title: Progressive painless lower limbs weakness in a dialyzed patient: undiagnosed tertiary syphilis: a case report.
abstract: BACKGROUND
  Syphilis is a sexually transmitted disease, remaining under-estimated, under-recognized due to the variability of clinical presentation and ageing of the population with chronic comorbidities. Hence, some manifestations of the past are nowadays superimposed on the course of chronic diseases. Clinical suspicion should be guided by past medical history of contracting any other sexual disease in a heterosexual person or man who has sex with man.
  
  
  METHODS
  We describe a rare case of tertiary syphilis in a hemodialyzed diabetic patient whom was career of chronic liver disease due to the evolution of chronic hepatitis B virus infection complicated by a hepatocellular carcinoma. Initial orientation in diagnosing this rare presentation of progressive painless lower limbs weakness was attributed to possible side effects of ongoing anti viral therapy including lamivudine and adefovir. We continued administering both drugs while patient notified a spectacular improvement under Ceftriaxone therapy introduced empirically for a possible chest infection. Routine ophthalmologic examination realized in a teaching hospital, scheduled without knowing the course of late infection showed the presence of a syphilitic uveitis.
  
  
  CONCLUSIONS
  This case emphasizes the need for a high index of clinical suspicion for syphilis before the occurrence of symptoms related to its end organ damage dominated by neurosyphilis form. Early diagnosis is the key to preventing significant morbidity and mortality and improving prognosis. However, in the setting of chronic diseases such as chronic kidney diseases either before setting up methods of renal replacement therapy or under immune-suppressive therapy; clinical presentation might resemble any disease, delaying the certitude of the diagnosis by prescribing a rapid plasma reagin.
authors.affiliation: Department of nephrology, CH Louis Jaillon Saint-Claude, 39206, France. omardahmani@hotmail.com.
authors.forename: O
authors.initials: O
authors.lastname: Dahmani
authors.forename: N
authors.initials: N
authors.lastname: Target
authors.forename: Jp
authors.initials: J
authors.lastname: Guy
authors.forename: S
authors.initials: S
authors.lastname: Belkhelfa
authors.forename: F Mermet
authors.initials: FM
authors.lastname: Jeanvoine
authors.forename: J
authors.initials: J
authors.lastname: Servonnat
authors.forename: J
authors.initials: J
authors.lastname: Djellid