1
|
Abstract
Dermatologists are familiar with the classic aspects of syphilis. Our objective in this update is to display novel features of sexually acquired syphilis, its pathophysiology, natural history, atypical clinical variants, skin of color, clinical pearls, and prospects. Textbook knowledge, congenital syphilis, epidemiology, and historical data are excluded.
Collapse
Affiliation(s)
- Jorge Navarrete
- Department of Dermatology, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile; Department of Dermatology and Sexually Transmitted Infections Clinic, Hospital Padre Hurtado, Santiago, Chile.
| | - Stephanie Saavedra-Portales
- Department of Dermatology and Sexually Transmitted Infections Clinic, Hospital San Juan de Dios, Santiago, Chile
| |
Collapse
|
2
|
Human Immunodeficiency Virus and Uveitis. Viruses 2023; 15:v15020444. [PMID: 36851658 PMCID: PMC9962278 DOI: 10.3390/v15020444] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/31/2023] [Accepted: 02/03/2023] [Indexed: 02/09/2023] Open
Abstract
Uveitis is one of the most common ocular complications in people living with the Human immunodeficiency virus (HIV) and can be classified into HIV-induced uveitis, co-infection related uveitis, immune recovery uveitis, and drug-induced uveitis. The introduction of antiretroviral therapy has considerably changed the incidence, diagnosis, and treatment of different types of HIV-related uveitis. Furthermore, the specific immune condition of patients infected with HIV makes diagnosing HIV-related uveitis difficult. Recent studies have focused on the growing prevalence of syphilis/tuberculosis co-infection in uveitis. Simultaneously, more studies have demonstrated that HIV can directly contribute to the incidence of uveitis. However, the detailed mechanism has not been studied. Immune recovery uveitis is diagnosed by exclusion, and recent studies have addressed the role of biomarkers in its diagnosis. This review highlights recent updates on HIV-related uveitis. Furthermore, it aims to draw the attention of infectious disease physicians and ophthalmologists to the ocular health of patients infected with HIV.
Collapse
|
3
|
Ling CJM, Zhang KY, Taubenslag KJ, Alexander N, Champ K, Murali N. The Mydriatic Red Eye as the Initial Presentation of Syphilis. J Emerg Med 2022; 63:296-299. [PMID: 36038437 DOI: 10.1016/j.jemermed.2022.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/09/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Syphilis is a sexually transmitted infection that has been increasing in prevalence since the early 2000s. Ocular involvement occurs in a minority of patients and must be in the differential diagnosis for patients who present with red eye and uveitis. CASE REPORT A 29-year-old woman presented to the emergency department with a painful, mydriatic red eye. Review of systems revealed a rash as well as a recent genital lesion and, on further questioning, she admitted to a history of intravenous drug use and high-risk sexual activity. Ophthalmology was consulted and the patient was diagnosed with bilateral uveitis. Serologic testing was positive for syphilis, and she was admitted and treated with intravenous penicillin, with resolution of her uveitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Red eye is a common ocular symptom in patients presenting to the emergency department. The differential diagnosis of the red eye is broad and can range from benign etiologies, such as conjunctivitis, to life- and sight-threatening conditions, such as endogenous endophthalmitis. Systemic diseases such as syphilis may present with primarily ocular symptoms, and ocular syphilis must be identified and managed appropriately to prevent devastating sequelae.
Collapse
Affiliation(s)
- Carlthan J M Ling
- Department of Ophthalmology and Visual Sciences, University of Maryland Medical Center, Baltimore, Maryland
| | - Kevin Y Zhang
- Creighton University Medical School, Omaha, Nebraska
| | - Kenneth J Taubenslag
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nicole Alexander
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kathryn Champ
- Department of Internal Medicine, University of Maryland Medical Center, Midtown Campus, Baltimore, Maryland
| | - Neeraja Murali
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland.
