a 35-year - old man with an unremarkable medical history sought treatment for headaches , hearing loss , and night sweats .
they came on as the day progressed and were neither positional nor associated with nausea , vomiting , or visual changes .
three weeks before arriving at the hospital , he noted a sense of " fullness " in his ears ; he said that spoken voices sounded muffled , and he had difficulty hearing telephone conversations .
when someone at the restaurant where he worked dropped a dish , he heard that sound clearly and reported that it was almost painful , causing him to become dizzy .
his appetite was good , and he had not lost weight . although he reported no fever , he did report night sweats for several weeks .
he had no rash , diarrhea , abdominal pain , chest pain , shortness of breath , joint complaints , or dysuria .
he also said that he was exposed to dust at his workplace because of remodeling .
he lived in new hampshire , had no pets , and worked as part owner of a restaurant .
exposures included multiple male and female sexual partners with inconsistent condom use , and he had acquired several tattoos 8 months earlier while traveling in spain and italy . he had no known tuberculosis exposure .
temperature was 36.7c , blood pressure 128/84 mm hg , pulse 80 , respirations 16/minute .
sclerae were anicteric , and his pupils reacted to direct and consensual testing and responded normally to accommodation .
bedside testing showed that his hearing was diminished to low volume sounds , but he was able to hear loud sounds , which he found painful .
when the examiner clapped his hands loudly a few feet from the patient 's ear , the patient exhibited nystagmus .
the patient 's neck was supple ; a 1.5-cm , nontender lymph node was palpated in the left upper anterior cervical chain .
the remainder of the examination was unremarkable , with negative romberg test ; normal gait ; and normal motor , sensory , and reflex performance .
rapid plasma reagin ( rpr ) was positive at a titer of 1:128 and was confirmed by a fluorescent treponemal antibody test .
subsequent studies showed a cd4 receptor  positive t - cell ( cd4 ) count of 899/ml and an hiv viral load of 878 copies / ml .
a lumbar puncture showed protein 33 mg / dl , glucose 78 mg / dl , 9 erythrocytes/l , and 8 leukocytes/l ( 100% lymphocytes ) .
cerebrospinal fluid venereal disease research laboratory test ( csf - vdrl ) results were negative .
csf - vdrl , cerebrospinal fluid venereal disease research laboratory test ; elisa , enzyme - linked immunosorbent assay ; wb , western blot ; rt - pcr , reverse transcription  polymerase chain reaction .
the patient was started on 24 mu of iv penicillin per day for 14 days . at the end of this period , he reported notable improvement in his headaches , hearing loss , and vertiginous symptoms .
one month after completing treatment , his rpr titer was 1:32 ; 3 months after he completed treatment , it was nonreactive .
the course of syphilis in an hiv - positive patient may be altered from the natural history of the disease in hiv - negative patients .
an increased frequency of ocular disease , multiple and slower resolving primary chancres , and a higher titer rpr have been reported ( 16 ) .
in addition , delay or failure of titer decline after treatment , predilection for developing the jarisch - herxheimer reaction , and clinical relapse have also been described in hiv infection ( 1,4,7,8 ) .
treponema pallidum is thought to invade the central nervous system in 25% of patients with syphilis , irrespective of hiv status ( 9 ) .
most of these persons successfully clear the infection ( 10 ) , but other patients harbor the spirochete and remain at risk for sequelae of neurosyphilis .
syphilitic meningitis , meningovascular disease ( often occurring with stroke ) , labyrinthitis , or cranial nerve palsies , as seen in this case , can be early findings .
loud sounds or even routine acoustic stimuli can result in vertigo , nystagmus , or nausea and vomiting .
the physiologic underpinnings of the tullio phenomenon were first described in 1929 , when tullio noted that experimentally induced fenestrations in the bony capsule of the lateral semicircular canals of pigeons caused the canals to be sound - responsive , inducing vestibular activation ( 11,12 ) .
shortly thereafter , benjamins described a tullio reaction in a human patient with fistulizing cholesteatoma ( 13 ) .
today , the term has been generalized to include vestibular activation in response to stimulation by sound of any part of the vestibular apparatus ( 12 ) .
