Grand Rounds
Prat Itharat MDDecember 1, 2006
Vanderbilt Eye Institute
History 49 year old Caucasian male “red eye” for 3 days Questions?
History Redness in left eye for 3 days Gradual onset of redness OS Associated with photophobia, tearing Blurry vision OS Global headache, 4/10 No flashes, floaters No nausea, vomiting
History POH: no lasers/surgeries/trauma PMH: chronic sinusitis, GERD,
seasonal allergies PSH: negative FH: no glaucoma SH: 1ppd cig; +etoh; no ivda
History Allg: nkda Meds: ranitidine, loratadine,
mometasone, citalopram ROS: fevers, chills, sore throat,
cough; no back pain
Ocular examination
VAsc OD: 20/60
OS: 20/400 PH 20/200 Pupils: no rapd Ta: OD 26 OS 20 Motility: full ou CVF: full ou Ext: wnl ou
Ocular examination
SLEl/l: wnl ouconj: quiet od; 2+injection oscornea: clear oua/c: d+q od; 2+cells osiris: intact oulens: 1+nsc ouant vit: quiet od; +1 cells os
Ocular examination
Differential Diagnosis
Differential Diagnosis
Toxoplasmosis Syphilis Tuberculosis Fungal – cryptococcal, pneumocystis
carinii Sarcoidosis Lymphoma Bacterial endophthalmitis Acute retinal necrosis Metastases Lyme, cat-scratch
Our patient
Empirically started on sulfadiazine, pyrimethamine and folinic acid for toxoplasmosis
CXR, ACE, RPR, HIV, CBC, PPD Returned twice within the week
without improvement Blood cultures obtained
Our patient
CXR - old granulomatous disease; no active lesion
ACE - wnl PPD – negative RPR - positive FTA-ABS – reactive TPPA – reactive HIV – negative Cultures - negative
Our patient
Further questioning-syphilis 1970s – “I don’t know how”-red rash below waist -”blister” on arch of foot-since 7/1/06, has not been feeling well, treated by outside facility without improvement
Our patient
Poor follow-up CDC notified Received 2.5M units PCN IM weekly
x3 VA improved; constitutional
symptoms improved; no pain, photophobia
Scheduled to follow up at VA clinic
Syphilis
Spirochete bacterium Treponema pallidum
0.18 microns in width; 5-15 microns long
Sexual transmission most common Transplacental transmission
Syphilis: epidemiology
Syphilis: epidemiology
Syphilis: stages
Primary: -after 10-90 days incubation (3 weeks avg)-painless chancre at site of inoculation-lymphadenopathy-resolve spontaneously in 4 weeks
Syphilis: stages
Secondary: -6 weeks to 6 months after chancre-develop in 25% untreated patients-hematogenous spread-maculopapular rash (70%)
Syphilis: stages
Secondary: -lymphadenopathy, HA, malaise, joint pain, mouth ulcers, hair loss-resolve spontaneously but 25% recurrent-10% ocular findings
Syphilis: stages
Latent phase Tertiary stage (40% untreated)
-vasculitis-local granulomatous reaction = gumma-cardiac: aortitis/aortic insufficiency/aneurysm-neuro: tabes dorsalis, general paresis, meningitis, stroke
*CNS findings may present early
Syphilis: ocular
Young et al. Ocular Manifestations and treatment of syphilis. Seminars in Ophthalmology 20(2005): 161-167.
Syphilis: Ocular
Congenital-pigmentary retinopathy -interstitial keratitis-cataracts
Syphilis: Ocular
Uveitis most common presentation May occur as soon as 6 weeks or in
latent phase Granulomatous or non-
granulomatous Unilateral or bilateral Prior to 1940, second most common
cause of uveitis Only 2.45% of cases (Tamesis and
Foster); others 1-2% of uveitis Iris atrophy, nodules, roseola
Syphilis: Ocular
Chorioretinitis: posterior pole/mid-periphery
Lesions usually ½ to 1 DD but can be confluent
Variable amount of vitritis May be associated with vasculitis,
papillitis, serous RD, BRVO, necrotizing retinitis
May just involve RPE (syphilitic posterior placoid chorioretinitis)
Syphilis: Ocular
Syphilis: Ocular
Syphilis: Ocular
Syphilis: Ocular
Argyll Robertson pupil Miotic, irregular Light-near dissociation Interruption of fibers from pretectum
to EW nuclei Also seen ms, dm, chronic
alcoholism, encephalitis
Syphilis: workup
Definitive: darkfield microscopy or direct fluorescent antibody of tissue/exudate
Non-treponemal tests: RPR/VDRL Treponemal tests FTA-ABS/TP-PA PCR HIV: may cause false negative CSF: in HIV+
Syphilis: workup
Syphilis: treatment
Primary, secondary, early latent: benzathine penicillin G 2.4M units IMx1
Late latent, uncertain duration, tertiary syphilis: penicillin G 2.4M units IMx3 (weekly)
Alternatives: doxycycline 100mg BID for 2/4 weeks or tetracycline 500mg QID for 2/4 weeks
Neurosyphilis: aqueous penicillin G 3-4M units IV Q4H for 10-14 days
Syphilis: treatment
Jarisch-Herxheimer reaction: hypersensitivity reaction to antigens
Fever, myalgia, headache, malaise May be associated with worsening
ocular findings May been avoided with steroids
Syphilis: treatment
VDRL/RPR does not respond in all treated
97% of primary stage 77% of secondary stage VDRL usually positive for life FTA-ABS positive for life
Bibliography Knox, David. Retinal syphilis and tuberculosis. Chapter 100.
Retina (1994): Mosby 1633-1641. Uptodate Clinical Medicine Exposto et al. Evaluation of the Treponema pallidum Particle
Agglutination Technique (Tppa) in the diagnosis for neurosyphilis. J Clin Lab Analysis 20 (2006):233-238.
Szilard Kiss, Francisco Max Damico, and Lucy H Young. Ocular Manifestations and Treatment of Syphilis. Seminars in Ophthal 20(2005): 161-167.
Lehoang, et al. Syphilic Uveitis in patients infected with human immunodeficiency virus. Graefe Arch Clin Exp Ophthal 243(2005): 863-869.
Rao et al. Syphilis: Reemergence of an Old Adversary. Ophthal 113:11(2006): 2074-2079.
Margo, CE and Hamed LM. Ocular Syphilis. Survey of Ophthal 37:3(1992): 203-220.
Good luck, applicants!