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Park SW, Kim KH, Kwon HJ, Byon IS, Khan YH, Nguyen QD. Ocular syphilis masquerading as refractory retinal diseases. BMC Infect Dis 2024; 24:165. [PMID: 38326787 PMCID: PMC10848460 DOI: 10.1186/s12879-023-08739-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 10/23/2023] [Indexed: 02/09/2024] Open
Abstract
PURPOSE To report two cases of syphilis masquerading as chronic refractory macular diseases. CASE DESCRIPTIONS Two patients had been diagnosed with neovascular age-related macular degeneration (neovascular AMD) and diabetic macular edema (DME), respectively. The disease worsened despite repeated intravitreal injections of anti-vascular endothelial growth factor (VEGF) and also surgical treatment (in suspected case of DME). Systemic evaluations were positive for syphilis. Intravenous penicillin was started, and the macular diseases improved. The lesions were well controlled afterward. CONCLUSIONS The current two cases demonstrated that ocular syphilis can masquerade as refractory chronic retinal diseases such as DME and neovascular AMD. Laboratory evaluations for syphilis may be needed, not only for uveitis but also for refractory retinal diseases. Indocyanine green angiography may be helpful to reveal occult syphilis.
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Affiliation(s)
- Sung Who Park
- Department of Ophthalmology, School of Medicine, Pusan National University, Busan, South Korea
- Medical Research Institute, School of Medicine, Pusan National University Hospital, Busan, South Korea
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA
| | - Kye-Hyung Kim
- Department of Infection, School of Medicine, Pusan National University, Busan, South Korea
| | - Han Jo Kwon
- Department of Ophthalmology, School of Medicine, Pusan National University, Busan, South Korea
- Medical Research Institute, School of Medicine, Pusan National University Hospital, Busan, South Korea
| | - Ik Soo Byon
- Department of Ophthalmology, School of Medicine, Pusan National University, Busan, South Korea
- Medical Research Institute, School of Medicine, Pusan National University Hospital, Busan, South Korea
| | - Youan Hasan Khan
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA
| | - Quan Dong Nguyen
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, 2370 Watson Court, Suite 200, Palo Alto, CA, 94303, USA.
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Vieira R, Furtado MJ. Long-Term Bilateral Poorly Treated Acute Syphilitic Posterior Placoid Chorioretinitis Complicated with Choroidal Neovascularization: A Case Report. Int Med Case Rep J 2022; 15:543-549. [PMID: 36212618 PMCID: PMC9532261 DOI: 10.2147/imcrj.s369324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/06/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To describe a case of long-term poorly treated bilateral acute syphilitic posterior placoid chorioretinitis (ASPPC) complicated with choroidal neovascularization, with a multimodal imaging approach. Patients and Methods Retrospective case report. Analysis of patient’s clinical data. Case Report A healthy 66-year-old man complained of decreased visual acuity in the right eye (RE). He had a past history of bilateral exudative maculopathy of unknown etiology, lasting for more than 10 years and leading to severe and irreversible vision loss on the left eye. The corrected distance visual acuity (CDVA) was 20/63 on the RE and <20/400 on the left eye (LE). On slit-lamp, no anterior chamber reaction was observed, a vitreous haze was present on the RE as well as large, bilateral yellowish lesions in the macula, with exuberant macular atrophy, particularly on the LE. These well-defined lesions were confined to the posterior pole. The spectral domain optical coherence tomography (SD-OCT) showed a flat retinal pigmented epithelium (RPE) detachment with hyperreflective material beneath the RPE and cystoid macular edema on the RE and an exuberant macular atrophy on the LE, with both eyes showing anomalous enlargement of choroidal vessels. The fluorescein angiography showed general hypofluorescence and indocyanine green angiography revealed a heterogeneous pattern. The OCT angiography (OCTA) of the RE demonstrated an anomalous vascular network related to the presence of choroidal neovascularization (CNV). An etiological study was performed and a positive treponemal test (TPHA) was found. The patient experienced visual acuity improvement to 20/25 after systemic treatment with Penicillin and anti-VEGF injections. Conclusion Clinical data and multimodal imaging information suggest that this case represents a complication of long-term untreated bilateral acute syphilitic posterior placoid chorioretinitis (ASPPC) with associated choroidal neovascularization. Once the RE presented signs of active disease, besides intravitreal anti-VEGF, treatment of the underlying disease was essential for visual recovery.
