Can tertiary syphilis cause right facial numbness, right upper extremity (RUE) numbness, and right lower extremity (RLE) numbness?

Tertiary Syphilis Can Cause Unilateral Neurological Symptoms Including Right-Sided Facial and Extremity Numbness

Yes, tertiary syphilis can cause right facial numbness, right upper extremity numbness, and right lower extremity numbness through neurosyphilis, which is a manifestation of central nervous system involvement. This unilateral presentation is consistent with the neurological complications of tertiary syphilis.

Neurosyphilis as a Manifestation of Tertiary Syphilis

Tertiary syphilis refers to the late stage of syphilis infection, which can occur years to decades after initial infection with Treponema pallidum. It primarily manifests as:

1. Gummatous syphilis (formation of granulomatous lesions)
2. Cardiovascular syphilis (affecting the aorta and heart)
3. Neurosyphilis (central nervous system involvement) 1

Neurological Manifestations

Neurosyphilis can occur during any stage of syphilis but is commonly associated with tertiary syphilis. It can present with various neurological symptoms including:

• Cranial nerve palsies leading to facial numbness
• Motor or sensory deficits affecting extremities (such as numbness in limbs)
• Cognitive dysfunction
• Ophthalmic or auditory symptoms
• Signs of meningitis 1

The unilateral presentation (right-sided symptoms) is consistent with focal lesions that can occur in neurosyphilis, as demonstrated in case reports of neurosyphilis presenting with focal neurological deficits 2.

Diagnostic Approach for Suspected Neurosyphilis

When a patient presents with unilateral neurological symptoms and suspected syphilis:

1. Serological testing:

   • Nontreponemal tests (VDRL, RPR)
   • Treponemal tests (FTA-ABS, TP-PA) 3

2. CSF examination is mandatory for patients with:

   • Neurological symptoms (including numbness)
   • Evidence of active tertiary syphilis
   • HIV co-infection with late latent syphilis 1

3. Neuroimaging may reveal:

   • Cerebral infarcts
   • Focal lesions
   • Meningeal enhancement 2

Treatment of Neurosyphilis

For patients with neurosyphilis presenting with unilateral neurological symptoms:

The recommended treatment regimen is intravenous aqueous crystalline penicillin G, 18-24 million units daily, administered as 3-4 million units IV every 4 hours or by continuous infusion for 10-14 days 1, 3.

Alternative Regimen

If compliance can be ensured:

• Procaine penicillin 2.4 million units IM once daily PLUS
• Probenecid 500 mg orally four times a day, both for 10-14 days 1

Some experts recommend following neurosyphilis treatment with benzathine penicillin G, 2.4 million units IM weekly for up to 3 weeks, to provide a comparable total duration of therapy 1.

Special Considerations

Penicillin Allergy

• Patients allergic to penicillin should be desensitized and treated with penicillin, as alternative regimens have not been well studied for neurosyphilis 1

HIV Co-infection

• HIV-infected patients may have higher rates of neurological complications and require more careful follow-up 3
• CSF examination is recommended for all HIV-infected patients with late latent syphilis or syphilis of unknown duration 1

Follow-Up

• If CSF pleocytosis was present initially, CSF examination should be repeated every 6 months until the cell count normalizes 1
• Quantitative nontreponemal serologic tests should be repeated at 6,12, and 24 months 1, 3
• Clinical response depends on the nature and extent of neurological involvement

Clinical Pearls and Pitfalls

• Unilateral neurological symptoms can be mistaken for stroke, multiple sclerosis, or other neurological disorders, leading to delayed diagnosis of neurosyphilis 2, 4
• Neurosyphilis can present with minimal or no CSF abnormalities in some cases, making diagnosis challenging 5
• Serological tests may have low titers or even be negative in tertiary syphilis, requiring high clinical suspicion 5, 6
• Treatment should not be delayed if neurosyphilis is suspected, as early intervention is essential to prevent disease progression and permanent neurological damage 2

The unilateral presentation of numbness affecting the right face and extremities is consistent with focal central nervous system involvement in tertiary syphilis, and prompt diagnosis and treatment are essential to prevent further neurological deterioration.