Background Tabes dorsalis is a neurological form of tertiary syphilis and is considered to be rare in the post antibiotic era. It results from damage to nerve cells in the dorsal column and roots of the spinal cord. It is characterised by sensory ataxia, lightening pains and urinary incontinence. If left untreated it can progress to paralysis and dementia.

Case summary We present the case of an HIV positive 47 year old male with a CD4 count of 400 and an undetectable viral load on HAART. He presented with an 8 month history of progressively severe lightening pains, gait disturbance, tinnitus, hearing loss, and urinary incontinence. He had a positive plasma VDRL with a titre of 1:32, and his CSF was VDRL positive. Whole spine MRI scan demonstrated high signal in the dorsal cord with associated atrophy. He was treated with intravenous benzylpenicillin 2.4 grams 4 hourly for 14 days. Follow up at 4 and 8 months demonstrated marked clinical improvement with a falling serum VRDL titre. Repeat LP at 6 month post treatment demonstrated VDRL negativity.

Discussion Tabes Dorsalis may still occur in the post antibiotic era. Early recognition and appropriate treatment can lead to good clinical outcomes.