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Affiliation(s)
- Rita Vieira
- Ophthalmology Department of Centro Hospitalar Universitário do Porto (CHUPorto), Oporto, Portugal
- Correspondence: Rita Vieira, Ophthalmology Department of Centro Hospitalar Universitário do Porto (CHUPorto)- Largo do Prof. Abel Salazar, Oporto, 4099-001, Portugal, Tel +351 913748812, Email
| | - Maria João Furtado
- Ophthalmology Department of Centro Hospitalar Universitário do Porto (CHUPorto), Oporto, Portugal
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Schimansky S, Burke T. Case Report: Bilateral Choroidal Neovascular Membranes in a Patient With a Delayed Diagnosis of Acute Syphilitic Posterior Placoid Chorioretinopathy. FRONTIERS IN OPHTHALMOLOGY 2022; 2:890872. [PMID: 38983504 PMCID: PMC11182146 DOI: 10.3389/fopht.2022.890872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 05/24/2022] [Indexed: 07/11/2024]
Abstract
We report the case of a 78-year old man with a delayed diagnosis of syphilis and an advanced phenotype of acute syphilitic posterior placoid chorioretinopathy after receiving 5 months of high dose steroids prior to anti-treponemal treatment. Bilateral choroidal neovascular membranes were present at the time of diagnosis and were successfully treated with intravitreal aflibercept, following completion of anti-treponemal therapy.
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Affiliation(s)
- Sarah Schimansky
- Uveitis and Medical Retina Service, Bristol Eye Hospital, Bristol, United Kingdom
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Wai KM, Gong D, Rodriguez M, Cunningham Jr ET, Vavvas DG, Eliott D. Acute Syphilitic Posterior Placoid Chorioretinitis With Subfoveal Choroidal Neovascularization Managed With Anti-VEGF Therapy. JOURNAL OF VITREORETINAL DISEASES 2022; 6:246-250. [PMID: 35967270 PMCID: PMC9368478 DOI: 10.1177/24741264211057663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE We describe the development and management of choroidal neovascularization (CNV) in a patient with acute syphilitic posterior placoid chorioretinitis (ASPPC). METHODS A retrospective case review is presented. RESULTS A 66-year-old man presented with unilateral blurry vision. He had a history of systemic syphilis infection twice, the last diagnosed 15 years before presentation and treated with intravenous ceftriaxone, resulting in seroreversion of an initially positive rapid plasma reagin (RPR). Examination revealed ASPPC with subfoveal CNV. Repeat testing revealed an RPR titer of 1:16 384. He was treated with 6 monthly intravitreal injections of bevacizumab and systemic antibiotics, resulting in resolution of his ASPPC and regression of his CNV. CONCLUSIONS CNV is a rare complication of ASPPC. Multimodal imaging can be useful to suggest the diagnosis, and prompt treatment with systemic antibiotics and intravitreal anti-vascular endothelial growth factor agents can lead to resolution of ASPPC and regression of CNV, respectively.
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Affiliation(s)
- Karen M. Wai
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Dan Gong
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | | | - Emmett T. Cunningham Jr
- The Francis I. Proctor Foundation, UCSF School of Medicine, San Francisco, CA, USA
- The Department of Ophthalmology, California Pacific Medical Center, San Francisco, CA, USA
- The Department of Ophthalmology, Stanford University School of Medicine, Stanford, CA, USA
| | - Demetrios G. Vavvas
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Dean Eliott
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Giuffrè C, Marchese A, Cicinelli MV, Miserocchi E, Querques G, Bandello F, Modorati G. MULTIMODAL IMAGING AND TREATMENT OF SYPHILITIC CHOROIDAL NEOVASCULARIZATION. Retin Cases Brief Rep 2022; 16:85-88. [PMID: 31425448 DOI: 10.1097/icb.0000000000000912] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE To report a rare case of choroidal neovascularization (CNV) developed 2 years after successful treatment of ocular syphilis, identified by optical coherence tomography angiography. METHODS Case report. RESULTS A 31-year-old man with a history of syphilitic chorioretinitis developed a CNV 2 years after clinical remission of the infection. Structural optical coherence tomography (OCT) and optical coherence tomography angiography were helpful in providing detailed evidence of an extrafoveal CNV in an easy and noninvasive way. In comparison, the identification of CNV on fluorescein angiography was difficult because of the retinal blood barrier breakdown and intense choroidal background fluorescence for diffuse chorioretinal scarring of syphilitic chorioretinitis. The patient underwent 3 intravitreal injections of anti-vascular endothelial growth factor in addition to 25 mg/day of oral prednisone, with the restoration of previous visual acuity. CONCLUSION Choroidal neovascularization is a rare, but sight-threatening complication of syphilitic chorioretinitis. The combination of different imaging modalities, and in particular optical coherence tomography angiography, allowed reaching a definite diagnosis of CNV. Combined treatment of systemic steroid and intravitreal anti-vascular endothelial growth factor was effective in controlling the CNV and improving the visual outcome.
