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Fatimah-Halwani I, Wahab Z, Masnon NA, Wan Hitam WH, Shatriah I, Haron J. Bilateral Optic Perineuritis in Tuberculosis-Immune Reconstitution Inflammatory Syndrome. Cureus 2022; 14:e27600. [PMID: 36059337 PMCID: PMC9435306 DOI: 10.7759/cureus.27600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 11/28/2022] Open
Abstract
Optic perineuritis (OPN) in pulmonary tuberculosis (PTB) patients while on anti-tuberculous treatment is rare. It may occur due to tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS). Visual prognosis is poor if not treated early. We report a rare case of bilateral OPN in an elderly patient on treatment for PTB. A 79-year-old Malay man presented with a painless bilateral blurring of vision for three weeks. He was diagnosed to have PTB and has been on anti-tuberculous treatment for five months. Visual acuity in both eyes was only counting fingers. Optic nerve function tests were significantly reduced bilaterally. Fundoscopy showed bilateral segmental temporal optic disc pallor. Both visual field assessments were constricted. Other infective screenings and tumor markers were negative. Neuro-imaging revealed bilateral OPN involving the intraorbital segment. High-dose intravenous corticosteroid therapy was commenced, followed by slow tapering of oral prednisolone. Anti-tuberculous treatment was continued for a total course of nine months. The left visual acuity improved to 3/60. However, the right eye vision remained poor. His general condition was good.
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2
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Liebman DL, Tam EK, Lithgow MY, Kane JE, Fischbein NJ, Lefebvre DR, Chwalisz BK, Gaier ED. Optic Perineuritis Associated With Cryptococcal Meningitis Presenting With a "Hot Orbit" in a Patient With Chronic Lymphocytic Leukemia. J Neuroophthalmol 2022; 42:272-277. [PMID: 35421041 PMCID: PMC9124683 DOI: 10.1097/wno.0000000000001538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT A 75-year-old man presented with 3 days of progressive left retro-orbital pain, eyelid swelling, tearing, and pain with extraocular movement. His medical history was significant for type II diabetes mellitus and chronic lymphocytic leukemia, stable on no therapy since diagnosis 8 years prior. The initial examination was significant for diffuse restriction of left ocular motility, marked lid edema, and mild dyschromatopsia. Computed tomography demonstrated asymmetric left periorbital soft tissue swelling and intraconal fat stranding with an irregular left optic nerve sheath complex and clear paranasal sinuses. He was hospitalized for orbital cellulitis and treated empirically with broad-spectrum intravenous antibiotics, but his visual acuity declined over the ensuing 2 days. Subsequent MRI demonstrated left-greater-than-right circumferential optic nerve sheath enhancement, and leptomeningeal enhancement. An orbital biopsy demonstrated monoclonal B-cell lymphocyte aggregation, whereas a lumbar puncture was positive for Cryptococcus antigen with subsequent demonstration of abundant Cryptococcus by Papanicolaou stain. The final diagnosis was optic perineuritis secondary to cryptococcal meningitis presenting with orbital inflammation. Although his clinical course was complicated by immune reconstitution inflammatory syndrome, symptoms and signs of optic neuropathy ultimately resolved after 1 month of intensive antifungal therapy.
