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Syphilitic spinal disease is a rare condition caused by the spirochete Treponema pallidum, either from direct spirochete involvement of the cord, or as a consequence of indirect spirochete involvement of the meninges, blood vessels, or the vertebral column. Following the introduction of penicillin therapy in the 1940s, it has become an increasingly rare condition. We report three challenging cases of syphilitic spinal disease presenting as myelopathy - one with an extra-axial gumma of tertiary syphilis causing cord compression, and two with tabes dorsalis complicated by tabetic spinal neuroarthropathy - each presenting a diagnostic dilemma to their treating physicians. We also review the literature for updates on modern investigative modalities, and discuss pitfalls physicians need to avoid in order to arrive at the diagnosis.

Background: Diagnosis of syphilis is difficult. Follow-up and therapy evaluation of syphilitic patients are poor. Little is known about positron emission tomography (PET) in syphilis. This review was to systematically review usefulness of PET for diagnosis, disease extent evaluation, follow-up, and treatment response assessment in patients with syphilis. Methods: We searched PubMed, EMBASE, SCOPUS, Cochrane Library, Web of Science, ClinicalTrials.gov, and three Chinese databases (SinoMed, Wanfang, and CNKI) for English and Chinese language articles from inception to September 2016. We also collected potentially relevant studies and reviews using a manual search. The search keywords included the combined text and MeSH terms "syphilis" and "positron emission tomography" . We included studies that reporting syphilis with a PET scan before and/or after antibiotic treatment. The diagnosis of syphilis was based on serological criteria or dark field microscopy. Outcomes include pre- and post-treatment PET scan, pre- and post-treatment computed tomography, and pre- and post-treatment magnetic resonance imaging. We excluded the articles not published in English or Chinese or not involving humans. Results: Of 258 identified articles, 34 observational studies were included. Thirty-three studies were single-patient case reports and one study was a small case series. All patients were adults. The mean age of patients was 48.3 ± 12.1 years. In primary syphilis, increased fluorodeoxyglucose (FDG) accumulation could be seen at the site of inoculation or in the regional lymph nodes. In secondary syphilis with lung, bone, gastrointestinal involvement, or generalized lymphadenopathy, increased FDG uptake was the most commonly detected changes. In tertiary syphilis, increased glucose metabolic activity, hypometabolic lesions, or normal glucose uptake might be seen on PET. There were five types of PET scans in neurosyphilis. A repeated PET scan after treatment revealed apparent or complete resolution of the asymmetry of radiotracer uptake. Conclusion: PET is helpful in targeting diagnostic interventions, characterizing disease extent, assessing nodal involvement, and treatment efficacy for syphilis. Key words: Diagnosis; Positron Emission Tomography; Syphilis; Therapeutics

Item does not contain fulltext A 55-year-old man presented with a painless destruction of multiple joints and neurologic deficits. He was admitted with a painless pyogenic arthritis of the right ankle. Four years earlier, he had experienced instability of the right knee after an inexplicable, progressive but painless destruction of the joint. Radiographs showed erosive changes at the smaller joints of both hands and the left foot, as well as deformation and destruction of the right foot. Results from both treponemal and nontreponemal serologic test were positive in blood. The Treponema pallidum particle agglutination index was positive in the cerebrospinal fluid. Tabetic arthropathy was diagnosed.Tabetic arthropathy is a manifestation of neurosyphilis. Because syphilis is known as "the great imitator" and tertiary syphilis is rare, recognizing the disease is the biggest challenge for health care providers. Symptoms may mimic any other disease, and many different medical specialists may be faced with these patients, or as Sir William Osler put it: "He who knows syphilis, knows medicine." Initial diagnosis is usually made on serum and cerebrospinal fluid examination. Penicillin is an effective treatment for neurosyphilis to stop progression of neurologic damage, but it does not cure the previously developed tabetic arthropathy. This case is reported to raise awareness of this uncommon but important manifestation of tertiary syphilis. Unfamiliarity with the clinical presentation of tabetic arthropathy may lead to considerable delay in diagnosis.

Rationale Tertiary syphilis can manifest as gummatous disease, but gumma of the spine has been extremely rarely reported. Patient concerns A 61-year-old male complained of worsening pain and numbness in both lower legs for four weeks. Diagnoses Syphilis of the Lumbar Spine. Interventions Pedicle screw fixation (L3-S1) and posterior decompression of the vertebral canal at L4-5 were performed. Outcomes The postoperative VAS score of both lower extremities decline to 2 from 7 at admission. Dorsal thumb extensor motor power (left/right) at day 7 postoperatively was 3/3 (versus admission: 1/1). Laboratory examinations showed normal white blood cell count (versus admission: 13.8 × 10/L; reference value: 4.00-10.00 × 10/L) and decline in C-reactive protein (20.35 mg/L versus admission: 77.43 mg/L; reference value: 0.00-10.00 mg/mL) and ESR (58 mm versus admission: 73 mm; reference value: 0-15 mm). Lessons Our case illustrates that although gummatous disease of the spine may be extremely rare, it should be considered in the differential diagnosis of tuberculosis or malignancy of the spine so as to avoid a wrong diagnosis and incorrect treatment.

Secondary corneal amyloidosis is a rare finding and only 17 cases have been reported in the literature. A case of unilateral secondary localized corneal amyloidosis is presented in a patient with bilateral interstitial keratitis and other stigmata of tertiary syphilis.

A case of tertiary syphilis is reported in which CT demonstrated liver involvement. There were calcifications in the liver indistinguishable from hepatic calcifications due to other diseases. Syphilitic gummata should be considered in the differential diagnosis of liver calcifications when the clinical history is appropriate.