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Grand Rounds Prat Itharat MD

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  • 60% may go unnoticed due to painless process
  • Episcleritis: 2 nd stage; scleritis: 3 rd stage Keratitis: immune mediated, nonulcerative, nonsuppurative
  • Hutchinson’s teeth (peg shaped incisor), mulberry molars, saddle nose, enlarged liver and spleen, petechiae, jaundice, snuffles, rhaghades (linear scars at angles of mouth and nose)
  • Roseola due to treponemal emboli
  • RPR: rapid plasma reagin VDRL: venereal disease research laboratory False positive to non-treponemal test: autoimmune disease, IVDA, TB, vaccinations, pregnancy, mono, HIV, rickettsial, bacterial endocarditis in 1-2% FTA-ABS: fluorescent treponemal antibody absorbed TP-PA: t pallidum particle agglutination False positive in treponemal: malaria, leprosy
  • RPR: rapid plasma reagin VDRL: venereal disease research laboratory False positive to non-treponemal test: autoimmune disease, IVDA, TB, vaccinations, pregnancy, mono, HIV, rickettsial, bacterial endocarditis in 1-2% FTA-ABS: fluorescent treponemal antibody absorbed TP-PA: t pallidum particle agglutination False positive in treponemal: malaria, leprosy

Grand Rounds Prat Itharat MD Grand Rounds Prat Itharat MD Presentation Transcript