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MESH Headings
- Aged
- Diabetes Mellitus, Type 2/complications
- Edema
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Male
- Meningitis, Cryptococcal/complications
- Meningitis, Cryptococcal/diagnosis
- Meningitis, Cryptococcal/drug therapy
- Orbit
- Pain/complications
- Vision Disorders
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Affiliation(s)
| | - Emily K. Tam
- Department of Ophthalmology, Boston Medical Center, Boston, MA
| | | | - Joseph E. Kane
- Department of Optometry, Boston VA Medical Center, Boston, MA
| | - Nancy J. Fischbein
- Department of Radiology, Stanford University Medical Center, Stanford, CA
| | - Daniel R. Lefebvre
- Department of Ophthalmology, Boston VA Medical Center, Boston, MA
- Division of Ophthalmic Plastic and Reconstructive Surgery, Mass Eye and Ear, Boston, MA
| | - Bart K. Chwalisz
- Division of Neuro-Ophthalmology, Mass Eye and Ear, Boston, MA
- Division of Neuro-Immunology, Massachusetts General Hospital, Boston, MA
| | - Eric D. Gaier
- Department of Ophthalmology, Mass Eye and Ear, Boston, MA
- Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
- Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, MA
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3
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Gupta S, Sethi P, Duvesh R, Sethi HS, Naik M, Rai HK. Optic perineuritis. BMJ Open Ophthalmol 2021; 6:e000745. [PMID: 34104798 PMCID: PMC8144033 DOI: 10.1136/bmjophth-2021-000745] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/23/2021] [Indexed: 11/03/2022] Open
Abstract
Optic perineuritis (OPN) is a rare inflammatory disorder in which the inflammation is confined to optic nerve sheath. It can be idiopathic or secondary to underlying systemic autoimmune disorder. It usually presents with unilateral progressive diminution of vision with pain on eye movements and optic disc oedema. Hence, clinically OPN mimics optic neuritis resulting in delayed diagnosis and suboptimal treatment. In contrast to optic neuritis, patients with OPN are usually of older age group and more likely show sparing of central vision. MRI is an important tool for diagnosis of OPN apart from optic nerve sheath biopsy. Perineural enhancement on MRI is diagnostic of OPN. Oral corticosteroid therapy gives dramatic and rapid improvement in signs and symptoms. Rapid tapering of steroids increases the risk of relapse. Overall, prognosis of OPN is generally good if adequate treatment is given timely.
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Affiliation(s)
- Sukriti Gupta
- Ophthalmology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India
| | - Prabhpreet Sethi
- National Institute of TB and Respiratory Diseases, New Delhi, Delhi, India
| | - RamKrishan Duvesh
- Ophthalmology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India
| | - Harinder Singh Sethi
- Ophthalmology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India
| | - Mayuresh Naik
- Ophthalmology, Hamdard Institute of Medical Science and Research, New Delhi, India
| | - Harminder K Rai
- Ophthalmology, Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield, Derbyshire, UK
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4
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Gonzalez-Martinez A, Quintas S, Vivancos DC, Cebrián J, Vivancos J. Diagnosis of Syphilitic Bilateral Papillitis Mimicking Papilloedema. Emerg Infect Dis 2021; 26:171-173. [PMID: 31855531 PMCID: PMC6924901 DOI: 10.3201/eid2601.191122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Syphilis produces myriad nonspecific signs and symptoms. For example, optic disk swelling might be seen in patients with syphilis as a result of cranial hypertension (papilloedema), inflammatory optic neuritis with papillitis, or optic perineuritis. We report a case involving differential diagnosis of syphilitic bilateral papillitis mimicking papilloedema.
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5
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Li H, Zhou H, Sun J, Wang H, Wang Y, Wang Z, Li J. Optic Perineuritis and Its Association With Autoimmune Diseases. Front Neurol 2021; 11:627077. [PMID: 33584521 PMCID: PMC7880123 DOI: 10.3389/fneur.2020.627077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 12/31/2020] [Indexed: 01/24/2023] Open
Abstract
Background: Optic perineuritis (OPN) is a special optic neuropathy that has a distinct etiology from neuromyelitis optica spectrum disorders (NMOSDs) or multiple sclerosis (MS)-related optic neuritis (ON). The mechanisms of how this inflammation developed and invaded the nerve sheath remain unknown. This study is aimed to analyze the etiology and different clinical characteristics of OPN in a Chinese patient population. Methods: Neuro-ophthalmological examination, orbit magnetic resonance imaging (MRI) and a series of blood samples were used in this retrospective observational cohort study to compare characteristics of OPN with idiopathic demyelination optic neuritis (IDON). Results: Forty-four OPN cases (74 eyes) and 61 IDON cases (78 eyes) were analyzed. OPN cases included 33 cases (59 eyes) were associated with specific autoimmune diseases, 10 cases (13 eyes) were associated with infection diseases, 1 case was idiopathic disease. The causes of OPN with CTD were Graves' disease, Immunoglobulin G4-related disease (IgG-4 RD), granulomatosis with polyangiitis (GAP), systemic lupus erythematosus (SLE), Sarcoidosis, Rheumatoid arthritis, scleroderma, Behcet's disease, and gout. All patients received orbital MRI. Overall, 33 cases showed orbit fat infiltration. Specifically, nine cases with IgG-4 RD showed trigeminal nerve branch involvement, 12 cases with Graves' disease showed extraocular muscle belly enlargement, and 4 cases with GAP showed pterygopalatine fossa pseudotumor. Compared to IDON patients, OPN patients were older (p = 0.004) and more likely bilateral involvement 26 (78.79%) patients had bilateral involvement in OPN group vs. 17 (27.87%) in the IDON group (p < 0.001). Visual acuity scores using LogMAR testing was better in OPN patients compared to those with IDON, 0.55 ± 0.91 vs. 1.19 ± 1.24 (p < 0.001). Other ophthalmologic findings unique to the OPN group include 11 (33.33%) cases of ptosis, nine (27.27%) cases of diplopia, and 10 (30.30%) cases of exophthalmos, compared to zero cases of these conditions in the IDON group. Eight (13.11%) IDON patients also had multiple sclerosis (MS) and 7 (11.48%) patients had neuromyelitis which was significantly more than the zero patients in OPN group (p = 0.04). Conclusions: OPN had distinct etiologies and clinical characteristics from IDON and is more often associated with autoimmune diseases. Using OPN characteristics to diagnose autoimmune diseases should prove useful for clinicians when presented with patients that have multiorgan dysfunction that include ophthalmologic findings.
