To emphasize the importance of considering the Neurosyphilis as a differential diagnosis in patients presenting with stroke like symptoms.

Neurosyphilis is a late-stage manifestation of syphilis. It can present with diverse neurological symptoms, often mimicking stroke. This case report underscores the importance of considering neurosyphilis, in cases where routine diagnostic evaluations fail to elucidate a cause.

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We present a case of a middle-aged man with hypertension, prediabetes, and polysubstance abuse, who sought medical attention for persistent headaches and dizziness lasting for two weeks, followed by acute onset of left hemibody weakness and numbness.

MRI Brain showed right paramedian medullary infarction. Etiology remained cryptogenic despite work up.

He was started on aspirin, atorvastatin, and antihypertensive medications. The patient had mild left-sided deficits at the time of discharge.

One week later he represented with altered mental status and unresponsiveness.

Repeat MRI revealed acute infarctions in the posterior limb of the left internal capsule, left medial temporal lobe, and anteromedial right pontomedullary junction. CT Angio head and neck showed focal high-grade narrowing of the distal right M2-M3 branch. Digital subtraction angiography showed tapered narrowing of the distal right V3/proximal V4 segment, with high-grade stenosis of the distal right vertebral artery, and nonspecific narrowing of the left supraclinoid ICA, indicating a pattern consistent with vasculitis.

Laboratory work-up revealed positive T. pallidum antibodies, a reactive RPR with a titer of 1:64. CSF showed elevated total nucleated cell count of 838 with lymphocytic predominance (99%), elevated proteins (112.9), and positive CSF VDRL.

Initiation of intravenous penicillin led to gradual improvement in the patient's mental status.

Neurosyphilis should be considered in patients presenting with stroke-like symptoms, especially in cryptogenic cases. This case underscores the importance of considering rare but treatable conditions such as neurosyphilis in the diagnosis, ultimately guiding appropriate management and improving patient outcomes.