Transcript Grand Rounds

Grand Rounds
Prat Itharat MD
December 1, 2006
Vanderbilt Eye Institute
History
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49 year old Caucasian male
“red eye” for 3 days
Questions?
History
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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
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POH: no lasers/surgeries/trauma
PMH: chronic sinusitis, GERD, seasonal
allergies
PSH: negative
FH: no glaucoma
SH: 1ppd cig; +etoh; no ivda
History
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Allg: nkda
Meds: ranitidine, loratadine, mometasone,
citalopram
ROS: fevers, chills, sore throat, cough; no
back pain
Ocular examination
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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
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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
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Toxoplasmosis
Syphilis
Tuberculosis
Fungal – cryptococcal, pneumocystis carinii
Sarcoidosis
Lymphoma
Bacterial endophthalmitis
Acute retinal necrosis
Metastases
Lyme, cat-scratch
Our patient
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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
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CXR - old granulomatous disease; no active
lesion
ACE - wnl
PPD – negative
RPR - positive
FTA-ABS – reactive
TPPA – reactive
HIV – negative
Cultures - negative
Our patient
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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
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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
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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
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Primary:
-after 10-90 days incubation (3 weeks avg)
-painless chancre at site of inoculation
-lymphadenopathy
-resolve spontaneously in 4 weeks
Syphilis: stages
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Secondary:
-6 weeks to 6 months after chancre
-develop in 25% untreated patients
-hematogenous spread
-maculopapular rash (70%)
Syphilis: stages
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Secondary:
-lymphadenopathy, HA, malaise, joint pain,
mouth ulcers, hair loss
-resolve spontaneously but 25% recurrent
-10% ocular findings
Syphilis: stages
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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
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Congenital
-pigmentary retinopathy
-interstitial keratitis
-cataracts
Syphilis: Ocular
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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
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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
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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
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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
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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
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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
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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
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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.
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