Altered Mental Status- a surprise diagnosis

[Stcroix]

Recently had a 80+ year old man admitted for AMS (altered mental status) and pneumonia. No big whoop. He was given a complete workup and started on antibiotics. Elevated WBC, neg CXR, cat scans of chest and head, and neg urine (first thing we thought of). This guy was off his rocker, talking nonsense, wouldn't stay in bed, more or less out of control. We had gotten a sitter and had to resort to restraints to keep him safe. He had been living with family and they stated that his deterioration had come on fairly suddenly. The patient got several consults and finally a neurologist came up with the idea for a syphilis test. Bingo! This poor guy had probably had syphilis for a great deal of his life and now was in the tertiary (neuro) stage. Was placed on high dose IV penicillin and within 3 days his mental status made a rapid turn around. Felt good to have seen a real 'cure' although some of his dementia will never go away.

I haven't seen a case of this before, anyone else have surprise diagnosis story to share?

[xoemmylouox, ASN, RN]

I have to say I immediately thought UTI as well. This has reminded me to not forget those less common dieases. I don't currently treat many elderly patients, but this could apply to even our younger populations. Thanks for the reminder.

[mariebailey, MSN, RN]

I thought once it reached the neuro stage it was untreatable? Then again, I am by no means an expert on syphilis lol.

I think it's still treatable in that you can kill the syphilis with antibiotics, but there is likely damage to the CNS that can't be undone, depending on how long you've had it.

[dudette10, MSN, RN]

I've seen lots of syphilis panels for acute AMS admissions where the cause is still being investigated or where there is evidence of improvement for the initial infectious diagnosis (like PNA), but AMS persists. It's almost always ordered by infectious disease consults.