Summary

A Pakistani man aged 60 years presented with personality change, aggression, paranoid delusions and sexual disinhibition while being treated for severe chest sepsis in intensive care. Collateral history confirmed that these personality changes had been developing over the course of the previous 2 years. He was found to have positive syphilis serology during a routine confusion screen, and the possibility of neurosyphilis was raised. Cerebrospinal fluid examination revealed elevated protein but negative syphilis testing. Following multidisciplinary discussion, the decision was made to treat as neurosyphilis, which resulted in a significant improvement in symptoms. The genitourinary department was able to carry out thorough contact tracing. This case demonstrates the importance of including syphilis in a confusion screen as this patient was diagnosed following a low clinical suspicion. It also highlights some potential pitfalls and difficulties in the diagnosis of neurosyphilis and the importance of the use of a multidisciplinary team.