| |
Collapse
|
4
|
Classification Criteria for Syphilitic Uveitis. Am J Ophthalmol 2021; 228:182-191. [PMID: 33845020 PMCID: PMC8594749 DOI: 10.1016/j.ajo.2021.03.039] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 01/29/2021] [Accepted: 03/31/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To determine classification criteria for syphilitic uveitis. DESIGN Machine learning of cases with syphilitic uveitis and 24 other uveitides. METHODS Cases of anterior, intermediate, posterior, and panuveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on the diagnosis, using formal consensus techniques. Cases were analyzed by anatomic class, and each class was split into a training set and a validation set. Machine learning using multinomial logistic regression was used on the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the different uveitic classes. The resulting criteria were evaluated on the validation set. RESULTS Two hundred twenty-two cases of syphilitic uveitis were evaluated by machine learning, with cases evaluated against other uveitides in the relevant uveitic class. Key criteria for syphilitic uveitis included a compatible uveitic presentation (anterior uveitis; intermediate uveitis; or posterior or panuveitis with retinal, retinal pigment epithelial, or retinal vascular inflammation) and evidence of syphilis infection with a positive treponemal test. The Centers for Disease Control and Prevention reverse screening algorithm for syphilis testing is recommended. The misclassification rates for syphilitic uveitis in the training sets were as follows: anterior uveitides 0%, intermediate uveitides 6.0%, posterior uveitides 0%, panuveitides 0%, and infectious posterior/panuveitides 8.6%. The overall accuracy of the diagnosis of syphilitic uveitis in the validation set was 100% (99% confidence interval 99.5, 100)-that is, the validation set's misclassification rates were 0% for each uveitic class. CONCLUSIONS The criteria for syphilitic uveitis had a low misclassification rate and seemed to perform sufficiently well for use in clinical and translational research.
Collapse
|
5
|
Kumar A, Kumar P, Mishra SK, Goyal S. Unilateral hypopyon associated acute syphilitic posterior placoid chorioretinitis: Unusual presentation leading to HIV diagnosis. Trop Doct 2021; 51:444-446. [PMID: 33779397 DOI: 10.1177/0049475521998178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Syphilis has a wide variety of ocular presentations such as anterior or posterior uveitis, chorioretinitis, retinal vasculitis, retinitis, perineuritis, papillitis, retrobulbar neuritis, optic atrophy and optic nerve gumma. Therefore, it is recommended to test every patient with ocular inflammation for syphilis. It is, however, a relatively rare cause of uveitis in HIV disease. A few studies suggested that HIV contributes to the ocular manifestations of syphilis and HIV co-infection in approximately 30%. Acute syphilitic posterior placoid chorioretinopathy is a rare ocular manifestation in immune-competent patients characterised by the development of a deposit in the outer retina. We describe an unusual such presentation with hypopyon.
Collapse
Affiliation(s)
- Ashok Kumar
- Department of Ophthalmology, 29590Armed Forces Medical College, Pune, India
| | - Poninder Kumar
- Department of Ophthalmology, 29590Armed Forces Medical College, Pune, India
| | - Sanjay Kumar Mishra
- Department of Ophthalmology, 214250Army College of Medical Sciences & Base Hospital, Delhi, India
| | - Sumit Goyal
- Department of Ophthalmology, 214250Army College of Medical Sciences & Base Hospital, Delhi, India
| |
Collapse
|
6
|
Phadke VK, Shantha JG, O’Keefe G. Relapsing Uveitis due to Human T-lymphotropic Virus Type 1 in a Patient Living With HIV Diagnosed by Metagenomic Deep Sequencing. Open Forum Infect Dis 2020; 7:ofaa078. [PMID: 32206676 PMCID: PMC7081385 DOI: 10.1093/ofid/ofaa078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/06/2020] [Indexed: 12/17/2022] Open
Abstract
HIV infection can result in vision loss from different causes, including HIV retinopathy and uveitis secondary to other infections, such as toxoplasmosis and viral retinitis. It is imperative to identify any infectious causes of uveitis to successfully treat the condition and prevent further vision loss. Metagenomic deep sequencing (MDS) is an emerging technology that presents an unbiased approach to the evaluation of clinical syndromes, including uveitis, that have not been diagnosed by pathogen-specific testing. Herein we present a case of a woman living with HIV with 11 years of relapsing bilateral uveitis refractory to systemic corticosteroid therapy who was diagnosed with human T-lymphotropic virus type 1 (HTLV-1)–associated uveitis by this technology. We also briefly review the literature of MDS as a diagnostic tool and the epidemiology, pathogenesis, and diagnosis of HTLV-1-associated uveitis.
