Acute neurosyphilis as a cause of death in the 21st century - autopsy case report in a prisoner.

Syphilis, a chronic sexually transmitted infection caused by Treponema pallidum, has become a rare cause of death in the antibiotic era when diagnosed and treated promptly. Nevertheless, severe and fatal complications may still occur in vulnerable populations. We report the case of a 45-year-old imprisoned intravenous drug user who died following acute neuroinflammation most likely associated with neurosyphilis. The patient was admitted with loss of consciousness and generalized tonic-clonic seizures. Medical records documented a diagnosis of neurosyphilis established five months earlier, while cerebrospinal fluid analysis demonstrated inflammatory changes consistent with central nervous system involvement. Despite anticonvulsive and antibiotic therapy, he died shortly after admission. Autopsy revealed mild cerebral edema and cloudy leptomeninges. Histopathological examination demonstrated chronic lymphoplasmacytic meningoencephalitis with perivascular inflammatory infiltrates, leptomeningeal inflammation, gliosis, neuronal loss, and chronic vascular changes. Warthin-Starry staining and immunohistochemistry for Treponema pallidum were negative. Although these findings were compatible with neurosyphilis, they were not pathognomonic. In the absence of complete clinical documentation and comprehensive ancillary investigations, the diagnosis was based on integration of the available clinical history, autopsy, histopathological, and toxicological findings, together with exclusion of more likely alternative causes. This case highlights the diagnostic challenges of postmortem evaluation of suspected neurosyphilis and emphasizes the importance of cautious clinicopathological correlation in forensic practice, particularly when supporting diagnostic investigations are incomplete.