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Dans En rade de J.-K. Huysmans (1848-1907), le roman clinique naturaliste se mue en critique de la médecine, au nom de l’âme. Cette dernière, oubliée des praticiens, devient l’expression de la subjectivité et d’une résistance à la catégorisation. Typique du récit de cas en apparence seulement, En rade brouille les signes neurologiques de la maladie exposée pour en proposer une interprétation psychologique et spirituelle, interrogeant à nouveaux frais les liens entre médecin et patient.

Tabetic arthropathy (TA) is a type of neuropathic arthropathy that has become rare. The purpose of this report is to describe a case of tabetic arthropathy involving the knee. A 53-year-old man was hospitalized for painless right knee arthropathy. Clinical examination demonstrated hydarthrosis of the right knee, peripheral neuropathic syndrome of the lower limbs, and paralysis of the IXth and Xth cranial pairs. Plain radiography showed the presence of lytic lesions in the internal femoral condyle and tibial plateau. Syphilitic serology tests were positive in the blood and cerebrospinal fluid.

The authors report three cases revealed by tabes arthropathy in patients younger than 45 years. The age of patients was respectively 42, 40, 42. The clinical symptoms consisted of a painless knee strain, isolated in one case, associated with radiculocordonal posterior syndrome in two cases. The radiological lesions showed bone destruction. The biological assessment was for a venereal disease. The outcome was disappointing, despite a well conducted treatment. The observation of such cases should suggest a syphilitic origin ahead any advanced painless arthropathy even in young patients.

Neurosyphilis is rare today. It arises on average 20 years after poorly treated or untreated primary syphilis. Considering the decline in the incidence of syphilitic meningo encephalitis and the little known MRI aspects, we report the case of a patient affected by neurosyphilis occurring after primary syphilis untreated for 25 years.A 65-year-old man presented typical clinical features including general paresis with psychiatric disorders, maniac access, and frontal syndrome as well as tabes dorsalis and Argyll-Robertson pupil. Brain MRI showed bilateral high intensity signals on the T2 weighted sequence located in mesiotemporal, insular, frontal regions.Very few cases of neurosyphilis with detailed brain MRI aspects have been reported. The interest of this case report is first to recall the importance of syphilitic serology in patients with subacute psychiatric disorders and secondly to present rarely reported aspects of the brain MRI.

Neurosyphilis accounts for 56%-70% of all visceral syphilis and is a complication in 5%-10% of cases of untreated syphilis. The aim of this study was to evaluate the epidemiological aspects and clinical presentations of neurosyphilis in Morocco through a series of 201 patients attending the Centre for Neurological Services at the university hospital in Rabat between 1986 and 1997. The mean age of the patients was 41.26 (SD 9.23) years (range: 17-70 years); the majority (91%) were male. The incidence of neurosyphilis in Morocco is high. From 31 cases per year in 1985, it has fallen since 1990 to reach 10 cases in 1997. Among the different clinical presentations recorded, chronic meningoencepahalitis was the commonest, followed by meningovasculitis, tabes dorsalis and optic atrophy.

Syphilitic spinal cord gumma Syphilitic gummas of the central nervous system are exceptional and are in general described in the brain. We report the case of a Brown-Sequard syndrome in a 25-year-old patient. The cervical myelography and the brain CT as well as the vertebro-occipital junction were normal. The diagnosis of multiple sclerosis was evoked and corticosteroid therapy was initiated. The patient experienced clinical improvement. Two years later, the patient was readmitted. Immunological reactions for syphilis were positive, in serum and CSF. Tests for HIV were negative. The MRI showed a cervical spinal cord process at the C3 level with adhesive spinal associated arachnoiditis. Penicillin therapy was started prior to surgery for the spinal process. The syphilitic nature was confirmed by pathology. To our knowledge, the MR appearance of a syphilitic gumma of the spinal cord has not been described previously in the scientific literature.

The authors report the case of a 63 years old man who presented 13 years after a diagnosis of a tabes dorsalis, stress fractures of the lower limbs and Charcot's joints (knees). 7 years later, he had multiple stress fractures of the sacrum and pelvis and of the ribs following a minor trauma. Laboratory investigations revealed a major osteoporosis probably related to the neurochirurgical complications of the tabes dorsalis.

Two-dimensional electrophoresis isolates the various proteins in the CSF in peaks ; this a method which gives very reliable results ; the height of the peaks has a certain quantitative value, similar to that obtained with electro-immunodiffusion. The peaks visible in the CSF can be increased separately -- mainly the "alpha 2", "alpha 2 beta", the IgA and IgG peaks -- in another type of recording, the height and number of the peaks may be increased, indicating the presence in the CSF of normally absent protein originating in the serum. An increase in the "alpha 2" or "alpha 2 beta" peaks is not specific, but it is always indicative that the development of a neurological process is under way ; the increase of IgG and IgA retains its character of great specificity in evolutive inflammatory conditions. Multiple peaks indicate the passage of serum proteins into the CSF in oedematous and destructive processes, in expansive or compressive processes and in polyradiculoneuritis. This method with its well-codified technique, which may be carried out on an unconcentrated CSF without risk of denaturing the proteins, may be carried out routinely in clinical practice with human anti-serum immune serum or with more specific serum, anti CSF for example, which seems to give quite reliable results.

In 1868, J.M. Charcot published his memoir "sur quelques athropathies qui paraissent dépendre d'une lésion du cerveau ou de la moelle épinière "based on 4 cases of tabes dorsalis. This work was subsequently developed and presented in London in 1881 when Sir James Paget acknowledged the significance of this entity. "Charcot's joint" has come in use to mean that particular joint disease which results, from nervous lesions, whatever its nature. A controversy lasted between those who thought, e.g. Volkman, that mechanical trauma is the significant pathophysiological factor and those, e.g. Charcot, who ascribed a trophic role to the spinal cord. At the beginning, Charcot thought that lesions of the anterior horn were responsible but finally concluded that be could not bring a precise answer to that point. Subsequently Raymond, Dejerine (who insisted on the absence of pain), Foix and Alajouanine, Alajouanine and his collaborators extended Charcot's observations. Alajouanine proposed that lesions of the sympathetic nervous system played a major pathophysiological role. In 1960 Castaigne and Cambier proposed a unified theory with complementary roles ascribed to trauma and to nervous lesions. In 1936, diabetic neuropathy was described by W. Jordan. In 1942, Thevenard described "acropathie ulcéro-mutilante" now widely known as hereditary sensory neuropathy. Amyloidosis, familial dysautonomia, congenital insensitivity to pain were added to the list of causes of Charcot's joint. Less well known are the works of Charcot on joint diseases in hemiplegics. These were later studied by Alajouanine and Thurel and de Sèze and Ryckewaert have proposed to call them "algoneurodystrophies décalcifiantes réflexes" a topic which nowadays arises much interest in rheumatology.

The authors present a case of cauda equina paraparesis due to compression by tabetic osteo-arthropathy. Diagnosis was confirmed by the typical clinical picture of tabes and by the history of a chancre 53 years earlier. Radiography of the spine showed vertibral osteo-arthropathy. Opaque contrast myelography showed compression at the D 11/D 12 and L 4/L 5 levels, with poor contrast filling athe the L 1/L 3 level. Surgical treatment by decompressive laminectomies from D 12 to L 4 led to a satisfactory result with motor recovery and regression of the cauda equina syndrome.