A 62-year-old man comes to the office with his daughter due to 3 months of progressive unsteadiness and difficulty walking. The patient recently arrived in the United States to visit his daughter. On several occasions, he has lost balance and almost fallen while taking a shower. The patient also reports episodes of transient, sharp, stabbing pain in his back and lower limbs, as well as involuntary dribbling of urine. He has no history of back injury. The patient lives in rural Nigeria and has not seen a health care provider in many years. He smoked a half pack of cigarettes daily for 30 years and drinks 1 or 2 alcoholic beverages every day. Physical examination shows bilateral knee and ankle reflexes are 1+, and vibratory and position sensations are impaired in both feet. His gait is broad based. Bilateral pupils are small and irregular and constrict poorly to light but constrict normally when he is instructed to look at a finger placed near the tip of his nose. Which of the following would be most helpful in treatment of this patient's current symptoms?

Question

A 62-year-old man comes to the office with his daughter due to 3 months of progressive unsteadiness and difficulty walking.  The patient recently arrived in the United States to visit his daughter.  On several occasions, he has lost balance and almost fallen while taking a shower.  The patient also reports episodes of transient, sharp, stabbing pain in his back and lower limbs, as well as involuntary dribbling of urine.  He has no history of back injury.  The patient lives in rural Nigeria and has not seen a health care provider in many years.  He smoked a half pack of cigarettes daily for 30 years and drinks 1 or 2 alcoholic beverages every day.  Physical examination shows bilateral knee and ankle reflexes are 1+, and vibratory and position sensations are impaired in both feet.  His gait is broad based.  Bilateral pupils are small and irregular and constrict poorly to light but constrict normally when he is instructed to look at a finger placed near the tip of his nose.  Which of the following would be most helpful in treatment of this patient's current symptoms?

Quizplus · Accepted Answer

11ec25c8_d565_37ff_bc81_a34581120eeb_MD0003_00 This patient's ataxia, urinary retention, diminished proprioception/vibration/reflexes, and pupillary findings raise suspicion for late neurosyphilis, a form of tertiary syphilis that manifests years or decades after untreated Treponema pallidum infection. Although less common in the present age due to widespread syphilis testing and treatment, cases still occur, particularly in those with HIV or limited access to health care. Late neurosyphilis is marked by general paresis (a progressive dementia) or tabes dorsalis. Tabes dorsalis is a neurodegenerative condition of the posterior spinal columns and nerve roots. Posterior column damage results in impaired vibration sensation/proprioception, sensory ataxia, and instability during the Romberg test. Nerve root damage leads to diminished pain/temperature sensation and reduced/absent deep tendon reflexes. Patients often develop lancinating pains, brief periods of shooting/burning pain in the face, back, or extremities. Late neurosyphilis is often associated with Argyll Robertson pupils, which are miotic and irregular and characterized by normal pupillary constriction with accommodation but not with light. Tabes dorsalis The primary treatment for neurosyphilis is intravenous (IV) aqueous crystalline penicillin G for 10-14 days due to excellent central nervous system penetration and efficacy. (Choice B) IV immunoglobulin is often given to those with Guillain-Barré syndrome, which typically presents with rapidly progressive, symmetric ascending muscle paralysis and reduced/absent deep tendon reflexes following Campylobacter jejuni or viral infection. (Choice C) Spinal decompression surgery may be indicated in patients with compressive myelopathy (eg, due to spinal stenosis, epidural hematoma, abscess). Myelopathy can present with back pain, loss of motor and sensory function below the level of the spinal lesion, and incontinence, but Argyll Robertson pupils would not occur. (Choice D) Thiamine (vitamin B₁) deficiency causes Wernicke-Korsakoff syndrome, which is associated with ataxia, encephalopathy, and ophthalmoplegia. Although patients often develop nystagmus or lateral rectus/gaze palsy (opthalmoplegia), pupillary changes would be atypical. Prompt treatment with IV thiamine usually leads to clinical improvement. (Choice E) Long-standing vitamin B₁₂ deficiency may cause subacute combined degeneration of the dorsal columns (loss of position and vibration sense, positive Romberg sign), lateral corticospinal tracts (spastic paresis, hyperreflexia), and spinocerebellar tracts (ataxia). It is not associated with Argyll Robertson pupillary changes. Treatment requires vitamin B₁₂ supplementation. subacute combined degeneration Educational objective: Late neurosyphilis manifests years after untreated Treponema pallidum infection with general paresis (progressive dementia) or tabes dorsalis (sensory ataxia, lancinating pains, reduced/absent deep tendon reflexes). Patients often have Argyll Robertson pupils (normal pupillary constriction with accommodation but not with light). Intravenous penicillin is the treatment of choice. References: The Argyll Robertson pupil. (http://www.ncbi.nlm.nih.gov/pubmed/20103017) Neurosyphilis. (http://www.ncbi.nlm.nih.gov/pubmed/24365430)

A 62-Year-Old Man Comes to the Office with His Daughter