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Grand Rounds Prat Itharat MD December 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 SLE l/l: wnl ou conj: quiet od; 2+injection os cornea: clear ou a/c: d+q od; 2+cells os iris: intact ou lens: 1+nsc ou ant 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/midperiphery 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!