It was in the 1960s when I first met the one truly ‘mad’ person that I encountered in my medical career. I had just commenced a short rotation as a psychiatric RMO at a reputable Melbourne psychiatric hospital. The patient was a 52-year-old Londoner who had migrated to Australia with her husband and son. She had been ‘certified’ to the hospital with the presumptive diagnosis of ‘mania—for management’! Taking a history was difficult as she was forever restless, distracted and had flights of ideas. Furthermore she had an alluring ‘fetching’ body language, which led to sexual escapades in the hospital grounds with the inevitable willing male inpatients. She was soon accommodated in a secure ward and was assessed by the medical director and a consultant neurologist—two extremely brilliant clinicians.
As they left the ward they said, ‘John, we want you to perform a lumbar puncture—we suspect neurosyphilis’. This came as a surprise in view of her apparent clean-cut background and doting family members. However, we did determine that she had probably had sexual encounters with servicemen who lived in the family boarding house during World War II.
Well, my futile attempt at performing the procedure was a nightmare which remains with me to this day. The shrieking and wailing (I kept thinking that a banshee would sound like her) were punctuated by threats to the nurse and to me of injury from the instruments we were handling. I was honestly frightened by this unfortunate woman and felt so sad that a human being could be so tormented and manic.
The boss was not impressed with my failure but I heard that the specialist team’s effort to get the cerebrospinal fluid under general anaesthesia was like a scene from Dante’s ‘Inferno’. The spinal fluid did test positive for syphilis.
She was treated with parenteral penicillin and large doses of antipsychotics but unfortunately I have no information about the eventual outcome.
DISCUSSION AND LESSONS LEARNED
Our patient probably had Cupid’s disease, which is increased libido in older people with neurosyphilis, as described by Oliver Sacks in The Man Who Mistook His Wife for a Hat (Sacks, 1985).
Fortunately tertiary syphilis is rare but we now know that primary syphilis is staging a comeback especially with associated HIV infection.
Penicillin is most effective for primary syphilis but unlikely to be effective at the tertiary level. A particular problem with treatment by penicillin is the dramatic Jarisch–Herxheimer reaction, albeit of low morbidity. The reaction can be modified with concomitant use of oral corticosteroids (Fauci et al., 2008).
Think twice about performing a procedure—even a simple one—on a mentally ill patient. Plan carefully.
The patient was a 71-year-old male, a native of Papua New Guinea, resident in Australia for six years. He presented with fever, diffuse crackles in the ...