Neurosyphilis is the progression of the untreated sexually transmitted infection caused by Treponema pallidum. When the initial infection is not adequately treated, progression of primary syphilis can lead to a wide variety of serious health sequelae. While neurosyphilis can appear up to 10-30 years after the initial infection, syphilis can invade the nervous system at any stage of infection and can imitate symptoms of many other diseases. This variety of symptoms is why syphilis has been called “The Great Pretender” or “The monkey among diseases” (12). This is a case report of an 83-year-old female with a history of multiple TIAs, dementia, and breast cancer who presented to the emergency department with complaints of her head “not feeling right” and intermittent ataxia. The patient underwent further work-up, demonstrating negative brain imaging for cerebral vascular accident and laboratory findings negative initially, for acute infection. An RPR was drawn as part of an broadened altered mental status workup as patient/family reported patient was not at baseline and was positive with a quantitative titer of 1:8. Fluorescent treponemal antibody absorption (FTA-ab) was found to be positive as well. The patient was started on three million units intravenous Penicillin G every four hours and was discharged with a peripherally inserted central catheter in order to receive two weeks of Rocephin at two grams daily. Through this case, we hope to provide information on neurosyphilis and its differentiation from other disease processes and when neurosyphilis should be suspected during an evaluation of altered mental status.

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