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Affiliation(s)
- Hongyang Li
- Department of Ophthalmology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hang Zhou
- Department of Rheumatology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jiao Sun
- Department of Ophthalmology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Huihui Wang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yanling Wang
- Department of Ophthalmology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhenchang Wang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jing Li
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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6
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Singh S, Puranik P, Lin E, Marti M, Liu A. Neurosyphilis in AIDS patient presenting as isolated cranial nerve 6 palsy. Clin Case Rep 2020; 8:1877-1879. [PMID: 33088510 PMCID: PMC7562863 DOI: 10.1002/ccr3.3018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 04/14/2020] [Accepted: 05/15/2020] [Indexed: 12/23/2022] Open
Abstract
Early neurosyphilis can occur in an immunocompromised host. It has a widely varied presentation. Isolated CN6 as presenting symptom has not been described.
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Affiliation(s)
| | | | - Ethan Lin
- Department of Family Practice California Hospital Medical Center Los Angeles California USA
| | - Miriam Marti
- Department of Neurology Adventist Health White Memorial Los Angeles California USA
| | - Antonio Liu
- Department of Neurology Adventist Health White Memorial Los Angeles California USA
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7
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McNally MA, Murira A, Dillard CM, Aisenberg G. The Great Masquerader: Syphilis Mimicking Papilledema and Traction Alopecia. Cureus 2020; 12:e7391. [PMID: 32337118 PMCID: PMC7179977 DOI: 10.7759/cureus.7391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/24/2020] [Indexed: 11/18/2022] Open
Abstract
Syphilis is often referred to as "the great masquerader," as it may present with a wide array of clinical symptoms and may mimic a variety of other diseases making diagnosis challenging. We report the case of a young, married woman who presented with a one-month history of significant hair loss, unintentional weight loss, blurred vision, and intermittent headaches. In addition, she endorsed positional dizziness and intermittent arthralgias. Physical exam was only remarkable for a non-scarring alopecia over the frontal marginal hairline and optic disc edema on fundoscopic exam. Laboratory tests were largely unremarkable except for a rapid plasma reagin titer of 1:128 and a positive confirmatory treponemal test. Cerebrospinal fluid analysis showed lymphocytic pleocytosis and negative Venereal Disease Research Laboratory test. Opening pressure was 15 cm H2O twice, ruling out papilledema. She was treated with 4 million units of intravenous penicillin every four hours for 14 days, and her symptoms improved. A diagnosis of syphilis should remain high on the differential diagnosis in patients with unexplained hair loss or ocular abnormalities.