Collapse
Affiliation(s)
- Varun K Phadke
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jessica G Shantha
- Emory Eye Center, Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ghazala O’Keefe
- Emory Eye Center, Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
| |
Collapse
|
7
|
Human Immunodeficiency Virus Infection Increases the Risk of Incident Uveitis Among People Living With HIV/AIDS. J Acquir Immune Defic Syndr 2019; 79:149-157. [PMID: 30212432 DOI: 10.1097/qai.0000000000001782] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Case reports indicated that HIV itself may be a direct cause of uveitis. However, the association of HIV with incident uveitis has not been extensively studied. This nationwide cohort study determined the association of HIV with incident uveitis. METHODS Since January 1, 2003, we identified adult people living with HIV/AIDS (PLWHA) from Taiwan Centers for Disease Control HIV Surveillance Database. A control cohort without HIV infection, matched for age and sex, was selected for comparison from the Taiwan National Health Insurance Research Database. The time-dependent Cox proportional hazards model was used to determine the associations of HIV and highly active antiretroviral therapy (HAART) with incident uveitis, while considering death as a competing risk event. RESULTS Of the total 120,430 patients (24,086 PLWHA and 96,344 matched controls), 609 (0.51%) had incident uveitis, including 334 (1.39%) PLWHA and 265 (0.28%) controls. After adjusting for age, sex, and comorbidities, HIV infection was found to be an independent risk factor for incident uveitis [adjusted hazard ratio (AHR), 5.55; 95% confidence interval (CI): 4.67 to 6.59]. Within PLWHA, the risk of incident uveitis was significantly higher in those who received HAART (AHR, 2.46; 95% CI: 1.71 to 3.54). In addition, considering the short- and long-term effects of HAART on incident uveitis, HAART was found to associate with a higher risk of uveitis development within 1 year of treatment (AHR, 3.36; 95% CI: 2.41 to 4.69), but not after 1 year of HAART initiation (AHR, 1.14; 95% CI: 0.76 to 1.72). CONCLUSIONS HIV infection is an independent risk factor for incident uveitis.
Collapse
|
8
|
Rothova A, Hajjaj A, de Hoog J, Thiadens AA, Dalm VA. Uveitis causes according to immune status of patients. Acta Ophthalmol 2019; 97:53-59. [PMID: 30239127 PMCID: PMC6585906 DOI: 10.1111/aos.13877] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 06/13/2018] [Indexed: 12/25/2022]
Abstract
Purpose The advances in medicine have led to an increased number of people living with some form of immunodeficiency. Most ocular infections in immunocompromised patients may lead to irreversible blindness. We identify the causes of uveitis in immunocompetent and immunocompromised patients. Methods A retrospective cohort study of 1354 consecutive patients. All patients underwent a standard work‐up for uveitis. Results An immunocompromised state was identified in 171/1354 patients (13%), of whom 40 had Human immunodeficiency virus (HIV) infection, 52 received immunosuppressive medications, 28 had concurrent malignant disorder and 20 had other causes for their immunosuppression. In addition, 93/1354 patients (7%) had diabetes mellitus (DM). The prevalence of intraocular infections was much higher in immunocompromised patients than in immunocompetent patients and DM (p < 0.001). Causes of uveitis differed between the diverse immunocompromised groups. The non‐HIV immunocompromised patients showed primarily intraocular herpes simplex and varicella zoster virus infections, whilst HIV‐positive patients exhibited frequently cytomegalovirus (CMV) retinitis and syphilis. Patients with generalized malignancies were characterized by a lower prevalence of infections and higher prevalence of sarcoidosis. Patients with DM typically showed sarcoidosis and bacterial intraocular infections. The percentage of undetermined uveitis diagnoses was markedly lower in immunosuppressed patients (p < 0.001). Conclusion In immunocompromised patients with uveitis, infections were diagnosed in 46% of cases in contrast to 12% in the immunocompetent patients. The causes of uveitis differed among the various types of immunosuppression. Immunocompromised patients with uveitis require a rapid assessment for the most expected infections.
