The World Health Organization defines stroke as the sudden onset of clinical signs of focal or global cerebral dysfunction lasting more than 24 hours or leading to death, with no apparent cause other than vascular. The ischemic form is the most common, accounting for approximately 85% of cases. In young adults, infectious and inflammatory causes should be considered, including sexually transmitted infections (STIs). Syphilis, caused by Treponema pallidum , is an STI that, if inadequately treated, may progress to neurosyphilis – a form that can occur at any stage of the disease. Among its presentations, the meningovascular form is particularly associated with cerebrovascular events. We report the case of a 25 year old male patient, with a history of smoking, alcohol use, severe depression, and inadequate treatment for previous syphilis. He was admitted with sialorrhea, confusion, aphasia, facial paralysis, and gait disturbance. CT imaging revealed hypodensity in the left middle cerebral artery territory. On examination, he presented aphasia, right-sided hemiplegia, and hypoesthesia, with an NIHSS score of 18. He was admitted to the ICU and started on acetylsalicylic acid and atorvastatin. Given his age, an extensive etiological investigation was performed. Serological testing showed VDRL 1:2048 in serum and 1:8 in cerebrospinal fluid, confirming neurosyphilis. He received crystalline penicillin G for 14 days, along with prophylaxis for Pneumocystis infection. HIV testing was positive, with a CD4 count of 388 cells/mm³ and viral load of 111,000 copies/mL. Urine LF-LAM testing for tuberculosis was positive, and RIPE therapy was initiated. The patient showed clinical improvement and was discharged with a therapeutic plan that included initiating ART six weeks after starting RIPE. This case underscores the importance of investigating infectious causes of stroke in young patients, particularly those with risk behaviors. Although treatable, syphilis remains a public health challenge due to poor treatment adherence, stigma, and screening gaps. Neurosyphilis should be included in the differential diagnosis of ischemic events in young adults, emphasizing the need for adequate STI screening and management.
Maia et al. (2026) studied this question.