Meningovascular Neurosyphilis Presenting as Multifocal Stroke: A Case Report and Literature Review

Neurosyphilis (NS) remains a diagnostic challenge due to its diverse clinical manifestations and its ability to mimic other neurological disorders. Despite the global decline in syphilis incidence during the antibiotic era, a recent resurgence has led to an increase in atypical and meningovascular presentations. Early diagnosis is critical, as timely treatment can prevent irreversible neurological damage. We report the case of a 38-year-old immunocompetent male who presented with acute vertigo, unsteady gait, and subsequent confusion. Initial imaging and laboratory investigations were unremarkable; however, MRI revealed multifocal ischemic lesions. Serological testing demonstrated high-titer Treponema pallidum antibodies (rapid plasma reagin 1:256), while CSF analysis showed lymphocytic pleocytosis, elevated protein, and an increased IgG index, with a negative CSF VDRL. The diagnosis of meningovascular NS (MVS) was established. The patient received intravenous penicillin G for three weeks, resulting in gradual cognitive and functional recovery. After rehabilitation, his Functional Independence Measure score improved from 83 to 121, and his Mini-Mental State Examination score improved from 9 to 21. MVS should be considered in patients presenting with stroke-like symptoms, particularly when conventional vascular risk factors are absent. A negative CSF VDRL does not exclude the diagnosis; combined clinical, serologic, and radiologic evidence is essential. Early recognition and appropriate antibiotic therapy can lead to significant neurological recovery.