The Patient's Story
An 83-year-old man from Belgium sought medical care due to sudden muscle weakness on one side of his face, a condition known as unilateral peripheral facial-nerve palsy. Alongside this, he had recently experienced a fever, which resolved before his hospital visit.
Initial Findings and Diagnosis Challenges
Upon examination by the neurology department, the patient revealed he had anemia, fatty liver disease, and an enlarged spleen. The medical team initially suspected a viral infection, mainly due to the recent fever, but tests for several viruses, including HIV and hepatitis, returned negative.
After a week, while his facial-nerve palsy improved with corticosteroid treatment, new symptoms emerged. The patient experienced pain and stiffness in his knees and ankles, swelling in his legs and feet, and noted a general malaise accompanied by an unexplained weight gain of 11 pounds. Additionally, darkening urine suggested kidney issues.
Long-Standing Health Issues
The man had a history of long-term high blood pressure, elevated cholesterol, an enlarged prostate, and chronic obstructive pulmonary disease (COPD). Notably, he had been treated for rectal cancer two decades prior, and he and his wife had been sexually inactive since that treatment.
Emergency Room Visit
His condition escalated when he developed severe itching and a red, scaly rash on his calves, prompting another emergency room visit. Through further questioning regarding his medical history, he mentioned unprotected sexual encounters during his military service, where he had been treated for various sexually transmitted infections (STIs) without recalling the specifics.
Investigative Tests
In the emergency setting, tests confirmed persistent anemia, bloody urine, and high levels of protein. An autoimmune screen showed elevated antinuclear antibodies, hinting at more severe underlying issues. Given his recent facial-nerve problems, doctors conducted an analysis of his cerebral spinal fluid, which indicated elevated white blood cell levels, suggesting an infective process.
The Diagnosis of Syphilis
While tests for HIV and tuberculosis were negative, a serological test for Treponema pallidum, the bacterium causing syphilis, returned positive results. Syphilis can progress through distinct stages, and unaddressed infections can remain dormant before reactivating. His clinical presentation suggested a secondary syphilis infection complicated by neurological involvement.
Understanding the Case Uniqueness
Secondary syphilis typically occurs within the first year of untreated infection. The man's case, however, raised questions due to the significant period since his initial treatments. The patient's history of STIs indicated potential past exposure, yet the nature and timing of the current infection remained uncertain. Interestingly, it’s uncommon for syphilis to affect both the liver and kidneys, complicating the clinical picture even further.
The doctors highlighted the possibility of a more recent exposure needing to be considered, rather than solely attributing the infection to his distant past.
Treatment and Recovery
After being administered penicillin before the diagnosis was finalized, he received a 14-day intravenous penicillin course appropriate for neurosyphilis. His treatment also included antihistamines for the severe itching and diuretics to alleviate swelling. Follow-up assessments a month later showed significant improvement, with normalization of his liver tests and a reduction in swelling.
Public Health Implications
The patient's diagnosis prompted a notification to public health officials, and his wife was recommended for testing, although the outcome of her testing remains undocumented.
Clinical Reflection
This case reaffirms the complexity of diagnosing rare infections in older patients with multifaceted health backgrounds. While prior exposure to STIs often informs diagnosis, the reality that syphilis may reactivate under certain conditions adds layers of intricacy to such medical dilemmas. Ongoing research and awareness could enhance understanding and improve diagnostic accuracy for similar cases in the future.
This article is for informational purposes only and is not intended to provide medical advice.
This article was first published on February 18, 2026.
