The case of a 40‐year‐old man with headaches, memory changes, and acute ischemic stroke

A 40-year-old right-handed male with a past medical history of HIV well-controlled on antiretrovirals (last CD4 count 834, absent viral load) presented with headaches, memory changes, and 2 days of right-sided numbness and weakness. He had gradual onset of intermittent headaches over the last month. The headaches were throbbing and, at times, holocephalic. The severity of the headaches worsened over the course of a month. There were no clear triggers to these headaches or preceding aura. There was no associated nausea or vomiting or positional component. The patient has no prior history of headaches. Two days prior to admission, the patient awoke with right-sided numbness and weakness that started in his arm and leg. He noted difficulty writing with his right hand. His friend noted that the patient had been slurring his words in the last 2 days and also that the patient appeared confused over the same time course (Figs. 1-3). An MRI on admission demonstrated multifocal acute infarcts and areas of enhancement. A lumbar puncture demonstrated a positive CSF VDRL, concerning for meningovascular syphilis. The patient was treated with 14 days of penicillin and his symptoms of headache and fatigue improved significantly. He underwent physical therapy for his right-sided weakness. After the initiation of treatment, he denied any new neurologic symptoms. Meningovascular syphilis is more common in HIV and often is preceded by a prolonged prodrome of headache, confusion, and meningismus, such as in our patient. Meningovascular syphilis

Abstract licence: CC BY-NC-ND

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