Syphilitic Myelitis is not Rare and is Usually Associated with Cerebral Manifestations of the Infection

We read with interest the article by Wang et al about a 50-year-old man with neurosyphilis that manifested as paraparesis of the lower limbs and sensory disturbances of the lower limbs due to meningomyelitis.[1] Syphilis was diagnosed by serologic (toluidine red unheated serum test [TRUST], treponema pallidum particle agglutination [TPPA]) and cerebrospinal fluid tests (pleocytosis, elevated proteins, TRUST, TPPA).[1] The patient received penicillin for 5 weeks and made a full recovery within 3 months.[1] The study is noteworthy, but several points should be discussed.

The first point is that meningomyelitis is not a rare complication of syphilis. Both myelitis and meningomyelitis (myelitis associated with meningitis) have been repeatedly reported as manifestations of neurosyphilis.[2] [3] In a retrospective study from a single hospital in China, four patients with syphilitic myelitis were reported within 5 years.[4]

The second point is that the description “flickering candle” may have been misinterpreted; the original authors used the term “candle guttering appearance,” which refers to the characteristic pattern of peripheral nodular enhancement. The use of the term “flickering candle” may therefore be considered ambiguous, as static images may not convey the intended dynamic impression that “guttering” implies. Clarification of this terminology through references or comparable cases could improve readability.

Third, in view of the known association of neurosyphilis with human immunodeficiency virus and tuberculosis,[5] it would be informative to know whether screening for these infections was performed in this case. It would also be interesting to know how the patient became infected with Treponema pallidum and whether there was any evidence of previous stages of Lues in his medical history.

The fourth point is that it was not reported whether the patient also manifested in the brain or not. The early stage of neurosyphilis usually manifests as meningitis, headache, or hemiparesis.[6] The late stage of neurosyphilis is characterized by vasculitis, encephalitis, meningitis, and myelitis.[6] Did the patient also show personality changes, aggressive behavior, mania, auditory and visual hallucinations, illusions, overt paranoia, progressive cognitive impairment, delirium, paranoia, or dementia? Was there evidence of hemiparesis, extrapyramidal manifestations, stroke, epilepsy, cranial nerve lesions, Argyll-Robertson sign, optic neuritis, ocular syphilis, or otosyphilis? Was cerebral imaging with contrast normal or was there evidence of cerebral syphilis? Cerebral involvement in syphilis can be asymptomatic but still show up on cerebral imaging.[7]

In summary, this interesting study has limitations that affect the results and their interpretation. Addressing these limitations could strengthen the conclusions and support the message of the study. Syphilitic myelitis belongs to the late stage of neurosyphilis and is often associated with cerebral manifestations such as vasculitis, encephalitis, and meningitis. Given the frequent cooccurrence of cerebral involvement, brain imaging should be considered in all cases of syphilitic myelitis.

 

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Conflict of Interest

None declared.

Data Availability Statement

All data are available from the corresponding author.

Author's Contributions

J.F. was responsible for the design and conception, discussed available data with coauthors, wrote the first draft, and gave final approval.

• References

• 1 Wang L, Fang J, Wang J. Uncommon neurosyphilis: subacute meningomyelitis with distinctive “candle guttering appearance”. Indian J Radiol Imaging 2024; 35 (01) 196-198
• 2 Safadi AL, Day D, Nagle B, Di Maria G, Malla P. Treatment challenges in a severe case of syphilitic myelitis with a longitudinally extensive spinal cord lesion. Neurohospitalist 2022; 12 (02) 400-403
• 3 Dong H, Liu Z, Duan Y. et al. Syphilitic meningomyelitis misdiagnosed as spinal cord tumor: case and review. J Spinal Cord Med 2021; 44 (05) 789-793
• 4 Wu Y, Wu W. Neurosyphilis presenting with myelitis-case series and literature review. J Infect Chemother 2020; 26 (02) 296-299
• 5 Clark W, Tanti M, Azzam I, McGill F, Vinjam M. Unusual demyelinating disease in a patient with HIV infection. J Neurovirol 2024; 30 (04) 434-440
• 6 Hamill MM, Ghanem KG, Tuddenham S. Executive summary: state-of-the-art review: neurosyphilis. Clin Infect Dis 2024; 78 (05) 1085-1087
• 7 He C, Kong Q, Shang X. et al. Clinical, laboratory and brain magnetic resonance imaging (MRI) characteristics of asymptomatic and symptomatic HIV-negative neurosyphilis patients. J Infect Chemother 2021; 27 (11) 1596-1601

Publication History

Article published online:
21 August 2025