With a presumed diagnosis of neurosyphilis, the patient was given 4 million units of IV penicillin every 4 hours for 18 days and subsequent oral penicillin. The patient received a few days of corticosteroid treatment at the onset of penicillin therapy to prevent the Jarisch-Herxheimer reaction. The positive Lyme titer was thought to be a “spillover” from the systemic syphilitic reaction, and the CSF lymphocytes were thought to be reactive. The patient tolerated the treatment without any problems.

Two weeks after treatment, the fundi showed improvement (Figure 6 & Figure 7).

Follow-up spinal taps demonstrated a decrease in protein, a marked decrease in the cellular response, and the disappearance of aytpical lymphocytes, confirming that they were reactive in nature and not lymphomatous, which had concerned the cytopathologist reading the initial spinal tap.