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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 125-126

Neurosyphilis and movement disorder: Old box, new “candy”

Department of Neurology, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, New Delhi, India

Date of Submission05-Jul-2020
Date of Decision05-Jul-2020
Date of Acceptance06-Jul-2020
Date of Web Publication07-Nov-2020

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AOMD.AOMD_34_20

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How to cite this article:
Mishra A, Pandey S. Neurosyphilis and movement disorder: Old box, new “candy”. Ann Mov Disord 2020;3:125-6

How to cite this URL:
Mishra A, Pandey S. Neurosyphilis and movement disorder: Old box, new “candy”. Ann Mov Disord [serial online] 2020 [cited 2023 May 31];3:125-6. Available from: https://www.aomd.in/text.asp?2020/3/3/125/300262

Dear Editor

The earliest description of syphilis dates back to as early as the fifteenth century when it was referred to as “Great Pox” or “Evil Pox” in the poem of Girolamo Fracastoro, “Syphilis sive Morbus Gallicus”.[1] Literature is rife with myriad accounts of syphilis ranging from the great novelist Thomas Mann’s account in one of his masterpieces, “Doctor Faustus—The Life of the German Composer Adrian Leverkühn as Told by a Friend,” in which he goes on to illustrate various manifestations of the disease known as “General Paralysis of the Insane,” to the assumption of the affliction of mighty classical music composers by the same disease: Beethoven, whose progressive hearing loss influenced his career, culminating in complete deafness; Donizetti who developed behavioral changes, as well as headaches, general paresis, and seizures; Schumann and Wolf who suffered from personality changes, persecutory delusions, and general paresis; Joplin and Delius also had symptoms attributed to syphilis; and Smetana, who developed dementia, deafness, and auditory hallucinations with rapid progression (his tinnitus was musically represented in his first String Quartet).[2],[3] The Latin term that denotes this disease “tabes” means wasting, consumption, or the “disease, which rots the blood.”[4] The spectrum of the disease may range from the involvement of meningitis, cranial nerve defects, meningovascular disease, or stroke in early neurosyphilis to involvement of the brain and spinal cord, and may result in general paresis, dementia, or tabes dorsalis in late neurosyphilis.[2]

Movement disorders can also be an important clinical feature in neurosyphilis. In this issue of the journal, Pitton Rissardo and Fornari Caprara[5] have done an extensive review of the literature and reported tremor, chorea,  Parkinsonism More Details, ataxia, myoclonus, dystonia, athetosis, and ballism as the common movement disorders in neurosyphilis. Rarely patients with neurosyphilis may develop subtle orofacial dyskinesias known as the “candy” sign.[6] Lenka et al.[6] reported that it can be one of the presenting symptoms, and they suggested that subacute-onset involuntary movements with behavioral abnormalities may indicate a chronic infection such as neurosyphilis. The mechanism by which movement disorders are produced is diverse and includes vasculitis-induced cerebral and cerebellar infarction, and direct inflammation secondary to parenchymal spread.[7] There may be associated hydrocephalus also leading to gait dysfunction and parkinsonism. Some of the movement disorders may be related to the neuroleptic medications used to treat the underlying psychiatry condition. Whether the presentation of neurosyphilis has changed in the antibiotic era or not is a question that has been repeatedly posed.[8] Tabes dorsalis was the most common manifestations of neurosyphilis in the pre-penicillin era, but asymptomatic presentations have been extensively reported in the antibiotic era.[8] Hooshmand et al.[9] reported 241 new cases of neurosyphilis, and the majority of them were asymptomatic and the remainder had atypical syndromes. The classic presentation of neurosyphilis may have changed, but, as opposed to the developed world, the countries with poorer access to health care are still struggling with the significant disease burden. The physicians should be aware that movement disorders can be one of the atypical presentations of neurosyphilis and may provide an important clue, which may be helpful in the early diagnosis and management of this dreaded disease.

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  References Top

Fracastoro G Syphilis sive Morbus Gallicus. Lud. Cyaneus; 1720.  Back to cited text no. 1
Boller F, Caputi N Thomas Mann’s depiction of neurosyphilis and other diseases. J History Neurosci 2018;27:1-9.  Back to cited text no. 2
Pedro MK, Germiniani FM, Teive HA Neurosyphilis and classical music: The great composers and “The Great Imitator”. Arquivos de Neuro-Psiquiatria 2018;76:791-4.  Back to cited text no. 3
Joubert J Dictionnaire françois et latin: tiré des auteurs originaux et classiques... Chez Louis Declaustre, libraire; 1710.  Back to cited text no. 4
Pitton Rissardo J, Fornari Caprara AL Neurosyphilis-associated movement disorder: A literature review. Ann Mov Disord2020;3:129-44.  Back to cited text no. 5
Lenka A, Thota N, Stezin A, Pal PK, Yadav R Orofacial involuntary movements in neurosyphilis: Beyond the candy sign. Tremor Other Hyperkinet Mov (N Y) 2017:7:507.  Back to cited text no. 6
Shah BB, Lang AE Acquired neurosyphilis presenting as movement disorders. Mov Disord 2012;27:690-5.  Back to cited text no. 7
Timmermans M, Carr J Neurosyphilis in the modern era. J Neurol Neurosurg Psychiatry 2004;75:1727-30.  Back to cited text no. 8
Hooshmand H, Escobar MR, Kopf SW Neurosyphilis. A study of 241 patients. JAMA 1972;219:726-9.  Back to cited text no. 9


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