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Affiliation(s)
- Michelle A McNally
- Dermatology, John P. and Kathrine G. McGovern School of Medicine, University of Texas Health Center at Houston, Houston, USA
| | - Angela Murira
- Internal Medicine, John P. and Kathrine G. McGovern Medical School, University of Texas Health Science Center at Houston, Houston, USA
| | - Christen M Dillard
- Internal Medicine, John P. and Kathrine G. McGovern Medical School, University of Texas Health Science Center at Houston, Houston, USA
| | - Gabriel Aisenberg
- Internal Medicine, John P. and Kathrine G. McGovern Medical School, University of Texas Health Science Center at Houston, Houston, USA
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8
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Chen JJ, Bhatti MT, Bradley E, Garrity J, Thurtell MJ. Incipient Syphilitic Papillitis. Neuroophthalmology 2020; 44:11-15. [PMID: 32076443 DOI: 10.1080/01658107.2019.1615959] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/27/2019] [Accepted: 05/03/2019] [Indexed: 10/26/2022] Open
Abstract
Patients with syphilis can present with optic disc oedema (ODE) without visual compromise, which has been primarily attributed to papilloedema from raised intracranial pressure or optic perineuritis from optic nerve sheath inflammation. We report four cases of ODE in the setting of syphilis with preserved visual function, normal intracranial pressure, and no enhancement of the optic nerve or sheath on magnetic resonance imaging. We propose the term "incipient syphilitic papillitis" for cases presenting with ODE, preserved vision and absence of optic nerve sheath enhancement, which is likely a more common presentation than syphilitic optic perineuritis.
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Affiliation(s)
- John J Chen
- Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA.,Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - M Tariq Bhatti
- Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA.,Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - James Garrity
- Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA
| | - Matthew J Thurtell
- Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa, IA, USA
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9
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Akalp FD, Yılmaz S, Erol MK, Avcı E, Avcı R. Ocular Syphilis Unmasked Following Bilateral Intravitreal Dexamethasone Implant (Ozurdex) Injection. Ophthalmic Surg Lasers Imaging Retina 2019; 50:e77-e80. [PMID: 30893461 DOI: 10.3928/23258160-20190301-16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/03/2018] [Indexed: 11/20/2022]
Abstract
Intraocular corticosteroids are used in ophthalmologic conditions such as macular edema secondary to vascular occlusions, diabetes, and uveitis. Infectious ocular diseases must be ruled out before intravitreal corticosteroid implantation. Here, the authors report a case that has been referred to their clinic for surgical treatment due to dense vitreous hemorrhage in the right eye after bilateral intravitreal dexamethasone implantation. As an intraoperative finding, diffuse changes in the color-like paleness of the retina as well as intraretinal white-colored deposits were observed. Serology tests were performed, and syphilis serology was positive. Intravenous penicillin provides resolution of inflammation. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e77-e80.].
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10
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Karti O, Top Karti D, Ozkan Ozdemir H, Eskut N, Zengin MO, Kusbeci T, Saatci AO. Coexistence of Papillitis and Posterior Placoid Chorioretinopathy as the Presenting Symptoms of Syphilis-Human Immunodeficiency Virus Coinfection. Neuroophthalmology 2019; 43:196-200. [PMID: 31312245 DOI: 10.1080/01658107.2018.1493515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 06/20/2018] [Accepted: 06/22/2018] [Indexed: 10/28/2022] Open
Abstract
A 27-year-old male was presented with a decrease in vision in the left eye. Best-corrected visual acuity was 10/10 in the right eye and counting fingers at 2 m in the left eye. On fundus examination, the left optic disc was oedematous and there was a wide yellowish, well-defined placoid lesion between the temporal vascular arcades with mild vitreous inflammation. However, a small yellowish well-defined placoid lesion was detected in the inferior temporal region of the macula in the right eye. He was diagnosed with posterior placoid chorioretinopathy (PPC), papillitis, and neurosyphilis after performing fundus fluorescein angiography, fundus autofluorescence imaging, optical coherence tomography, serology for human immunodeficiency virus (HIV) and syphilis, and cerebrospinal fluid examination. Intravenous penicillin treatment was commenced as soon as the diagnosis was established. Seven days after treatment initiation, lesions were partially regressed. PPC and papillitis are rare manifestations of ocular syphilis. In addition, neurosyphilis may also accompany these manifestations. Therefore, syphilis should be considered in the differential diagnosis of patients who have PPC or papillitis and all patients should be tested for HIV coinfection and neurosyphilis.
