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Skin Rash and Visual Loss: “Looking for Love in All the Wrong Places”

Clinical conference discussing two cases of skin rash, visual loss, and other symptoms, ultimately diagnosed as syphilis. Covers the clinical stages, presentation, and ocular manifestations of syphilis.

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Skin Rash and Visual Loss: “Looking for Love in All the Wrong Places”

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  1. Skin Rash and Visual Loss:“Looking for Love in All the Wrong Places” Clinical Conference July 28, 2004 Edward L. Goodman, MD

  2. Case 1History • 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.

  3. Exam • VS were normal. • Skin had generalized reticular rash not involving palms or soles • Bilateral shoddy axillary nodes • Normal heart, lungs, abdomen, neurologic

  4. 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

  5. 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

  6. Sequential Serology’s

  7. Case 2History • 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

  8. Exam • Temp 100.2, HR 104 • Cloudy vitreous, white patches in pharynx • Skin rash all over including palms and soles • Penile ulcer

  9. 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

  10. 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!

  11. Clinical Stages and Presentation of Syphilis

  12. Typical Rash of Secondary Syphilis

  13. Plantar Syphilid in Secondary Syphilis

  14. Mucous Patch

  15. CSF in SyphilisKinghorn in Cohen and Powderly 2004

  16. CSF in Posterior Segment Ocular SyphilisBrowning.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

  17. Ocular Syphilis • Can involve all areas of the eye • Conjunctiva • Iritis/iridocyclitis • Chorioretinitis • Posterior uveitis • Neuroretinitis • Evolving syndromes associated with HIV

  18. Ocular SyphilisAldave AJ et al. Curr Opin Opthalmol 2001 Dec;12(6):433-41

  19. Ocular SyphilisAldave et al

  20. Ocular Syphilis

  21. Ocular Syphilis

  22. Optic Neuritis

  23. Differential Dx of Acute Unilateral Optic Neuropathy

  24. Specific Causes of Neuroretinitis • Viral and post viral • Sarcoidosis • Systemic Lupus and other vasculitides • Syphilis • Lyme Disease • OI’s complicating HIV/AIDS

  25. Optic Disc Edema and Macular Star in 13 yo girl with Bartonella Neuroretinitis

  26. Interaction between Syphilis and HIV Cohen and Powderly 2004

  27. Syphilis in MSM San Francisco

  28. Syphilis in MSM Los Angeles

  29. CDC 2002 STD Guidelines

  30. 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.

  31. Bibliography • CDC. Trends in Primary and Secondary Syphilis and HIV Infection in MSM – San Francisco and Los Angeles, California. MMWR 2004;53:575-578 • Dugel P, Thach A. Syphilitic Uveitis. Yanoff: pp. 1135-44. • Kinghorn GR. Syphilis in Cohen and Powderley. Infectious Diseases 2004: Elsevier, pp. 807-816

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