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Images in Neurology
December 2013

Oculomotor Nerve Palsy as the Presenting Symptom of Gummatous Neurosyphilis and Human Immunodeficiency Virus InfectionClinical Response to Treatment

Author Affiliations
  • 1Department of Neurology, Neurological Institute of New York, Columbia University College of Physicians and Surgeons, New York, New York
  • 2University of Florida Center for Movement Disorders and Neurorestoration, Gainesville
  • 3Malcom Randall VA Medical Center, Gainesville, Florida
  • 4Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
JAMA Neurol. 2013;70(12):1582-1583. doi:10.1001/jamaneurol.2013.1485

A 39-year-old man presented with 5 months of worsening right eyelid ptosis, fatigue, and diplopia, which progressed to include anorexia, low-grade fevers, and arthralgias. An examination revealed a subtle macular rash on his trunk, arms, and palms. The right pupil was dilated to 5 mm without direct or consensual response to light or accommodation with inferotemporal deviation of the eye. Extraocular movements were impaired in all directions except abduction, with near-complete ptosis of the eyelid. Serum studies showed a positive rapid plasma reagin test result (to 1:64) and reactive fluorescent treponemal antibodies and Lyme antibodies. Cerebrospinal fluid analysis demonstrated a total protein level of 0.084 g/dL (to convert to grams per liter, multiply by 10.0); a glucose level of 47 mg/dL (to convert to millimoles per liter, multiply by 0.055); a white blood cell count of 18/μL (to convert to ×109 per liter, multiply by 0.001); red blood cell count of 3 × 106/μL (to convert to ×1012 per liter, multiply by 1.0); 91% lymphocytes; 9% monocytes; a polymerase chain reaction test result negative for Lyme disease; and a Venereal Disease Research Laboratory test result reactive to 1:2. Subsequent human immunodeficiency virus (HIV) antibody and Western Blot tests were positive with a CD4 lymphocyte count of 307 and a viral load of 30 000.

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