Collapse
Affiliation(s)
- Aniki Rothova
- Department of Ophthalmology; Erasmus Medical Center; Erasmus University; Rotterdam the Netherlands
| | - Anass Hajjaj
- Department of Ophthalmology; Erasmus Medical Center; Erasmus University; Rotterdam the Netherlands
| | - Joeri de Hoog
- Department of Ophthalmology; Erasmus Medical Center; Erasmus University; Rotterdam the Netherlands
- Department of Ophthalmology; Academic Medical Center; Amsterdam the Netherlands
| | - Alberta A.H.J. Thiadens
- Department of Ophthalmology; Erasmus Medical Center; Erasmus University; Rotterdam the Netherlands
| | - Virgil A.S.H. Dalm
- Department of Internal Medicine; Division Immunology; Erasmus Medical Center; Erasmus University; Rotterdam the Netherlands
| |
Collapse
|
9
|
Abstract
PURPOSE In this article, the authors describe multifocal choroiditis related to disseminated sporotrichosis in patients with HIV/AIDS. METHODS We conducted a retrospective observational study of three patients infected with HIV who presented with disseminated sporotrichosis characterized by cutaneous lesions, multifocal choroiditis, and other manifestations, including osteomyelitis and involvement of the bone marrow, larynx, pharynx, and nasal and oral mucosa. RESULTS Five eyes of three patients with HIV/AIDS showed multifocal choroiditis related to disseminated sporotrichosis. The CD4 counts ranged from 25 to 53 mm. All patients were asymptomatic visually. The ocular disease was bilateral in two patients. The lesion size ranged from 1/3 to 2 disc diameters. None of the patients had vitritis. Of the 12 lesions, 9 were localized in the posterior pole (Zone 1) and 3 were localized in the mild periphery (Zone 2). CONCLUSION Multifocal choroiditis due to disseminated sporotrichosis can occur in profoundly immunosuppressed patients with HIV/AIDS.
Collapse
|
10
|
Rishi E, Govindarajan MV, Biswas J, Agarwal M, Sudharshan S, Rishi P. Syphilitic uveitis as the presenting feature of HIV. Indian J Ophthalmol 2016; 64:149-50. [PMID: 27050352 PMCID: PMC4850812 DOI: 10.4103/0301-4738.179714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ekta Rishi
- Bhagwan Mahavir Vitreoretinal Services, Chennai, Tamil Nadu, India
| | | | | | | | | | | |
Collapse
|
11
|
Schaftenaar E, Meenken C, Baarsma GS, Khosa NS, Luijendijk A, McIntyre JA, Osterhaus ADME, Verjans GMGM, Peters RPH. Uveitis is predominantly of infectious origin in a high HIV and TB prevalence setting in rural South Africa. Br J Ophthalmol 2016; 100:1312-6. [PMID: 27307174 DOI: 10.1136/bjophthalmol-2016-308645] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 05/22/2016] [Indexed: 11/04/2022]
Abstract
AIMS To determine the burden of disease in a unique sample of patients with uveitis from a rural South African setting. METHODS Data in this cross-sectional study were collected from patients presenting with uveitis (n=103) at the ophthalmology outpatient department of three hospitals in rural South Africa. Demographic and clinical data were collected, and laboratory analysis of aqueous humour, serological evaluation and routine diagnostics for tuberculosis (TB) were performed. RESULTS Sixty-six (64%) participants were HIV infected. Uveitis was predominantly of infectious origin (72%) followed by idiopathic (16%) and autoimmune (12%). Infectious uveitis was attributed to herpes virus (51%), Mycobacterium tuberculosis (24%) and Treponema pallidum (7%) infection. HIV-infected individuals were more likely to have infectious aetiology of uveitis compared with HIV-uninfected individuals (83% vs 51%; p=0.001). CONCLUSIONS Microbial aetiology of uveitis is common in areas where HIV and TB are endemic. In these settings, a high index of suspicion for infectious origin of uveitis is warranted.
