Even though there were no significant alterations in the medullary MRI, the patient’s clinical picture was highly suggestive of TM. Open in a separate window Figure?3 Medullary MRI revealing multiple foci of hyper intensity in the posterolateral temporal topography at the left lateral ventricular horn, right posterior lenticular horn and head of the right caudate nucleus, without alterations around the perfusion in these areas. with signs and symptoms compatible with both SLE and secondary syphilis. SLE is usually a systemic, multifaceted autoimmune inflammatory disease with an unknown aetiology. The pathology of this condition can be partly explained by the deposition of immune complexes in several organs, which triggers match and other mediators of inflammation.2 SLE symptoms vary greatly. Constitutional symptoms, such as fatigue, are probably multifactorial and have been related not only to disease α-Terpineol activity but also to complications such as anaemia or hypothyroidism.3 Involvement of the musculoskeletal system is extremely common in patients with SLE,4 with myalgia, arthralgia and arthritis being the main manifestations. Skin involvement occurs in 70C80% of patients, including the classic malar and discoid rashes, scarring alopecia, mouth ulcers and photosensitivity. Other cutaneous S1PR4 manifestations of SLE are Raynaud phenomenon, livedo reticularis, vasculitic purpura, telangiectasias and urticarial.3 Haematological features include normocytic normochromic anaemia, thrombocytopenia and leukopenia.5 Renal disease affects about 30% of the patients with SLE and it remains one of the most important and life-threatening complications. Pleuritis, causing chest pain, cough and breathlessness, may occur and pulmonary embolism must always be considered, particularly in those who have positive antiphospholipid antibodies. Cardiac disease entails asymptomatic valvular lesions, pericarditis and pericardial effusions, while myocardial disease is usually relatively rare.2 Neurological involvement of SLE is reported in 25C75% of patients and can involve any portion of the nervous system.6 It can manifest as a variety of neurological presentations, ranging from a mild headache to status epilepticus, aseptic meningitis, myelopathy or stroke. Acute transverse myelitis (TM) is usually a late complication of lupus, but in rare circumstances it may be the presenting manifestation of the disease.7 There is an association between this early presentation and antiphospholipid antibodies.8 9 The most common presenting symptoms are paraesthesias, numbness and weakness of the lower limbs, urinary retention, faecal incontinence, low back pain and fever.7 10C12 Syphilis is a disease caused by the spirochete acquired through unprotected sexual intercourse and vertical transmission. Secondary syphilis is usually characterised by low-grade fever, lymphadenopathy, malaise, anorexia, excess weight loss and a mucocutaneous rash.13 Other less common presenting symptoms are hepatitis, nephrotic syndrome, glomerulonephritis, tenosynovitis and polyarthritis.14 Neurological manifestations of secondary syphilis include acute meningitis, sensorineural hearing loss, optic neuritis and Bell’s palsy.14 Acute meningitis occurs in only 1C2% of patients. When it occurs, it does so in α-Terpineol four different forms: aseptic meningitis (headache, nausea, fever, meningeal indicators), acute syphilitic meningitis (with meningismus and focal neurological indicators), acute syphilitic basilar meningitis (with meningeal indicators and asymmetric cranial nerve palsies) and α-Terpineol acute syphilitic hydrocephalus with papilloedema.15 16 Unlike α-Terpineol tertiary syphilis, the meningeal involvement of secondary syphilis usually responds completely to penicillin.14 Untreated acquired syphilis progresses through several stages. Early or infectious syphilis consists of a main stage, characterised by the chancre and regional lymphadenopathy, and a secondary stage (6?weeks after spontaneous healing of the chancre) characterised by mucocutaneous and multisystemic involvement. Skin lesions are usually symmetric, non-pruritic and non-bullous and may progress through four stages: macular salmon pink lesions are followed by maculopapular ones that resemble psoriasis but involve the palms and soles. Finally, papular indurated lesions may develop into necrotic, pustular ulcerations. Spontaneous healing of these lesions occurs and a latent asymptomatic period ensues. Latent syphilis is usually a stage at which the features of secondary syphilis have resolved, though patients remain seroreactive. Some patients experience recurrence of the infectious skin lesions of secondary syphilis during this period.17 Case presentation A 47-year-old man was referred to our department with extreme fatigability, muscular weakness α-Terpineol affecting the four limbs, non-quantified pounds reduction, faecal incontinence, urinary retention, fever (38C) and mental misunderstandings with 1?month of advancement. On entrance, the physical exam disclosed fever (38.3C), discoloured mucosae, a maculopapular rash relating to the hands and bottoms (numbers 1 and ?and2),2), bilateral oedema from the poor limbs extending before legs and a hypotonic anal sphincter on digital rectal exam. On pulmonary auscultation, there is a lower life expectancy vesicular murmur in both lung bases, without adventitious noises. Open in another window Shape?1 Maculopapular hyperpigmented rash present for the palm from the patient’s hands. Open in another window Shape?2 Maculopapular hyperpigmented rash present on the only real from the patient’s feet. On neurological exam, the.