Abstract Introduction Ischemic stroke in young individuals is uncommon and poses a significant diagnostic challenge, necessitating a broader investigation beyond traditional risk factors. Meningovascular syphilis is a rare, late manifestation of neurosyphilis that involves a vasculitis, or inflammation of the blood vessels, that can result in an ischemic stroke. This case underscores the importance of maintaining broad differentials when identifying causes of stroke in young patients. Case A 34-year-old male with a past medical history of uncontrolled hypertension and chronic kidney disease presented with new onset left-sided weakness. He was brought in after family noticed he had become progressively confused over the previous day, followed by left-sided weakness that morning. The patient denied other symptoms, including headache or gait instability issues. On ED arrival, blood pressure was 205/135, and a stroke alert was called. CT brain perfusion confirmed an acute ischemic stroke due to an obstruction in the pre-bifurcation segment of the right middle cerebral artery, resulting in a region of hypoperfusion and a viable penumbra. The patient subsequently underwent mechanical thrombectomy with a right MCA stent retriever. Follow-up infectious investigation revealed syphilis, with a positive RPR titer 1:256, but hypercoagulable workup was otherwise negative. Transthoracic echocardiogram with bubble was positive for a patent foramen ovale (PFO). The patient was started on high-dose IV penicillin, diltiazem, atorvastatin, and lovenox. This stroke was likely secondary to uncontrolled hypertension, confounded by meningovascular syphilis and/or PFO. The patient was discharged with follow up to cardiology for transesophageal echocardiogram and PFO closure evaluation, as well as infectious disease for antibiotics and repeat RPR. Discussion Meningovascular syphilis, a complication of syphilis infection, can precipitate a stroke by inflaming the brain's blood vessels. This inflammation can lead to the formation of thrombi, which in turn can reduce perfusion. This process can occur months to years after initial infection, causing symptoms like weakness, numbness, or confusion. Importantly, it is a treatable cause of recurrent ischemic strokes. Of note, although the patient has a PFO, findings are consistent with ischemic stroke and not embolic, regardless the PFO could be a contributing factor. Given the patient’s young age, a deeper investigation into less common etiologies was done, leading to the concern for meningovascular syphilis. This case underscores the importance of a comprehensive workup in young stroke patients, as prompt diagnosis and treatment with intravenous penicillin can prevent further neurological damage. This abstract is funded by: None
Sculthorpe et al. (Fri,) studied this question.