树胶肿型神经梅毒的临床特征及预后分析

Clinical features and prognoses of cerebral syphilitic gumma

目的探讨树胶肿型神经梅毒的临床表现、血清及脑脊液梅毒抗体检测结果、影像学特征及预后。方法回顾性报道苏州大学附属第二医院神经内科2023年3月收治的1例树胶肿型神经梅毒患者的临床资料,并检索国内外数据库,对已报道的54例树胶肿型神经梅毒患者及本例患者的临床资料进行汇总分析。结果55例患者主要表现为头痛(32例,58.2%)、偏侧肢体/面部乏力(25例,45.5%)、恶心呕吐(14例,25.5%)、头晕(11例,20.0%)、感觉障碍(10例,18.2%)、视物模糊(7例,12.7%)、癫痫发作(5例,9.1%)、听力下降(5例,9.1%)、耳鸣(5例,9.1%)、记忆力下降(3例,5.5%)、失语(3例,5.5%)、构音障碍(2例,3.6%)、跌倒发作(2例,3.6%)、睁眼乏力(2例,3.6%)、反应迟钝(1例,1.8%)、阿罗瞳孔(1例,1.8%)、脊髓痨步态(1例,1.8%)及发热(1例,1.8%)。51例具备完整血清学试验结果患者中,45例(88.2%)血清梅毒非特异性抗体检测阳性,51例(100.0%)血清梅毒特异性抗体检测阳性。行脑脊液检查的34例患者中,25例(73.5%)脑脊液梅毒非特异性抗体检测阳性,32例(94.1%)脑脊液梅毒特异性抗体检测阳性。55例患者的颅内病灶以单发为主(43例,78.2%),累及的部位依次为额叶(14例,25.5%)、顶叶(14例,25.5%)、颞叶(5例,9.1%)、额颞叶(3例,5.5%)、额顶叶(2例,3.6%)、顶枕叶(2例,3.6%)、豆状核(1例,1.8%)、斜坡(1例,1.8%)及中脑大脑脚(1例,1.8%)。30例(54.5%)患者被误诊为其他颅内占位性疾病,误诊情况依次为胶质瘤(11例,36.7%)、转移瘤(5例,16.7%)、脑膜瘤(4例,13.3%)、其他不明原因颅内占位(4例,13.3%)、脑脓肿(3例,10.0%)、海绵状血管瘤(1例,3.3%)、颅内淋巴瘤(1例,3.3%)、听神经瘤及垂体腺瘤(1例,3.3%)。42例报道了驱梅治疗预后情况的患者中,41例有不同程度的好转,1例死于脑疝。结论树胶肿型神经梅毒因临床表现不典型且无明确诊断标准而常被误诊为颅内肿瘤。血清及脑脊液梅毒非特异性抗体/特异性抗体阳性者出现神经系统症状及颅内占位病灶时应首先考虑树胶肿型神经梅毒的可能。经及时诊治,树胶肿型神经梅毒患者大多预后良好。

Objective To investigate the clinical manifestations,serological and cerebrospinal fluid test results for syphilis,imaging features,and prognoses of cerebral syphilitic gumma.Methods The clinical data of 1 patient with cerebral syphilitic gumma admitted to Department of Neurology,Second Affiliated Hospital of Soochow University in March 2023 were retrospectively analyzed.Papers about cerebral syphilitic gumma were searched from journals in Journal Citation Reports Q1 from 2000 to 2019,journals from 2020 to 2024 in PubMed,WOS,Embase,and Scopus databases,and journals from 2000 to 2024 in Wanfang Database,CNKI,and VIP database;the clinical data of 54 patients with cerebral syphilitic gumma reported in above databases and 1 patient in our hospital were collected for pooled analysis.Results The main clinical manifestations of 55 cerebral syphilitic gumma patients included headache(32,58.2%),lateral limb/facial weakness(25,45.5%),nausea and vomiting(14,25.5%),dizziness(11,20.0%),sensory disturbances(10,18.2%),blurred vision(7,12.7%),seizure(5,9.1%),hearing loss(5,9.1%),tinnitus(5,9.1%),memory loss(3,5.5%),aphasia(3,5.5%),dysarthria(2,3.6%),drop attack(2,3.6%),weakness in opening eyes(2,3.6%),unresponsiveness(1,1.8%),Argyll-Robertson pupil(1,1.8%),tabes dorsalis gait(1,1.8%),and fever(1,1.8%).In 51 patients who reported complete serologic test results,45 patients(88.2%)were positive for non-specific antibodies to syphilis,and all patients were positive for specific antibodies to syphilis.In 34 patients underwent cerebrospinal fluid examination,25(73.5%)were positive for non-specific antibodies to syphilis,and 32(94.1%)were positive for specific antibodies to syphilis.Isolated intracranial lesion(43,78.2%)was mostly common in imaging test,and the frequently involved cranial sites were,orderly,the frontal lobe(14,25.5%),parietal lobe(14,25.5%),temporal lobe(5,9.1%),frontotemporal lobe(3,5.5%),frontoparietal lobe(2,3.6%),parieto-occipital lobe(2,3.6%),nucleus pulposus(1,1.8%),clivus(1/55,1.8%),and cerebral peduncle of the midbrain(1,1.8%).Thirty patients(54.5%)were misdiagnosed as having other intracranial space-occupied diseases,orderly,glioma(11,36.7%),metastatic tumors(5,16.7%),meningiomas(4,13.3%),other unexplained intracranial space-occupying(4,13.3%),brain abscess(3,10.0%),cavernous hemangioma(1,3.3%),intracranial lymphoma(1,3.3%),auditory nerve and pituitary tumors(1,3.3%).Of the 42 patients who reported prognosis after anti-syphilitic treatments,41 had varying degrees of improvement,and one died of brain herniation.Conclusion Because of atypical clinical manifestations and lack of clear diagnostic criteria,cerebral syphilitic gumma is often misdiagnosed as intracranial tumors;cerebral syphilitic gumma should be considered in patients with positive non-specific antibodies to syphilis/specific antibodies to syphilis in serum and cerebrospinal fluid having neurological symptoms and intracranial space-occupied foci;timely diagnosed and treated patients can prognosed well.