HIV and ID Observations

During Thanksgiving, my brother-in-law — who is a professional musician and also a passionate history buff — gave me a scholarly paper to review on the strange death of the famous American explorer Meriwether Lewis, of “Lewis and Clark” fame.

The bottom line?  Lewis may well have had neurosyphilis — at least that’s the premise of the epidemiologist Reimert Thorolf Ravenholt, who, in a nearly 13,000 word report, ultimately concludes:

The fabric of evidence that syphilis acquired during the explorative trip to the Pacific Coast was the un­derlying cause of Lewis’s death includes these threads: (1) Lewis was in excellent health when he set forth up the Missouri River; (2) several Indian tribes suffering from syphilis were encountered; (3) sexual intercourse with women of these tribes by Corps members was frequently urged by the Indians and was commonplace; (4) several Corps members (probably at least eight) did develop syphilis; (5) when encountering the Shoshoni tribe on the Continental Divide, Lewis had both a propitious opportunity and a compelling need for sex­ual intercourse; (6) a few weeks later, he developed illness which became severe and disabling for several months, but the nature of which was not described; (7) for some months in 1807, following his return from the expedition, he was incapacitated by illness, the nature of which was not divulged; (8) during 1808­-809, he developed progressive illness afflicting his central nervous system and diminishing his judgment faculties; (9) his terminal months in 1809 were char­acterized by progressive, episodic, febrile illness, with severe mental and behavioral disorders highly charac­teristic of paresis; (10) Lewis himself recognized that he was suffering from a progressive disease likely to be fatal; (11) Thomas Jefferson and William Clark readily understood why his death was a probable act of self­ destruction.

Emphatically not the Lewis and Clark story I learned in 5th Grade!

But sure, the diagnosis of neurosyphilis sounds plausible.  Sexual indiscretion followed by rashes followed by a progressive neurologic disease with increasingly bizarre and unreliable behavior.  (Not so sure about the fever part.)

But while these speculative diagnoses are fascinating both historically and medically (Mozart’s death has 325 citations in PubMed), one inevitably gets back to the problem of confirming the diagnosis, which is almost always impossible.

Furthermore, there are several reasons why neurosyphilis is in particular a difficult diagnosis to prove, even today, including:

• Protean symptoms that wax and wane.
• Variable latency period.
• Relatively uncommon, especially since the discovery of penicillin.
• Unreliable diagnostic testing and no readily available culture.
• Clinical and lab-based manifestations have significant overlap with other diseases.
• Lots of what was called neurosyphilis back in the day probably was something else, making much of the clinical teaching about the disease highly subjective.

In fact, with the exception of obvious cases — ocular disease concurrent with secondary syphilis, or CSF pleocytosis and positive VDRL in the setting of a classic clinical presentation — it otherwise seems that the diagnosis of neurosyphilis is made only after an esteemed clinician definitively, confidently, and loudly states THIS IS NEUROSYPHILIS.

Especially if that clinician has a certain well-aged gravitas.