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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 48-49

Cognition, behavior, and pupillary reflex in neurosyphilis-associated movement disorder

Medicine Department, Federal University of Santa Maria, Rio Grande do Sul, Brazil

Date of Submission15-Dec-2020
Date of Decision19-Jan-2021
Date of Acceptance13-Mar-2021
Date of Web Publication17-Apr-2021

Correspondence Address:
Jamir Pitton Rissardo
Medicine Department, Federal University of Santa Maria, Rua Roraima, Santa Maria, Rio Grande do Sul.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AOMD.AOMD_61_20

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How to cite this article:
Pitton Rissardo J, Caprara AL. Cognition, behavior, and pupillary reflex in neurosyphilis-associated movement disorder. Ann Mov Disord 2021;4:48-9

How to cite this URL:
Pitton Rissardo J, Caprara AL. Cognition, behavior, and pupillary reflex in neurosyphilis-associated movement disorder. Ann Mov Disord [serial online] 2021 [cited 2023 Mar 23];4:48-9. Available from: https://www.aomd.in/text.asp?2021/4/1/48/313946

Dear Editor,

We recently published the article “Neurosyphilis-associated movement disorder: a literature review” on the esteemed “Annals of Movement Disorders,” where we discussed the movement disorders (MDs) related to neurosyphilis evaluating its clinical epidemiological profile, pathological mechanisms, and historical features.[1]

Developing countries are still struggling with a significant burden of neurosyphilis as pointed out by Mishra and Pandey.[2] Nevertheless, the numbers of patients affected by syphilis in the central nervous system are also increasing in some developed countries such as Canada and Australia. A Canadian author reported a change in the incidence of neurosyphilis from 4.7 to 17.0 per 100,000 in less than 10 years.[3] In Australia, similar to Canada, a rise in the neurosyphilis incidence was seen, but mainly in the indigenous population.[4] Therefore, worldwide general practitioners should be aware of possible atypical presentations of neurosyphilis.

In this letter, we would like to highlight some important facts that we did not discuss in our literature review. We revised [Table 1], to be more specific, we studied the data about the prognosis on the follow-up after the clinical management of neurosyphilis, which we found that was generally poor.[1] Only 32.55% (28/86) of the subjects had a full recovery. The individuals with the best prognosis were those that developed chorea, in which a full recovery was achieved in 61.11% (22/36). But, those who developed ataxia, dystonia, and athetosis had only a partial recovery or even did not have any improvement in their symptoms. Thus, even though the advent of penicillin probably decreased the percentage of severe forms, the early diagnosis of neurosyphilis could prevent the patient from developing permanent brain damage.
Table 1: Neurosyphilis-associated movement disorder: A literature review

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We reviewed the literature again to complement the information provided in our first publication. In the re-analysis, we included those articles with the previous inclusion/exclusion criteria of the literature review and selected those papers with descriptions of cognitive/behavioral symptoms [Figure 1].[1] We encountered a total of 50 individuals, which at presentation: 32% (16/50) of the individuals had only MD, 22% (11/50) had one MD, and 10% (5/10) had more than one MD without cognitive, behavioral, or other clinical features at the physical exam; 54% (27/50) a MD and cognitive impairment; 46% (23/50) a MD and behavioral abnormalities; 40% (20/50) a MD and characteristic syphilitic features in physical examination.
Figure 1: Clinical syndromes and overlap of neurosyphilis-associated movement disorder at presentation. A total of 50 individuals were found, 16 had only MD, 9 MD+PE+BHV+COG, 0 MD+PE, 2 MD+BHV, 5 MD+COG, 5 MD+PE+BHV, 7 MD+BHV+COG, and 6 MD+PE+COG. BHV, behavioral abnormality; COG, cognitive abnormality; MD, movement disorder; PE, a characteristic finding of syphilis in physical examination

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This data can support the hypothesis that MD patients presenting “abnormal pupillary reflex, cognitive, and/or psychiatry symptoms” should be investigated for syphilis. It is worthy of mentioning that the neuropsychological details in the literature about neurosyphilis-associated MDs are probably under-reported maybe due to the importance given to describe the abnormal movements.[5] Also, 1 in every 3 individuals presented only MD, which turns the syphilitic clinical diagnosis challenging. This finding reinforces the idea of continuous reviews on physical examination during follow-up, although a primary clinical diagnosis of a MD has been done.[6]



Financial support and sponsorship

None to declare. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest

There are no conflicts of interest.

  References Top

Rissardo JP, Caprara AL. Neurosyphilis-associated movement disorder: A literature review. Ann Mov Disord 2020;3:129-44.  Back to cited text no. 1
Mishra A, Pandey S. Neurosyphilis and movement disorder: Old box, new “candy.” Ann Mov Disord 2020;3:125-6.  Back to cited text no. 2
Peermohamed S, Kogilwaimath S, Sanche S. Neurosyphilis. CMAJ 2020;192:E844.  Back to cited text no. 3
Ramachandran PS, Baird RW, Markey P, Singleton S, Lowe M, Currie BJ, et al. Neurosyphilis: Still prevalent and overlooked in an at risk population. PLoS One 2020;15:e0238617.  Back to cited text no. 4
Rissardo JP, Caprara ALF. Mirtazapine-associated movement disorders: A literature review. Tzu Chi Med J 2020;32:318-30.  Back to cited text no. 5
  [Full text]  
Rissardo JP, Caprara ALF, Silveira JOF. Generalized convulsive status epilepticus secondary to Jarisch-Herxheimer reaction in neurosyphilis: A case report and literature review. Neurologist 2019;24:29-32.  Back to cited text no. 6


  [Figure 1]

  [Table 1]


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