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Grand Rounds

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

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Grand Rounds

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  1. 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

  6. 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

  7. 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

  8. Ocular examination

  9. Differential Diagnosis

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

  11. 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

  12. Our patient • CXR - old granulomatous disease; no active lesion • ACE - wnl • PPD – negative • RPR - positive • FTA-ABS – reactive • TPPA – reactive • HIV – negative • Cultures - negative

  13. 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

  14. 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

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

  16. Syphilis: epidemiology

  17. Syphilis: epidemiology

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

  19. Syphilis: stages • Secondary: -6 weeks to 6 months after chancre -develop in 25% untreated patients -hematogenous spread -maculopapular rash (70%)

  20. Syphilis: stages • Secondary: -lymphadenopathy, HA, malaise, joint pain, mouth ulcers, hair loss -resolve spontaneously but 25% recurrent -10% ocular findings

  21. 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

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

  23. Syphilis: Ocular • Congenital -pigmentary retinopathy -interstitial keratitis -cataracts

  24. 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

  25. 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)

  26. Syphilis: Ocular

  27. Syphilis: Ocular

  28. Syphilis: Ocular

  29. 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

  30. 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+

  31. Syphilis: workup

  32. 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

  33. 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

  34. 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

  35. 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.

  36. Good luck, applicants!

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