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Affiliation(s)
- Chiara Giuffrè
- Department of Ophthalmology, IRCCS Ospedale San Raffaele, University Vita-Salute San Raffaele, Milan, Italy
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Niederer R, Bar A, Al-Ani H, Sharief L, Sar S, Segal A, Lightman S, Tomkins-Netzer O. Management of inflammatory choroidal neovascular membranes. EXPERT REVIEW OF OPHTHALMOLOGY 2020. [DOI: 10.1080/17469899.2021.1842196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Rachael Niederer
- University of Auckland, Auckland District Health Board, Auckland, New Zealand
| | - Asaf Bar
- Department of Ophthalmology, Wolfson Medical Centre, Tel Aviv-Yafo, Israel
| | - Haya Al-Ani
- University of Auckland, Auckland District Health Board, Auckland, New Zealand
| | - Lazha Sharief
- UCL/Institute of Ophthalmology and Moorfileds Eye Hospital, London, UK
| | - Shaul Sar
- Department of Ophthalmology, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Adi Segal
- Department of Ophthalmology, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Sue Lightman
- UCL/Institute of Ophthalmology and Moorfileds Eye Hospital, London, UK
| | - Oren Tomkins-Netzer
- Department of Ophthalmology, Lady Davis Carmel Medical Center, Haifa, Israel
- Ruth and Bruch Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, Israel
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MULTIMODAL IMAGING OF CHOROIDAL LESIONS IN DISSEMINATED MYCOBACTERIUM CHIMAERA INFECTION AFTER CARDIOTHORACIC SURGERY. Retina 2020; 39:452-464. [PMID: 29206759 DOI: 10.1097/iae.0000000000001991] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To explore morphologic characteristics of choroidal lesions in patients with disseminated Mycobacterium chimaera infection subsequent to open-heart surgery. METHODS Nine patients (18 eyes) with systemic M. chimaera infection were reviewed. Activity of choroidal lesions were evaluated using biomicroscopy, fundus autofluorescence, enhanced depth imaging optical coherence tomography, fluorescein angiography/indocyanine green angiography, and optical coherence tomography angiography. Relationships of choroidal findings to systemic disease activity were sought. RESULTS All 9 male patients, aged between 49 and 66 years, were diagnosed with endocarditis and/or aortic graft infection. Mean follow-up was 17.6 months. Four patients had only inactive lesions (mild disease). In all five patients (10 eyes) with progressive ocular disease, indocyanine green angiography was superior to other tests for revealing new lesions and active lesions correlated with hyporeflective choroidal areas on enhanced depth imaging optical coherence tomography. One eye with a large choroidal granuloma developed choroidal neovascularization. Optical coherence tomography angiography showed areas with reduced perfusion at the inner choroid. All 5 patients with progressive ocular disease had evidence of systemic disease activity within ±6 weeks' duration. CONCLUSION Choroidal manifestation of disseminated M. chimaera infection indicates systemic disease activity. Multimodal imaging is suitable to recognize progressive ocular disease. We propose ophthalmologic screening examinations for patients with M. chimaera infection.
