Syphilis is a debilitating multisystem disease resulting from infection with the spirochete Treponema pallidum. Even though it is uncommon, it is a great mimic of stroke and is misdiagnosed almost 80% of the time. It commonly involves the middle cerebral artery and basilar or anterior spinal artery territories. 4% of patients with recurrent strokes can have syphilis. We present a patient with a recurrent stroke due to meningo-vascular syphilis (MVS).

A 62-year-old male with hypertension, hyperlipidemia, diabetes, and coronary artery disease presented with confusion and word-finding difficulty, and was found to have an acute ischemic stroke in the right basal ganglia (BG). The patient was discharged on dual anti-platelet therapy and statin for secondary stroke prevention. As a part of the stroke workup, he was found to be highly reactive for rapid plasma regain, and the subsequent fluorescent treponemal antibody absorption test was reactive with the diagnosis of syphilis. He presented again 3 weeks later with transient facial paralysis. The cerebrospinal fluid was positive for a Venereal Disease Research Laboratory test, indicative of MVS. He received 4 million units of penicillin every 4 hours intravenously for 14 days with improvement in symptoms and no further recurrence of strokes.

Our patient presented with acute ischemic infarct in BG, etiology thought to be small vessel disease in the setting of multiple stroke risk factors. Meningo-vascular syphilis, a subtype of neurosyphilis, can cause recurrent ischemic strokes. While uncommon, neurosyphilis remains prevalent in the United States and is often misdiagnosed because of its heterogenous clinical features. Syphilis screening is usually considered in young patients with a prior documented history of sexually transmitted disease however it is prudent that patients with recurrent strokes might benefit from routine screening tests for syphilis, regardless of age group or the presence of stroke risk factors.