  • Grand Rounds
    • Prat Itharat MD
    • December 1, 2006
    • Vanderbilt Eye Institute
  • History
    • 49 year old Caucasian male
    • “ red eye” for 3 days
    • Questions?
  • History
    • Redness in left eye for 3 days
    • Gradual onset of redness OS
    • Associated with photophobia, tearing
    • Blurry vision OS
    • Global headache, 4/10
    • No flashes, floaters
    • No nausea, vomiting
  • History
    • POH: no lasers/surgeries/trauma
    • PMH: chronic sinusitis, GERD, seasonal allergies
    • PSH: negative
    • FH: no glaucoma
    • SH: 1ppd cig; +etoh; no ivda
  • History
    • Allg: nkda
    • Meds: ranitidine, loratadine, mometasone, citalopram
    • ROS: fevers, chills, sore throat, cough; no back pain
  • Ocular examination
    • VAsc
    • OD: 20/60
    • OS: 20/400 PH 20/200
    • Pupils: no rapd
    • Ta: OD 26 OS 20
    • Motility: full ou
    • CVF: full ou
    • Ext: wnl ou
  • Ocular examination
    • SLE
    • l/l: wnl ou
    • conj: quiet od; 2+injection os
    • cornea: clear ou
    • a/c: d+q od; 2+cells os
    • iris: intact ou
    • lens: 1+nsc ou
    • ant vit: quiet od; +1 cells os
  • Ocular examination
  •  
  • Differential Diagnosis
  • Differential Diagnosis
    • Toxoplasmosis
    • Syphilis
    • Tuberculosis
    • Fungal – cryptococcal, pneumocystis carinii
    • Sarcoidosis
    • Lymphoma
    • Bacterial endophthalmitis
    • Acute retinal necrosis
    • Metastases
    • Lyme, cat-scratch
  • Our patient
    • Empirically started on sulfadiazine, pyrimethamine and folinic acid for toxoplasmosis
    • CXR, ACE, RPR, HIV, CBC, PPD
    • Returned twice within the week without improvement
    • Blood cultures obtained
  • Our patient
    • CXR - old granulomatous disease; no active lesion
    • ACE - wnl
    • PPD – negative
    • RPR - positive
    • FTA-ABS – reactive
    • TPPA – reactive
    • HIV – negative
    • Cultures - negative
  • Our patient
    • Further questioning
    • -syphilis 1970s – “I don’t know how”
    • -red rash below waist
    • -”blister” on arch of foot
    • -since 7/1/06, has not been feeling well, treated by outside facility without improvement
  • Our patient
    • Poor follow-up
    • CDC notified
    • Received 2.5M units PCN IM weekly x3
    • VA improved; constitutional symptoms improved; no pain, photophobia
    • Scheduled to follow up at VA clinic
  • Syphilis
    • Spirochete bacterium Treponema pallidum
    • 0.18 microns in width; 5-15 microns long
    • Sexual transmission most common
    • Transplacental transmission
  • Syphilis: epidemiology
  • Syphilis: epidemiology
  • Syphilis: stages
    • Primary:
    • -after 10-90 days incubation (3 weeks avg)
    • -painless chancre at site of inoculation
    • -lymphadenopathy
    • -resolve spontaneously in 4 weeks
  • Syphilis: stages
    • Secondary:
    • -6 weeks to 6 months after chancre
    • -develop in 25% untreated patients
    • -hematogenous spread
    • -maculopapular rash (70%)
  • Syphilis: stages
    • Secondary:
    • -lymphadenopathy, HA, malaise, joint pain, mouth ulcers, hair loss
    • -resolve spontaneously but 25% recurrent
    • -10% ocular findings
  • Syphilis: stages
    • Latent phase
    • Tertiary stage (40% untreated)
    • -vasculitis
    • -local granulomatous reaction = gumma
    • -cardiac: aortitis/aortic insufficiency/aneurysm
    • -neuro: tabes dorsalis, general paresis, meningitis, stroke
      • *CNS findings may present early
  • Syphilis: ocular Young et al. Ocular Manifestations and treatment of syphilis. Seminars in Ophthalmology 20(2005): 161-167.
  • Syphilis: Ocular
    • Congenital
    • -pigmentary retinopathy
    • -interstitial keratitis
    • -cataracts
  • Syphilis: Ocular
    • Uveitis most common presentation
    • May occur as soon as 6 weeks or in latent phase
    • Granulomatous or non-granulomatous
    • Unilateral or bilateral
    • Prior to 1940, second most common cause of uveitis
    • Only 2.45% of cases (Tamesis and Foster); others 1-2% of uveitis
    • Iris atrophy, nodules, roseola
  • Syphilis: Ocular
    • Chorioretinitis: posterior pole/mid-periphery
    • Lesions usually ½ to 1 DD but can be confluent
    • Variable amount of vitritis
    • May be associated with vasculitis, papillitis, serous RD, BRVO, necrotizing retinitis
    • May just involve RPE (syphilitic posterior placoid chorioretinitis)
  • Syphilis: Ocular
  • Syphilis: Ocular
  • Syphilis: Ocular
  • Syphilis: Ocular
    • Argyll Robertson pupil
    • Miotic, irregular
    • Light-near dissociation
    • Interruption of fibers from pretectum to EW nuclei
    • Also seen ms, dm, chronic alcoholism, encephalitis
  • Syphilis: workup
    • Definitive: darkfield microscopy or direct fluorescent antibody of tissue/exudate
    • Non-treponemal tests: RPR/VDRL
    • Treponemal tests FTA-ABS/TP-PA
    • PCR
    • HIV: may cause false negative
    • CSF: in HIV+
  • Syphilis: workup
  • Syphilis: treatment
    • Primary, secondary, early latent: benzathine penicillin G 2.4M units IMx1
    • Late latent, uncertain duration, tertiary syphilis: penicillin G 2.4M units IMx3 (weekly)
    • Alternatives: doxycycline 100mg BID for 2/4 weeks or tetracycline 500mg QID for 2/4 weeks
    • Neurosyphilis: aqueous penicillin G 3-4M units IV Q4H for 10-14 days
  • Syphilis: treatment
    • Jarisch-Herxheimer reaction: hypersensitivity reaction to antigens
    • Fever, myalgia, headache, malaise
    • May be associated with worsening ocular findings
    • May been avoided with steroids
  • Syphilis: treatment
    • VDRL/RPR does not respond in all treated
    • 97% of primary stage
    • 77% of secondary stage
    • VDRL usually positive for life
    • FTA-ABS positive for life
  • Bibliography
    • Knox, David. Retinal syphilis and tuberculosis. Chapter 100. Retina (1994): Mosby 1633-1641.
    • Uptodate Clinical Medicine
    • Exposto et al. Evaluation of the Treponema pallidum Particle Agglutination Technique (Tppa) in the diagnosis for neurosyphilis. J Clin Lab Analysis 20 (2006):233-238.
    • Szilard Kiss, Francisco Max Damico, and Lucy H Young. Ocular Manifestations and Treatment of Syphilis. Seminars in Ophthal 20(2005): 161-167.
    • Lehoang, et al. Syphilic Uveitis in patients infected with human immunodeficiency virus. Graefe Arch Clin Exp Ophthal 243(2005): 863-869.
    • Rao et al. Syphilis: Reemergence of an Old Adversary. Ophthal 113:11(2006): 2074-2079.
    • Margo, CE and Hamed LM. Ocular Syphilis. Survey of Ophthal 37:3(1992): 203-220.
  • Good luck, applicants!