Patient: 83-year-old male resident in Belgium
Symptoms: A man was admitted to the hospital after the muscles on one side of his face suddenly weakened and drooped. This condition is called unilateral peripheral facial paralysis. He also had a fever recently, but it has since subsided.
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The man’s liver abnormalities did not resolve after a week, but his facial paralysis resolved after 10 days of strong corticosteroids. However, over the next month, the man’s knees and ankles became stiff and painful, and his legs and feet, and sometimes his face, arms, and hands, also began to swell. He reported feeling generally unwell, gaining 11 pounds (5 kilograms) and having darker urine, even though he was drinking more water than usual. All of these signs pointed to problems with his kidney function.
In addition to the symptoms identified during a recent medical examination, the patient had long-standing conditions such as high blood pressure, high cholesterol, an enlarged prostate, and chronic obstructive pulmonary disease (COPD), for which he was taking medication. He was also diagnosed with rectal cancer 20 years ago and underwent various treatments over the years. He told doctors that he and his wife of 50 years had not been sexually active since that cancer treatment.
What happened next: After weeks of being in and out of the hospital, the man visited the emergency room because his skin suddenly felt extremely itchy. He had a red, scaly rash on his calf. Doctors said in their case report that a neurological exam revealed “normal motor strength, sensation, reflexes, coordination, and gait.”
In the ER, the patient was asked further questions about his medical history, at which point he told the doctor that he had unprotected sex with multiple casual partners when he was younger and while serving in the military. During that time, he reported receiving treatment for various sexually transmitted infections (STIs), although he forgot the specific diagnosis.
Tests revealed that the patient was anemic and his urine contained blood and an abnormal amount of protein. Additionally, tests for autoimmune diseases detected abnormally high levels of antinuclear antibodies that target the control centers of cells that house DNA. Because the patient had recently suffered facial paralysis, doctors analyzed his cerebrospinal fluid, the clear fluid that surrounds the brain and spinal cord. This reveals elevated white blood cell levels, suggesting an active infection.
Diagnosis: Tests for HIV and tuberculosis were negative, but tests for Treponema pallidum, the bacterium that causes syphilis, were positive, confirming that the patient had an active syphilis infection.
Syphilis infection progresses through four stages, each with different symptoms. If an infected person does not receive effective treatment during the primary and secondary stages, the bacteria can remain dormant, sometimes for decades. Also, in a small number of cases, latent syphilis can awaken and cause late, or tertiary, infection.
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More recent unreported exposures need to be considered.
The man’s doctors diagnosed him with secondary syphilis, which is associated with early neurosyphilis, when the bacteria attacks the nervous system, based on a positive syphilis test, rash, general unwellness, liver abnormalities, increased protein in the urine, swollen legs, droopy face, and swollen lymph nodes.
Treatment: The patient received one injection of penicillin before test results confirmed that the infection involved the nervous system. He then received 14 days of intravenous penicillin, which is recommended as a treatment for neurosyphilis, according to the case report.
Severe itching was treated with antihistamines, and diuretics were prescribed to reduce swelling in the feet. The rash, itching, and swelling had improved by the time the patient was seen 1 month later, and liver tests and urine output had normalized.
Public health authorities were informed of the patient’s diagnosis and his wife was referred for testing. The case report does not say whether the wife tested positive for syphilis.
Characteristics of this case: Secondary syphilis usually occurs within 1 year of untreated infection and rarely occurs after 4 years. Primary syphilis usually causes smooth, hard sores on the mouth and genitals that disappear, and if left untreated, secondary syphilis begins within a few months.
“Although the patient had multiple sexually transmitted infections in his youth and was referred for testing for syphilis, it is unlikely that infections at that time would explain his current symptoms,” the doctors wrote.
The man had an underlying infection that may have recently been reactivated, perhaps due to the immunosuppressive effects of recent steroid treatment. However, reactivation would be expected to cause only the symptoms of tertiary syphilis, such as neurological problems, and not the symptoms associated with secondary syphilis, such as fever, rash, and weight loss.
Therefore, it is unclear exactly when the man became infected. “More recent unreported exposures need to be considered,” the doctors wrote.
Case reports indicate that syphilis rarely affects the liver or kidneys, with an incidence of less than 10% of cases.
For more interesting medical cases, check out our Diagnostic Dilemma archives.
This article is for informational purposes only and does not provide medical advice.
Van Den Eynde, J., Van Der Pluijm, C., Shellekens, P., Vanhoutte, T., and Bammens, B. (2025). Draw a spiral into the distant past. New England Medical Journal, 393(18), 1844–1850. https://doi.org/10.1056/nejmcps2507868
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