Grand Rounds

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Grand Rounds

• Prat Itharat MD
• December 1, 2006
• Vanderbilt Eye Institute

2
History

• 49 year old Caucasian male
• red eye for 3 days
• Questions?

3
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

4
History

• POH no lasers/surgeries/trauma
• PMH chronic sinusitis, GERD, seasonal allergies
• PSH negative
• FH no glaucoma
• SH 1ppd cig etoh no ivda

5
History

• Allg nkda
• Meds ranitidine, loratadine, mometasone,
  citalopram
• ROS fevers, chills, sore throat, cough no back
  pain

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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

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Ocular examination

• SLE
• l/l wnl ou
• conj quiet od 2injection os
• cornea clear ou
• a/c dq od 2cells os
• iris intact ou
• lens 1nsc ou
• ant vit quiet od 1 cells os

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Ocular examination
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Differential Diagnosis
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Differential Diagnosis

• Toxoplasmosis
• Syphilis
• Tuberculosis
• Fungal cryptococcal, pneumocystis carinii
• Sarcoidosis
• Lymphoma
• Bacterial endophthalmitis
• Acute retinal necrosis
• Metastases
• Lyme, cat-scratch

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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

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Our patient

• CXR - old granulomatous disease no active lesion
• ACE - wnl
• PPD negative
• RPR - positive
• FTA-ABS reactive
• TPPA reactive
• HIV negative
• Cultures - negative

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Our patient

• Further questioning
• -syphilis 1970s I dont 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

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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

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Syphilis

• Spirochete bacterium Treponema pallidum
• 0.18 microns in width 5-15 microns long
• Sexual transmission most common
• Transplacental transmission

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Syphilis epidemiology
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Syphilis epidemiology
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Syphilis stages

• Primary
• -after 10-90 days incubation (3 weeks avg)
• -painless chancre at site of inoculation
• -lymphadenopathy
• -resolve spontaneously in 4 weeks

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Syphilis stages

• Secondary
• -6 weeks to 6 months after chancre
• -develop in 25 untreated patients
• -hematogenous spread
• -maculopapular rash (70)

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Syphilis stages

• Secondary
• -lymphadenopathy, HA, malaise, joint pain, mouth
  ulcers, hair loss
• -resolve spontaneously but 25 recurrent
• -10 ocular findings

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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

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Syphilis ocular
Young et al. Ocular Manifestations and treatment
of syphilis. Seminars in Ophthalmology
20(2005) 161-167.
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Syphilis Ocular

• Congenital
• -pigmentary retinopathy
• -interstitial keratitis
• -cataracts

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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

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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)

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Syphilis Ocular
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Syphilis Ocular
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Syphilis Ocular
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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

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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

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Syphilis workup
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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

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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

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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

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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 11311(2006) 2074-2079.
• Margo, CE and Hamed LM. Ocular Syphilis. Survey
  of Ophthal 373(1992) 203-220.

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Good luck, applicants!