often accompanied by cranial neuropathies), meningovascular syphilis (with associated ischemic stroke), or asymptomatic neurosyphilis. Late neurosyphilis occurs years to decades after exposure as cerebral or spinal gummatous disease or the classic parenchymal forms affecting the brain (general paresis or syphilitic encephalitis) or spinal cord and nerve roots (tabes dorsalis). Treponema pallidum, the causative agent, cannot be cultured in vitro, and microscopic techniques are laborious. Thus, diagnosis depends on serologic tests and cerebrospinal fluid (CSF) examination. The suboptimal sensitivity and specificity of these tests complicate diagnosis, particularly among patients coinfected with HIV. CSF examination should be performed to evaluate for neurosyphilis in all patients with positive serum syphilis serology and neurologic, ophthalmic, or tertiary disease, or in those who have failed therapy, and in HIV-infected patients with late latent syphilis or syphilis of unknown duration. Intravenous penicillin G is the recommended treatment for all forms of neurosyphilis and for syphilitic eye disease. An outpatient alternative, if adherence can be assured, is intramuscular benzathine penicillin with oral probenecid. Newer drugs that penetrate CSF, such as ceftriaxone or azithromycin, have not yet been adequately tested for neurosyphilis. Syphilis facilitates transmission of HIV (and vice versa), and thus all patients diagnosed with syphilis should be offered HIV testing.
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PMID:Treatment of neurosyphilis. 1656 77

Symptomatic early neurosyphilis is a rare manifestation of syphilis that usually occurs within the first 12 months of infection. Most neurologic symptoms of early neurosyphilis result from acute or subacute meningitis, abnormalities in cranial nerve function, and inflammatory vasculitis leading to a cerebrovascular accident. Symptomatic early neurosyphilis essentially disappeared in the United States after the introduction of penicillin treatment for syphilis in the late 1940s but reappeared in the 1980s among persons with human immunodeficiency virus (HIV) infection. The disease burden from neurosyphilis is unknown because national reporting of this disease is incomplete. Because the increase in syphilis cases during the past 5 years has occurred primarily among MSM, many of whom were infected with HIV, CDC conducted a review of possible neurosyphilis cases to describe the clinical course of symptomatic early neurosyphilis and to better characterize the risk for this illness among HIV-infected MSM. The review included health department records from four U.S. cities (Los Angeles, California; San Diego, California; Chicago, Illinois; and New York, New York) for the period January 2002-June 2004. This report describes the results of that review, which identified 49 HIV-positive MSM with symptomatic early neurosyphilis during that 30-month period. Among HIV-positive MSM with early syphilis, the estimated risk for having symptomatic early neurosyphilis was 1.7%, and the risk for having early neurosyphilis with persistent symptoms 6 months after treatment was 0.5%. These findings emphasize the importance of preventing syphilis in HIV-infected persons. HIV-infected persons with cranial nerve dysfunction or other unexplained neurologic symptoms should be evaluated for early neurosyphilis.
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PMID:Symptomatic early neurosyphilis among HIV-positive men who have sex with men--four cities, United States, January 2002-June 2004. 1817 79

A young adult patient with meningovascular neurosyphilis in the form of acute ischemic stroke with right hemiparesis and speech disturbance is reported. CT scan showed features of ischemic infarct and extensive laboratory studies were made before the diagnosis ultimately was revealed. Such cases could result in confusion for the clinician, and high index of clinical suspicion of this condition is required since syphilis is not routinely tested, as routine screening is seen to be of low diagnostic yield. As clinical practice indicates, it remains a difficult problem approaching diagnosis of neurosyphilis, and this is achieved through exclusion of neurosyphilis as a clinical possibility.
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PMID:Meningovascular neurosyphilis: a report of stroke in a young adult. 2057 Dec 97

There is scarce information about ischemic stroke in young adults in Thailand. The purpose of this study was to explore the causes of ischemic stroke in Thai adults age 16-50 years. All ischemic strokes treated in persons in this age range between August 2006 and December 2008 were prospectively included. Stroke subtypes were classified according to Trial of ORG 10172 in Acute Stroke Treatment criteria as large-artery atherosclerosis (LAA), cardioembolism (CE), small-artery occlusion (SAO), stroke of other determined cause (OC), or stroke of undetermined cause (UND). The study group comprised 99 patients, with a mean age of 40 years and a mean National Institutes of Health Stroke Scale score of 8. In patients age <41 years, UND (32%; P = .0652) and OC (30%; P = .0167) were the most common stroke subtypes. In patients age 41-50 years, SAO (29%; P = .0947) and UND (21%) were the most common subtypes. Antiphospholipid syndrome (6%) and neurosyphilis (4%) were the leading causes of the OC subtype. Hyperlipidemia, smoking, and hypertension were common risk factors. Although the distribution of stroke subtypes was comparable with that found in previous studies from other countries, the identified causes were different.
J Stroke Cerebrovasc Dis
PMID:Causes of ischemic stroke in young adults in Thailand: a pilot study. 2058 Feb 56

With the rising incidence and prevalence of syphilis, meningovascular syphilis and other forms of neurosyphilis have reappeared, particularly among persons infected with human immunodeficiency virus. We present a patient with meningovascular syphilis leading to stroke after treatment with penicillin and antiretroviral therapy.
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PMID:Stroke in a patient with human immunodeficiency virus and syphilis treated with penicillin and antiretroviral therapy. 2112 58

The incidence of syphilis has increased over the past decade, particularly among HIV-positive patients, and the presenting clinical features have changed since the beginning of the HIV epidemic. The clinical manifestations of neurosyphilis are protean, and include acute stroke. In patients with HIV, the diagnosis and treatment of neurosyphilis is challenging. We review the clinical presentation, pathophysiology, and treatment of neurosyphilis, with emphasis on neurosyphilis in the HIV population, and neurosyphilis as a cause of acute stroke.
Int J Stroke 2011 Apr
PMID:The changing face of neurosyphilis. 2137 Dec 76


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