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A Great Imitator of Positional Vertigo
Priya Chopra, MSIII, University of Colorado School of Medicine; Ericson Stoen, MD, University of Colorado School of Medicine; Chi Zheng, MD, Divison of Hospital Medicine, Denver Health and Hospital Authority
Vertigo with associated falls is a frequent cause of admission in elderly patients. We present the case of a patient in which a systematic approach will reveal common and less common causes of falls.
A 73-year-old woman presented after a fall at home resulting in a forehead hematoma in the setting of a four-month history of progressive dizziness and recurrent falls. She described the dizziness as “room spinning” exacerbated by changes in position; she also had a two-year history of right-sided tinnitus and progressive hearing loss. Her past medical history was notable for atrial fibrillation, type 2 diabetes mellitus with peripheral neuropathy, and hypertension. Medications included warfarin, NPH insulin, lisinopril, metoprolol, baclofen, tizanidine, and hydrocodone. Vital signs including orthostatics were normal. Cardiopulmonary exam was normal. Neurologic examination showed terminal dysmetria and deficits in bilateral lower extremity proprioception. Hemoglobin, glucose, troponin, TSH, B12, and HIV were all normal, and her INR was therapeutic. ECG showed sinus rhythm, and interrogation of the patient's loop recorder placed for her falls was unremarkable. CT and MRI of the brain were unremarkable. A prior audiometry report showed isolated right-sided neurosensory hearing loss. Treponemal pallidum antibody was positive, with subsequently positive RPR at 1:2 and a positive confirmatory FTA-ABS. Cerebrospinal fluid (CSF) protein was elevated at 58, and CSF VDRL was non-reactive. As she had a negative RPR 11 years prior and scored 18/25 on a partially completed Mini-Mental State Examination, the patient was treated for neurosyphilis with continuous penicillin G infusion for 14 days with improvement in her vertigo and tinnitus but not hearing.
Over 800,000 patients are hospitalized each year due to falls, and the possible etiologies of recurrent falls are numerous. Our patient had several potential causes for her falls, and many of which were systemically excluded from the differential, but her neurologic and vestibular symptoms gave concern for neuro and oto-syphilis.
Syphilis can present with both hearing loss and vertigo. This occurs when T. pallidum invades the cochleovestibular system resulting in otosyphilis, or the cerebrospinal fluid (CSF) resulting in neurosyphilis. In neurosyphilis, extra-otic symptoms such as impaired proprioception, stroke, and dementia may also be present. To differentiate neurosyphilis from otosyphilis, a lumbar puncture should be performed. Making this distinction is important, as the treatment may differ. The literature currently suggests intravenous penicillin G treatment for neurosyphilis; however, there is controversy regarding treatment for otosyphilis. Some studies suggest that three doses of intramuscular penicillin is sufficient, while other experts recommend the same treatment as neurosyphilis due to concerns of incomplete eradication.
This case exemplifies the importance of a thorough diagnostic evaluation after recurrent falls and peripheral vertigo, including ruling out “the great imitator.”
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