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Majumder PD, Mayilvakanam L, Palker AH, Sridharan S, Biswas J. Intravitreal sustained-release dexamethasone implant for the treatment of persistent cystoid macular edema in ocular syphilis. Indian J Ophthalmol 2019; 67:1487-1490. [PMID: 31436209 PMCID: PMC6727693 DOI: 10.4103/ijo.ijo_1795_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 04/09/2019] [Indexed: 12/20/2022] Open
Abstract
With a resurgence of syphilis with human immunodeficiency virus (HIV) infection in last few years, various ocular manifestations of syphilis have been described in literature. This case report described an HIV-positive patient on anti-retroviral therapy who was diagnosed and treated for posterior uveitis secondary to ocular syphilis in the recent past presented to our clinic with cystoid macular edema (CME). CME, which did not respond to periocular corticosteroid, resolved with intravitreal sustained release dexamethasone implant. There was a recurrence CME 9 months later and repeat injection of intravitreal implant showed complete resolution. A long-term follow-up did not reveal reactivation of the infection with intravitreal corticosteroid. Intravitreal sustained release dexamethasone implant can be an effective treatment for refractory CME in patients with regressed syphilitic uveitis.
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Affiliation(s)
| | - Lakshmi Mayilvakanam
- Department of Uvea and Medical Retina, Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Amit H Palker
- Department of Uvea and Medical Retina, Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Sudharshan Sridharan
- Department of Uvea, Medical and Vision Research Foundations, Chennai, Tamil Nadu, India
| | - Jyotirmay Biswas
- Department of Uvea, Medical and Vision Research Foundations, Chennai, Tamil Nadu, India
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Abstract
There are a number of autoimmune disorders which can affect visual function. There are a very large number of mechanisms in the visual pathway which could potentially be the targets of autoimmune attack. In practice it is the retina and the anterior visual pathway (optic nerve and chiasm) that are recognised as being affected in autoimmune disorders. Multiple Sclerosis is one of the commonest causes of visual loss in young adults because of the frequency of attacks of optic neuritis in that condition, however the basis of the inflammation in Multiple Sclerosis and the confirmation of autoimmunity is lacking. The immune process is known to be highly unusual in that it is not systemic and confined to the CNS compartment. Previously an enigmatic partner to Multiple Sclerosis, Neuromyelitis Optica is now established to be autoimmune and two antibodies - to Aquaporin4 and to Myelin Oligodendrocyte Glycoprotein - have been implicated in the pathogenesis. The term Chronic Relapsing Inflammatory Optic Neuropathy is applied to those cases of optic neuritis which require long term immunosuppression and hence are presumed to be autoimmune but where no autoimmune pathogenesis has been confirmed. Optic neuritis occurring post-infection and post vaccination and conditions such as Systemic Lupus Erythematosus and various vasculitides may cause direct autoimmune attack to visual structures or indirect damage through occlusive vasculopathy. Chronic granulomatous disorders such as Sarcoidosis affect vision commonly by a variety of mechanisms, whether and how these are placed in the autoimmune panoply is unknown. As far as the retina is concerned Cancer Associated Retinopathy and Melanoma Associated Retinopathy are well characterised clinically but a candidate autoantibody (recoverin) is only described in the former disorder. Other, usually monophasic, focal retinal inflammatory disorders (Idiopathic Big Blind Spot Syndrome, Acute Zonal Occult Outer Retinopathy and Acute Macular Neuroretinitis) are of obscure pathogenesis but an autoimmune disorder of the post-infectious type is plausible. Visual loss in autoimmunity is an expanding field: the most significant advances in research have resulted from taking a well characterised phenotype and making educated guesses at the possible molecular targets of autoimmune attack.
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Affiliation(s)
- Axel Petzold
- The Dutch Expert Center for Neuro-ophthalmology, VU University Medical Center, Amsterdam, The Netherlands and Molecular Neuroscience, UCL Institute of Neurology, London, UK
| | - Sui Wong
- Moorfields Eye Hospital and St. Thomas' Hospital, London, UK
| | - Gordon T Plant
- Moorfields Eye Hospital, The National Hospital for Neurology and Neurosurgery and St. Thomas' Hospital, London, UK.