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Affiliation(s)
- Omer Karti
- Department of Ophthalmology, Bozyaka Training and Research Hospital, İzmir, Turkey
| | - Dilek Top Karti
- Department of Neurology, Bozyaka Training and Research Hospital, İzmir, Turkey
| | - Hulya Ozkan Ozdemir
- Department of Infectious Disease, Bozyaka Training and Research Hospital, İzmir, Turkey
| | - Neslihan Eskut
- Department of Neurology, Bozyaka Training and Research Hospital, İzmir, Turkey
| | - Mehmet Ozgur Zengin
- Department of Ophthalmology, Bozyaka Training and Research Hospital, İzmir, Turkey
| | - Tuncay Kusbeci
- Department of Ophthalmology, Bozyaka Training and Research Hospital, İzmir, Turkey
| | - Ali Osman Saatci
- Department of Ophthalmology, Dokuz Eylul University, İzmir, Turkey
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11
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Abel A, McClelland C, Lee MS. Critical review: Typical and atypical optic neuritis. Surv Ophthalmol 2019; 64:770-779. [PMID: 31229520 DOI: 10.1016/j.survophthal.2019.06.001] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/22/2019] [Accepted: 06/07/2019] [Indexed: 10/26/2022]
Abstract
Typical optic neuritis is an idiopathic demyelinating condition that is often associated with multiple sclerosis. This has been well characterized and has an excellent prognosis. Atypical optic neuritis can result from an inflammatory, infectious, or autoimmune disorder. Differentiating the two types of optic neuritis is paramount and may be challenging early on in the clinical course. This review describes the recent literature describing the pathophysiology, clinical presentation, neuroimaging, and management of these disorders.
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Affiliation(s)
- Anne Abel
- Department of Ophthalmology, Hennepin Healthcare, Minneapolis, Minnesota, USA; Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, Minnesota, USA
| | - Collin McClelland
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael S Lee
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, Minnesota, USA; Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA; Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.
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12
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Abstract
Optic perineuritis (OPN) is a rare inflammatory disorder involving the optic nerve sheath characterized by visual loss. OPN may be isolated and idiopathic or part of an underlying disorder. This case series aimed to help clinicians investigate and manage this disorder. Presentation, clinical findings, and treatment of OPN are discussed. After review of medical records at the ophthalmology clinic at Sahlgrenska University hospital in Gothenburg, Sweden, seven OPN patients (three men and four women) were identified and included in the present case series. These included idiopathic cases and patients with underlying disorders. Age at OPN diagnosis ranged from 26 to 64 years (mean age 55 years, median age 58 years). Five of the patients were treated with corticosteroids. This study suggests that a high-dose course of corticosteroids is important in the treatment of OPN in severely affected patients.
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Affiliation(s)
- Olle Bergman
- Department of Ophthalmology, Sahlgrenska University Hospital
| | - Tommy Andersson
- Department of Ophthalmology, Sahlgrenska University Hospital
| | - Madeleine Zetterberg
- Department of Ophthalmology, Sahlgrenska University Hospital.,Department of Clinical Neuroscience/Ophthalmology, Institute of Neuroscience and Physiology, University of Gothenburg, Mölndal, Sweden
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13
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Jetley S, Jairajpuri ZS, Pujani M, Khan S, Rana S. Tuberculosis 'The Great Imitator': A usual disease with unusual presentations. Indian J Tuberc 2016; 64:54-59. [PMID: 28166920 DOI: 10.1016/j.ijtb.2016.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 01/05/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND A number of infectious diseases have been referred to by the phrase 'The Great Imitator', of which the oldest is syphilis; others include Lyme disease, nocardiosis, etc. Tuberculosis has been described as the second great imitator as it can imitate various other disease processes. An awareness of the atypical clinical manifestations of tuberculosis is important, especially in regions where tuberculosis continues to be a major public health problem, such as India. Extrapulmonary tuberculosis (EPTB) constitutes about 15-20% of all cases of tuberculosis in immunocompetent patients and accounts for more than 50% of the cases in human immunodeficiency virus (HIV)-positive individuals. METHODS We hereby report 4 cases of tuberculosis at unusual sites, which were not suspected clinically and were subsequently diagnosed by pathological examination and by ancillary techniques. OBSERVATIONS AND RESULTS In all the four cases, the involvement was extrapulmonary in nature and at unusual sites. Three cases were diagnosed by a positive Ziehl Neelsen stain while culture for Mycobacterium tuberculosis was positive in three cases. All the four patients tested negative for HIV status on serology. CONCLUSIONS AND IMPLICATIONS Unusual presentations, which mimic many diverse conditions, as seen in this series, highlight the importance of a high index of suspicion in the timely diagnosis of tuberculosis. Evidence of systemic or lung involvement may not always be present and laboratory and radiological findings play an important role.
