Ocular Syphilis Edward Goodman MD

Skin Rash and Visual Loss: “Looking for Love in All the Wrong Places” Clinical Conference July 28, 2004 Edward L. Goodman, MD Case 1 History • 57 year old divorced man referred to evaluate optic neuritis and skin rash. • He became ill three weeks earlier with febrile illness, myalgias and skin rash. His internist evaluated him and obtained normal CBC, CMP. • Shortly after, he had visual symptoms and saw an opthalmologist who diagnosed unilateral optic neuritis with visual field loss • Fever resolved but rash, fatigue, myalgias and visual loss persisted. Exam • VS were normal. • Skin had generalized reticular rash not involving palms or soles • Bilateral shoddy axillary nodes • Normal heart, lungs, abdomen, neurologic Lab • Normal CBC, CMP, CRP • Negative Toxo, HCV, HBV, CMV, HIV serologies • Negative blood culture • RPR 1:128 • CSF: 48 WBC (80% LM), protein 96, VDRL negative Course • Hospitalized overnight to obtain CSF and start intravenous penicillin • Completed 14 days IV penicillin as outpatient - 3 mu IV Q4H followed by one dose of Bicillin 2.4 mu • Complete resolution of rash and visual sx • Asymptomatic permanent isolated field loss • Refused follow-up LP Sequential Serology’s Date 10/1/03 1/27/04 Serum RPR 1:128 1:4 5/05/04 1:1 Case 2 History • 33 year old man referred 2/18/04 for rash and visual loss • 10/03 diagnosed as uveitis; + RPR and referred to Ft Worth ID physician; never went (couldn’t afford) • Fever, skin rash, progressive visual loss • Seen in office and admitted Exam • • • • Temp 100.2, HR 104 Cloudy vitreous, white patches in pharynx Skin rash all over including palms and soles Penile ulcer Lab • Normal CBC, low albumin • RPR 1:128; HIV and Western Blot + • CSF: 178 WBC (98% mononuclear), protein 79, glucose 33, VDRL 1:16 • Penile lesion: grew HSV • CD4 259, HIV viral load 190,000 Course • Admit to hospital for CSF and penicillin • 14 days of IV penicillin in hospital (self pay) – Herxheimer reaction first night • Rash transiently worsened • Fever transiently higher – Bicillin at end of 14 days • Valtrex for HSV: resolved • Defer HAART for fear of IRIS • LOST TO FOLLOW UP! Clinical Stages and Presentation of Syphilis Typical Rash of Secondary Syphilis Plantar Syphilid in Secondary Syphilis Mucous Patch CSF in Syphilis Kinghorn in Cohen and Powderly 2004 CSF in Posterior Segment Ocular Syphilis Browning.Opthalmology Nov 2000. • 14 patients with posterior segment ocular syphilis • 12/14 positive RPR (14/14 + FTA-ABS) • CSF examined in 10 – VDRL: + 3/9 – Pleocytosis: 4/9 – Protein elevated: 4/9 Ocular Syphilis • Can involve all areas of the eye – Conjunctiva – Iritis/iridocyclitis – Chorioretinitis – Posterior uveitis – Neuroretinitis • Evolving syndromes associated with HIV Ocular Syphilis Aldave AJ et al. Curr Opin Opthalmol 2001 Dec;12(6):433-41 Secondary Conjunctiva Sclera Cornea Tertiary Granulomatous Scleritis Stromal keratitis, precipitates Cataracts Papillary Episcleritis Marginal infiltrates, precipitates Cataracts Lens Ocular Syphilis Aldave et al Secondary Tertiary Uveal tract Iridocyclitis, Chorioretinitis, vascularized iris gummas nodules,isolated vitritis, chroioretinitis Ocular Syphilis Secondary Tertiary Retina Optic Nerve Necrotizing neuroretinitis, retinochoroid, vasculitis, serous retinal detachment Disc edema, Papilledema same Same plus atrophy, gumma Ocular Syphilis Secondary IOP Pupils Tertiary glaucoma Argyl Robertson Glaucoma EOM Various palsies Various palsies Optic Neuritis Differential Dx of Acute Unilateral Optic Neuropathy Specific Causes of Neuroretinitis • • • • • • Viral and post viral Sarcoidosis Systemic Lupus and other vasculitides Syphilis Lyme Disease OI’s complicating HIV/AIDS Optic Disc Edema and Macular Star in 13 yo girl with Bartonella Neuroretinitis Interaction between Syphilis and HIV Cohen and Powderly 2004 Syphilis in MSM San Francisco Syphilis in MSM Los Angeles CDC 2002 STD Guidelines Bibliography • Aldave A, King J, Cunningham E. Ocular Syphilis. Curr Opin Opthalmol. 2001 Dec;12(6):433-41. • Balcer L, Beck R. Inflammatory Optic Neuropathies and Neuroretinitis. Yanoff Opthalmology, 2nd ed. 2004; pp. 1263-74. • Browning DJ. Posterior Segment Manifestations of Active Ocular Syphilis, Their Response to a Neurosyphilis Rgimen of Penicillin Therapy, and the Influence of HIV Status on Response. Ophthalmology 2000;107:2015-2023. • CDC.STD Treatment Guidelines 2002. MMWR 2002;51 (No RR-6): 18-29. Bibliography • CDC. Trends in Primary and Secondary Syphilis and HIV Infection in MSM – San Francisco and Los Angeles, California. MMWR 2004;53:575578 • Dugel P, Thach A. Syphilitic Uveitis. Yanoff: pp. 1135-44. • Kinghorn GR. Syphilis in Cohen and Powderley. Infectious Diseases 2004: Elsevier, pp. 807-816