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Peripapillary choroidal neovascularisation in the context of ocular syphilis is sensitive to combination antibiotic and corticosteroid treatment. Int Ophthalmol 2012; 33:159-62. [DOI: 10.1007/s10792-012-9641-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 09/19/2012] [Indexed: 11/26/2022]
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Rouvas A, Petrou P, Maselos S, Douvali M, Vergados I, Markomichelakis N. Retinal angiomatous proliferation (RAP) in a 42-year-old woman with syphilitic retinitis. Ocul Immunol Inflamm 2010; 17:361-3. [PMID: 19831573 DOI: 10.3109/09273940903090189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To present a case of a young individual with retinal angiomatous proliferation (RAP) on the background of syphilitic retinitis. METHODS/DESIGN Interventional case report. RESULTS A 42-year-old Caucasian with confirmed diagnosis of syphilitic retinitis in both eyes revealed the existence of RAP in the RE that responded well to one session of intravitreal triamcinolone acetonide and photodynamic therapy. CONCLUSION To the best of our knowledge this is the first report of RAP in such a young individual. Further research is required in order to examine the possibility of inflammation playing a role in the pathophysiology of RAP.
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Affiliation(s)
- Alexander Rouvas
- Athens University, Ophthalmology Department, ATTIKON Hospital, Athens, Greece.
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Abstract
Retinal vasculitis is a sight-threatening intraocular inflammation affecting the retinal vessels. It may occur as an isolated ocular condition, as a manifestation of infectious or neoplastic disorders, or in association with a systemic inflammatory disease. The search for an underlying etiology should be approached in a multidisciplinary fashion based on a thorough history, review of systems, physical examination, and laboratory evaluation. Discrimination between infectious and noninfectious etiologies of retinal vasculitis is important because their treatment is different. This review is based on recently published articles on retinal vasculitis and deals with its clinical diagnosis, its link with systemic diseases, and its laboratory investigation.
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Affiliation(s)
- Ahmed M Abu El-Asrar
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
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Ho AC, Guyer DR, Yannuzzi LA, Brown GC. Ocular Syphilis: Classic Manifestations and Recent Observations. Semin Ophthalmol 2009. [DOI: 10.3109/08820539309060210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Tran THC, Cassoux N, Bodaghi B, Fardeau C, Caumes E, Lehoang P. Syphilitic uveitis in patients infected with human immunodeficiency virus. Graefes Arch Clin Exp Ophthalmol 2005; 243:863-9. [PMID: 16158310 DOI: 10.1007/s00417-005-1137-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2004] [Revised: 12/21/2004] [Accepted: 01/05/2005] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND This work investigates the incidence and clinical features of syphilitic uveitis in patients infected with human immunodeficiency virus (HIV). MATERIAL AND METHODS We retrospectively reviewed syphilitic uveitis in patients coinfected with HIV that presented at a referral center between July 2001 and November 2003. RESULTS Twelve patients (20 eyes) were included. The ocular manifestations of syphilis led to the discovery of HIV-1 seropositivity in three patients. All patients were male and homosexual. One patient has been previously treated for syphilis with benzathine penicillin G. One patient presented with anterior uveitis and 11 patients had panuveitis or posterior uveitis. Necrotizing retinitis was noted in seven eyes (35%), posterior placoid chorioretinitis in six eyes (30%) and optic nerve involvement in five eyes (25%). Of nine patients with available cerebrospinal fluid (CSF) studies, seven (77.8%) had CSF abnormalities. Eleven patients were treated with intravenous penicillin G and one with intravenous ceftriaxone sodium. One patient required a second course of antibiotics to control uveitis. Ocular inflammation decreased and visual acuity improved in all nine patients for whom follow-up was available after treatment. CONCLUSION Manifestations of syphilitic uveitis in HIV-infected patients are multiple, with high frequencies of posterior uveitis, posterior placoid chorioretinitis, necrotizing retinitis and optic nerve involvement. Syphilitic uveitis in HIV-infected patients seems to have a more severe course and may relapse despite high-dose intravenous penicillin therapy.