the tullio phenomenon is seen in a range of clinical contexts , including congenital deafness , meniere disease , suppurative middle ear disease , and spirochetal infections , such as syphilis or lyme disease .
nields et al . describe a woman who had nystagmus and vertigo with routine sounds ; running tap water caused her to fall to the floor or retch in pain ( 14 ) .
describe a series of patients with oscillopsia induced by pencil tapping , telephone ringing , or the sound of cutlery falling on the floor .
patients often report a vague sense of ear blockage and an unpleasant awareness of their own voice vibrating in their ear ( 12 ) .
symptomatic cranial nerve viii involvement in this patient prompted treatment for neurosyphilis , despite equivocal ( but typical ) csf findings .
interpreting csf findings in hiv - positive patients with syphilis is challenging because commonly encountered mild lymphocytic pleocytosis may be attributable to hiv .
csf - vdrl is often negative , with a 20%70% false - negative rate ( 15 ) .
optimally managing patients with hiv and syphilis has been debated ; to date routine recommendations are the same as for hiv - negative persons ( 16 ) .
although any patient in whom syphilis is diagnosed and who has neurologic symptoms should undergo lumbar puncture , csf evaluation should also be considered in asymptomatic patients in whom syphilis is diagnosed and who have an rpr titer > 1:32 or a cd4 + count < 350 , as these markers have been associated with increased risk for neurosyphilis ( 10 ) .
because of the high rate of relapse that has been reported in some series ( 4,7,8 ) , close clinical and serologic follow - up is essential .
a study of 59 patients with neurosyphilis showed that hiv - positive study participants were 2.5 times less likely to normalize csf - vdrl reactivity than hiv - negative patients .
this effect was even more pronounced in patients with cd4 + counts < 200 ( 17 ) .
the findings suggest that more intensive therapy for neurosyphilis in immunocompromised patients merits further study .
after an all - time low case - rate of syphilis in 2000 , reports of rising trends , specifically in groups at risk , such as men who have sex with men , were reported in 2001 ( 18 ) .
the outbreaks marked a 9.1% overall increased rate of primary and secondary syphilis ( 19 ) and were characterized by a high rate of hiv infection .
parallel increases in hiv infection rates were a concern because of the common mechanism of transmission and the increased efficiency of hiv transmission with coexistent genital ulcers ( 20 ) . in 2001 , increases in hiv rates were reported in several states with large urban populations ; men who have sex with men accounted for the largest known subgroup at risk in incident adult or adolescent hiv cases ( 32% ) and aids cases ( 44% ) ( 21 ) .
new hiv diagnoses increased in 29 states with mandatory reporting from 1999 to 2002 , notably by 17% among gay and bisexual men ( 22 ) .
syphilis incidence also continued to rise in the united states in 2002 , with a 12.4% increase since 2001 ( 19 ) , and the highest trends were estimated to be among men who have sex with men . in san francisco , primary and secondary syphilis rates increased by > 1,000% from 1998 to 2002 among men who have sex with men ( 23 ) .
high - risk behaviors have been documented in this group ( 24 ) and factor prominently in syphilis reemergence in the early 21st century .
this case report describes a patient who had tullio phenomenon as the index symptom of neurosyphilis with previously undiagnosed hiv infection .
his rpr titer was 1:128 , his cd4 count was preserved , and he responded well clinically and serologically to standard therapy . to our knowledge , this case is the first report of syphilis occurring as tullio phenomenon in an hiv - positive patient .
we suggest that syphilis be considered in patients who have cranial nerve viii symptoms and an appropriate risk - factor profile .
eradicating treponemes may be limited from sanctuary sites such as the cns . because control of syphilis likely depends not only on antimicrobial effect but also on host immune response ,
awareness of unusual symptoms of a relatively common disease will benefit not only the patient but also public health efforts in managing both syphilis and hiv infection .
preventive and educational efforts focused on men who have sex with men may prove particularly important in modifying behaviors that foster the growth of both epidemics .
 the incidence of syphilis has consistently increased from 2000 to 2002 . 
 we report a case of acquired syphilis with symptoms of tullio phenomenon in a patient concurrently diagnosed with hiv infection . 
 the resurgence of syphilis in hiv - positive groups at high risk has public health implications for prevention of both diseases . 
The Case
Conclusions