Teaching NeuroImages: Gummatous neurosyphilis: An atypical presentation in a patient with HIV

A 29-year-old HIV-infected man, on antiretroviral treatment with negative viral load and a low CD4+ T-cell count (344/mm3), presented with right eyelid ptosis and diplopia. On examination, right pupil was dilated, without reaction to light or accommodation. Extraocular movements were impaired in all directions, except abduction.