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Affiliation(s)
- Sujata Jetley
- Professor & Head, Dept. of Pathology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India
| | - Zeeba S Jairajpuri
- Associate Professor, Dept. of Pathology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India
| | - Mukta Pujani
- Associate Professor, Dept. of Pathology, ESI Medical College, Faridabad, India.
| | - Sabina Khan
- Associate Professor, Dept. of Pathology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India
| | - Safia Rana
- Lecturer, Dept. of Pathology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India
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14
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Drago F, Merlo G, Ciccarese G, Agnoletti AF, Cozzani E, Rebora A, Parodi A. Changes in neurosyphilis presentation: a survey on 286 patients. J Eur Acad Dermatol Venereol 2016; 30:1886-1900. [PMID: 27306850 DOI: 10.1111/jdv.13753] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 01/06/2016] [Indexed: 11/28/2022]
Abstract
Although neurosyphilis (NS) keeps plaguing worldwide, often with oligosymptomatic and atypical manifestations, the most recent reports fail to provide useful information, like details of the clinical history and even of the previous early therapy. We conducted a survey of the literature of the last 5 years on the clinical presentation of NS, recording the aforementioned inaccuracies. One hundred and thirty-seven articles were collected, reporting on 286 patients. General paresis was the commonest form (49%), often manifesting with cognitive impairment and psychiatric symptoms. Syphilitic meningitis was found in 63 patients (22%), mainly with ocular or auditory involvement. Meningovascular and tabetic form were both found in 12% of cases. Gummatous and epileptic manifestations were rare. Perusal of the literature confirms that NS prevalence is increasing, often with manifestations that are atypical for timing and type of lesions. Unfortunately, many articles are lacking of critical information, like an accurate clinical history and timing of the therapy making difficult to assess the effectiveness of penicillin in preventing NS.
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Affiliation(s)
- F Drago
- Di.S.Sal. Section of Dermatology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - G Merlo
- Di.S.Sal. Section of Dermatology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy.
| | - G Ciccarese
- Di.S.Sal. Section of Dermatology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - A F Agnoletti
- Di.S.Sal. Section of Dermatology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - E Cozzani
- Di.S.Sal. Section of Dermatology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - A Rebora
- Di.S.Sal. Section of Dermatology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - A Parodi
- Di.S.Sal. Section of Dermatology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
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15
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Boudreault K, Durand ML, Rizzo JF. Investigation-Directed Approach to Inflammatory Optic Neuropathies. Semin Ophthalmol 2016; 31:117-30. [DOI: 10.3109/08820538.2015.1114835] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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16
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Kahloun R, Abroug N, Ksiaa I, Mahmoud A, Zeghidi H, Zaouali S, Khairallah M. Infectious optic neuropathies: a clinical update. Eye Brain 2015; 7:59-81. [PMID: 28539795 PMCID: PMC5398737 DOI: 10.2147/eb.s69173] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Different forms of optic neuropathy causing visual impairment of varying severity have been reported in association with a wide variety of infectious agents. Proper clinical diagnosis of any of these infectious conditions is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular findings. Diagnosis is confirmed by serologic testing and polymerase chain reaction in selected cases. Treatment of infectious optic neuropathies involves the use of specific anti-infectious drugs and corticosteroids to suppress the associated inflammatory reaction. The visual prognosis is generally good, but persistent severe vision loss with optic atrophy can occur. This review presents optic neuropathies caused by specific viral, bacterial, parasitic, and fungal diseases.