Collapse
Affiliation(s)
- Erik Schaftenaar
- Department of Viroscience, Erasmus Medical Center, Rotterdam, The Netherlands Anova Health Institute, Johannesburg, South Africa
| | - Christina Meenken
- Department of Ophthalmology, VU University Medical Center, Amsterdam, The Netherlands
| | | | | | - Ad Luijendijk
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
| | - James A McIntyre
- Anova Health Institute, Johannesburg, South Africa School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Albert D M E Osterhaus
- Research Center for Emerging Infections and Zoonoses, University of Veterinary Medicine, Hannover, Germany
| | - Georges M G M Verjans
- Department of Viroscience, Erasmus Medical Center, Rotterdam, The Netherlands Research Center for Emerging Infections and Zoonoses, University of Veterinary Medicine, Hannover, Germany
| | - Remco P H Peters
- Anova Health Institute, Johannesburg, South Africa Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| |
Collapse
|
12
|
|
13
|
Abstract
Multidisciplinary management in the diagnosis and management of patients with ocular inflammatory disease is often critical. The workup of uveitis or scleritis may reveal an underlying systemic disease. Recognition of inflammation by the primary care physician can facilitate prompt referral to a uveitis specialist and improve patient outcomes. The primary care physician can assist the ophthalmologist in monitoring for potential side effects of corticosteroids and immunosuppressive drugs, including the newer biologic agents. The ophthalmologist in turn can assist the primary care physician in recognizing that active uveitis may suggest incomplete control of preexisting conditions.
Collapse
Affiliation(s)
- James P Dunn
- Uveitis Unit, Retina Division, Wills Eye Hospital, Sidney Kimmel Medical College, Thomas Jefferson University, 840 Walnut Street, Suite 1020, Philadelphia, PA 19107, USA.
| |
Collapse
|
14
|
Cordero-Coma M, Salazar-Méndez R, Yilmaz T. Treatment of severe non-infectious uveitis in high-risk conditions (Part 2): systemic infections; management and safety issues. Expert Opin Drug Saf 2015; 14:1353-71. [PMID: 26118392 DOI: 10.1517/14740338.2015.1061992] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Management of patients with severe immune-mediated uveitis requires the use of immunosuppressive (IS) drugs in selected cases. This may be particularly challenging in certain patients with associated conditions, which may increase the risk of side effects or modify guidelines for the use of such drugs. Chronic viral and mycobacterial infections in the setting of non-infectious uveitis create a number of diagnostic but also therapeutic dilemmas to clinicians because they can be exacerbated by IS therapies with detrimental effects. AREAS COVERED In this review, we will focus on very specific chronic infections that can be affected by IS therapies: human immunodeficiency virus infection, chronic hepatitis virus infection and tuberculosis. The main aim of this review is to provide an updated and comprehensive practical guide for practitioners regarding the therapeutic decision-making and management of patients with non-infectious uveitis affected by the aforementioned infectious conditions. EXPERT OPINION Clinicians should be aware of the risk of viral and mycobacterial reactivation of an underlying infection during IS therapy. However, most of these conditions do not represent an absolute contraindication if one were able to apply an appropriate prior screening and close monitoring of such therapy.
Collapse
Affiliation(s)
- Miguel Cordero-Coma
- a 1 University of León, Instituto Biomedicina (IBIOMED), University Hospital of León , León, Spain +34 654403609 ; +34 987 233322 ;
| | | | | |
Collapse
|
15
|
Abstract
Uveitides can be due to non-infectious and infectious etiologies. It has been observed that there is a gender difference with a greater preponderance of non-infectious uveitis in women than in men. This review will describe both non-infectious and infectious uveitides and describes some of the current autoimmune mechanisms thought to be underlying the gender difference. It will specifically look at non-infectious uveitides with systemic involvement including juvenile idiopathic arthritis, spondyloarthopathies, sarcoidosis, Behçet’s disease, and Vogt-Koyanagi-Harada disease and at uveitides without systemic involvement including sympathetic ophthalmia, birdshot chorioretinitis, and the white dot syndromes. Infectious uveitides like acute retinal necrosis, progressive outer retinal necrosis, and cytomegalovirus mediated uveitis will be mentioned. Different uveitides with female- or male- predominance are presented and discussed.
Collapse
|