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Affiliation(s)
- Thi Ha Chau Tran
- Service d'Ophtalmologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
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Lynn WA, Lightman S. Syphilis and HIV: a dangerous combination. THE LANCET. INFECTIOUS DISEASES 2004; 4:456-66. [PMID: 15219556 DOI: 10.1016/s1473-3099(04)01061-8] [Citation(s) in RCA: 266] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
HIV and syphilis affect similar patient groups and co-infection is common. All patients presenting with syphilis should be offered HIV testing and all HIV-positive patients should be regularly screened for syphilis. Syphilis agent may enhance the transmission of the other, probably through increased incidence of genital ulcers. Detection and treatment of syphilis can, therefore, help to reduce HIV transmission. Syphilis may present with non-typical features in the HIV-positive patient: there is a higher rate of symptomless primary syphilis and proportionately more HIV-positive patients present with secondary disease. Secondary infection may be more aggressive and there is an increased rate of early neurological and ophthalmic involvement. Diagnosis is generally made with serology but the clinician should be aware of the potential for false-negative serology in both primary and, less commonly, in secondary syphilis. All HIV-positive patients should be treated with a penicillin-based regimen that is adequate for the treatment of neurosyphilis. Relapse of infection is more likely in the HIV-positive patient and careful follow-up is required.
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Affiliation(s)
- W A Lynn
- Institute of Opthalmology, Moorfield Eye Hospital, London, UK.
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Ormerod LD, Puklin JE, Sobel JD. Syphilitic Posterior Uveitis: Correlative Findings and Significance. Clin Infect Dis 2001; 32:1661-73. [PMID: 11360205 DOI: 10.1086/320766] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/1999] [Revised: 08/16/2000] [Indexed: 11/03/2022] Open
Abstract
Twenty-one patients with syphilitic posterior uveitis were investigated retrospectively to study the disease spectrum, associations with neurosyphilis, and therapeutic implications. Ophthalmologic manifestations of syphilitic posterior uveitis are differentiated into acute and chronic uveitides. The several distinct acute uveitic syndromes are usually florid and are associated with early syphilis, with VDRL-positive syphilitic meningitis, and frequently with human immunodeficiency virus coinfection. The chronic posterior uveitides are often insidious, a manifestation of late syphilis, and associated commonly with subclinical neurosyphilis. All patients with acute cases and 54% of patients with chronic cases in our study received penicillin therapy appropriate for neurosyphilis. The frequent association of syphilitic posterior uveitis with neurosyphilis and the analogous spirochetal sequestration beyond the blood-brain and the blood-ocular barriers suggest that all patients with syphilitic posterior uveitis, irrespective of ocular disease intensity, should undergo evaluation of cerebrospinal fluid and be treated with penicillin regimens appropriate for neurosyphilis.
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Affiliation(s)
- L D Ormerod
- Mason Eye Institute, University of Missouri-Columbia, Columbia, MO 65212, USA
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Sandhu R, Khooshabeh R. Eccentric disciform lesions: a marker of treponemal disease? Eye (Lond) 2001; 15:104-7. [PMID: 11318270 DOI: 10.1038/eye.2001.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Venkatesh P, Verma L, Tandon R, Verma K, Menon V, Tewari HK. Syphilitic neuroretinitis, a report of three cases and review of literature. Neuroophthalmology 2001. [DOI: 10.1076/noph.26.1.1.8050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Browning DJ. Posterior segment manifestations of active ocular syphilis, their response to a neurosyphilis regimen of penicillin therapy, and the influence of human immunodeficiency virus status on response. Ophthalmology 2000; 107:2015-23. [PMID: 11054325 DOI: 10.1016/s0161-6420(00)00457-7] [Citation(s) in RCA: 112] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To determine the relative frequencies of signs in posterior segment ocular syphilis, the response to a neurosyphilis regimen of penicillin, and differences in findings between human immunodeficiency virus (HIV)-coinfected and -noncoinfected patients in a community setting. DESIGN Retrospective, noncomparative, consecutive case series. PARTICIPANTS Fourteen consecutive patients with posterior segment ocular syphilis over a 14-year period within or during the acquired immune deficiency syndrome era. INTERVENTION Neurosyphilis intravenous penicillin regimen. MAIN OUTCOME MEASURES Initial and final visual acuity; treponemal and nontreponemal serologic analyses; cerebrospinal fluid cell count, protein, and Venereal Disease Research Laboratory analyses; posterior segment signs; and relapses and recurrences. RESULTS Blacks and males were predominantly affected. Five (36%) of patients were HIV coinfected, and ocular syphilis led to the HIV infection diagnosis in three. Four (29%) patients had received previous antibiotic therapy for primary or secondary syphilis, raising the suspicion of relapse. Two patients had negative nontreponemal serologic results. All patients responded rapidly to neurosyphilis therapy. One patient subsequently relapsed after neurosyphilis therapy, and a second was reinfected with recurrence of ocular involvement. One previously undescribed retinal manifestation was discovered: a sectorial retinochoroiditis with delayed retinal circulation in the involved area. CONCLUSIONS Ocular syphilis is a form of neurosyphilis and requires neurosyphilis therapy regardless of when it develops after primary infection. Conventional syphilis staging is of little use in understanding ocular syphilis. A high suspicion for this diagnosis is appropriate, especially in poorer black males with posterior segment inflammatory disease. Human immunodeficiency virus coinfection with ocular syphilis is common, but does not affect response to a neurosyphilis regimen of penicillin in the short term. Awareness of the multiple presentations of posterior segment ocular syphilis will aid ophthalmologists in averting misdiagnosis or delayed diagnosis.