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Affiliation(s)
- Rim Kahloun
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Nesrine Abroug
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Imen Ksiaa
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Anis Mahmoud
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Hatem Zeghidi
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Sonia Zaouali
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Moncef Khairallah
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
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Bilateral idiopathic optic perineuritis with severe vision loss: A case report. ASIAN PACIFIC JOURNAL OF TROPICAL DISEASE 2015. [DOI: 10.1016/s2222-1808(15)60841-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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18
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Benson CE, Soliman MK, Knezevic A, Xu DD, Nguyen QD, Do DV. Bilateral papillitis and unilateral focal chorioretinitis as the presenting features of syphilis. J Ophthalmic Inflamm Infect 2015; 5:16. [PMID: 26069511 PMCID: PMC4456579 DOI: 10.1186/s12348-015-0045-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 03/30/2015] [Indexed: 11/23/2022] Open
Abstract
Background Syphilis is a multisystem bacterial infection caused by Treponema pallidum. The incidence of infection in the United States has risen by more than 75% since the year 2000, when it was at a low of 2.1 per 100,000 people. Ocular involvement may occur in any stage of infection and may present in a variety of ways, with posterior uveitis being the most common manifestation. We report a case of ocular syphilis infection with an unusual presentation of bilateral non-granulomatous panuveitis with papillitis and unilateral focal chorioretinitis. Findings This is a retrospective case report with literature review. A 39-year-old Caucasian female presented with a 2-week history of bilateral ocular flashes and left eye pain. Dilated fundus examination revealed mild optic disc edema in both eyes, the right eye more than the left. In the left eye, there was an area of retinal elevation and whitening involving the peripheral retina. Fluorescein angiography, B-scan ultrasonography, and ocular coherence tomography were performed, and laboratory tests were ordered based on the clinical presentation. After rapid plasma reagin (RPR) and fluorescent treponemal antibody absorption (FTA-Abs) were positive, syphilitic uveitis was confirmed, and the patient was admitted for a 14-day course of high-dose intravenous penicillin G. Conclusions The first signs and symptoms of syphilis may be ocular, which can lead to a diagnostic challenge. A high index of suspicion is the key for early diagnosis of ocular syphilis. Prompt treatment with intravenous penicillin G is highly effective in resolving the infection.
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Affiliation(s)
- Christy Elizabeth Benson
- Stanley M Truhlsen Eye Institute, University of Nebraska Medical Center, 3902 Leavenworth Street, Omaha, NE 68105 USA
| | - Mohamed Kamel Soliman
- Stanley M Truhlsen Eye Institute, University of Nebraska Medical Center, 3902 Leavenworth Street, Omaha, NE 68105 USA ; Department of Ophthalmology, Assiut University Hospital, Al Gamaa St, Assiut, 71516 Egypt
| | - Alexander Knezevic
- Stanley M Truhlsen Eye Institute, University of Nebraska Medical Center, 3902 Leavenworth Street, Omaha, NE 68105 USA
| | - Daisy Ding Xu
- Tenth People's Hospital, 301 Yanchang Road, Shanghai District, Shanghai, 200072 China
| | - Quan Dong Nguyen
- Stanley M Truhlsen Eye Institute, University of Nebraska Medical Center, 3902 Leavenworth Street, Omaha, NE 68105 USA
| | - Diana V Do
- Stanley M Truhlsen Eye Institute, University of Nebraska Medical Center, 3902 Leavenworth Street, Omaha, NE 68105 USA
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20
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Neurosyphilis presenting as asymptomatic optic perineuritis. Case Rep Ophthalmol Med 2012; 2012:621872. [PMID: 22606498 PMCID: PMC3350282 DOI: 10.1155/2012/621872] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 01/03/2012] [Indexed: 11/21/2022] Open
Abstract
Introduction. Syphilis is a sexually transmitted disease that is known as “the great imitator” due to its wide variety of clinical presentations, including ocular disorders. There has been an increase in the rate of syphilis in the United States, especially in persons with HIV. We report a case of optic perineuritis in an asymptomatic male secondary to central nervous system (CNS) syphilis. Case Report. A 41-year-old man was found to have bilateral disc edema on a routine exam. Brain MRI was unremarkable, and lumbar puncture revealed a normal opening pressure, with an elevated cerebrospinal fluid white cell count. Orbit MRI showed optic nerve sheath expansion and enhancement, consistent with optic perineuritis. He tested positive for syphilis based on serum RPR and FTA-ABS. Conclusion. Ophthalmologic findings, including disc edema, may be the presenting features of CNS syphilis. Even in asymptomatic persons, perineuritis should be considered early, as diagnosis and treatment are imperative given the progressive nature of the disease.
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O'Connell K, Marnane M, McGuigan C. Bilateral ocular perineuritis as the presenting feature of acute syphilis infection. J Neurol 2011; 259:191-2. [PMID: 21732063 DOI: 10.1007/s00415-011-6148-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 06/13/2011] [Indexed: 11/25/2022]
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