3 Meningovascular involvement is caused by an inflammatory, obliterating endarteritis of the leptomeninges, brain, and spinal cord with resulting ischemic attacks or infarcts. General Paralysis of the Insane (GPI or dementia paralytica) presents with insidious and variable psychological symptoms, dementia, epilepsy, focal neurological deficits, and often AR pupils. Argyll Robertson pupils are a valuable sign of tabes and may precede its typical sensory ataxia, absent ankle jerks, lighting pains, and visceral crises. Symptomatic neurosyphilis most often presents with posterior column lesions, the hallmark of tabes dorsalis, typically fifteen to twenty-five years after primary infection. Neurosyphilis may be asymptomatic with abnormal cerebrospinal fluid (CSF) but no neurological symptoms or signs. 3 The Argyll Robertson (AR) pupil (Fig 1) is an important, classical sign of neurosyphilis. Tertiary syphilis includes not only neurosyphilis but also gummata, cardiovascular, and meningovascular varieties. Historically, neurosyphilis was so common that Kinnier Wilson in his unique textbook Neurology in 1940 devoted over one hundred pages to it. Because we now have effective antibiotic treatment, both clinical clues and screening tests are of vital importance, especially in early and in asymptomatic latent cases. 2 A clinical diagnosis of syphilis is no longer the occasional curiosity it was at the end of the twentieth century, yet routine screening tests have fallen into disuse. 1 In 2020, 133,945 cases of all stages of syphilis were reported in the US, and in the UK the rate of newly diagnosed cases in 2020 was twice that in 2012. Since reaching a historic low in 2000 and 2001, the incidence of syphilis has increased almost every year. Several direct and serological tests of varying sensitivity and specificity have now replaced the WR. In my student days, the Wasserman reaction (WR), though not specific, was performed almost routinely in patients on medical wards to detect syphilis. Douglas Argyll Robertson and his pupils November 8, 2022įigure 1.
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