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Affiliation(s)
- D J Browning
- Charlotte Eye, Ear, Nose, and Throat Associates, Charlotte, North Carolina, USA.
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Villanueva AV, Sahouri MJ, Ormerod LD, Puklin JE, Reyes MP. Posterior uveitis in patients with positive serology for syphilis. Clin Infect Dis 2000; 30:479-85. [PMID: 10722431 DOI: 10.1086/313689] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The clinical features and ophthalmologic findings of 20 patients with syphilitic posterior uveitis seen at the Detroit Medical Center from November 1993 through February 1996 were reviewed. The mean age was 58 years; 8 patients were male and 12 were female; and all patients were black. Three of 9 patients tested were HIV positive. Patients were divided into 2 groups: those with acute (8) and those with chronic (12) syphilitic posterior uveitis. Chorioretinitis was the predominant uveitic pattern (15/20). Eighteen patients presented with blurred vision. All patients had reactive serum fluorescent treponemal antibody, absorbed (FTA-ABS); 3 had nonreactive rapid plasma reagin (RPR). Mean RPR titer in the chronic uveitis group and in the acute uveitis group was 1:27.3 and 1:209.8, respectively. Seven patients had abnormal cerebrospinal fluid (CSF); CSF VDRL was reactive in 2 patients. All patients were treated with intravenous penicillin G. Eight of 14 patients seen at follow-up showed improvement of ophthalmologic findings. Syphilis should be considered in the differential diagnosis of posterior uveitis.
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Affiliation(s)
- A V Villanueva
- Division of Infectious Diseases, Department of Internal Medicine, Wayne State University, Detroit, MI 48201, USA
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Williams JK, Kirsch LS, Russack V, Freeman WR. Rhegmatogenous Retinal Detachments in HIV-Positive Patients With Ocular Syphilis. Ophthalmic Surg Lasers Imaging Retina 1996. [DOI: 10.3928/1542-8877-19960801-09] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
There has been a steady increase in the number of cases of syphilis in the United States since the middle 1980s, with a dramatic rise in incidence among heterosexual men and women and of congenital syphilis. There also have been changes in geographic distribution of cases and an association with cocaine use. The ophthalmologic manifestations of syphilis are broad. There is anecdotal evidence that the natural history of syphilitic infection is altered by coinfection with human immunodeficiency virus. The potential of coinfection with HIV makes the clinical evaluation, treatment, and assessment of therapeutic outcome of syphilitic infection more confounding and controversial. This article provides a review of the changing demographics and ophthalmic manifestations of syphilis, the current status of laboratory testing techniques, and management approaches to various types of ocular syphilis.
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Affiliation(s)
- C E Margo
- Department of Ophthalmology, University of Florida College of Medicine, Gainesville
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Abstract
Seven cases of bilateral, scattered, yellow-white choroidal lesions have been seen in AIDS patients since January 1988. One resulted from presumed extension of cryptococcal meningitis into the optic nerve and choroid. All the remaining six patients had pneumocystis pneumonia at some time during the course of the disease and were receiving aerosolised pentamidine therapy. None died quickly of disseminated Pneumocystis carinii infection, unlike previously reported patients. Mycobacterial infection was also present in five of these six patients. The differential diagnosis of this entity in AIDS patients is discussed.
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Affiliation(s)
- M A Rosenblatt
- Department of Ophthalmology, Mt Sinai School of Medicine, New York, NY
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