Grand Rounds Prat Itharat MD

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  • 60% may go unnoticed due to painless process
  • Episcleritis: 2nd stage; scleritis: 3rd 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

    1. 1. Grand Rounds Prat Itharat MD December 1, 2006 Vanderbilt Eye Institute
    2. 2. History  49 year old Caucasian male  “red eye” for 3 days  Questions?
    3. 3. 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
    4. 4. History  POH: no lasers/surgeries/trauma  PMH: chronic sinusitis, GERD, seasonal allergies  PSH: negative  FH: no glaucoma  SH: 1ppd cig; +etoh; no ivda
    5. 5. History  Allg: nkda  Meds: ranitidine, loratadine, mometasone, citalopram  ROS: fevers, chills, sore throat, cough; no back pain
    6. 6. 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
    7. 7. 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
    8. 8. Ocular examination
    9. 9. Differential Diagnosis
    10. 10. Differential Diagnosis  Toxoplasmosis  Syphilis  Tuberculosis  Fungal – cryptococcal, pneumocystis carinii  Sarcoidosis  Lymphoma  Bacterial endophthalmitis  Acute retinal necrosis  Metastases  Lyme, cat-scratch
    11. 11. 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
    12. 12. Our patient  CXR - old granulomatous disease; no active lesion  ACE - wnl  PPD – negative  RPR - positive  FTA-ABS – reactive  TPPA – reactive  HIV – negative  Cultures - negative
    13. 13. 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
    14. 14. 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
    15. 15. Syphilis  Spirochete bacterium Treponema pallidum  0.18 microns in width; 5-15 microns long  Sexual transmission most common  Transplacental transmission
    16. 16. Syphilis: epidemiology
    17. 17. Syphilis: epidemiology
    18. 18. Syphilis: stages  Primary: -after 10-90 days incubation (3 weeks avg) -painless chancre at site of inoculation -lymphadenopathy -resolve spontaneously in 4 weeks
    19. 19. Syphilis: stages  Secondary: -6 weeks to 6 months after chancre -develop in 25% untreated patients -hematogenous spread -maculopapular rash (70%)
    20. 20. Syphilis: stages  Secondary: -lymphadenopathy, HA, malaise, joint pain, mouth ulcers, hair loss -resolve spontaneously but 25% recurrent -10% ocular findings
    21. 21. 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
    22. 22. Syphilis: ocular Young et al. Ocular Manifestations and treatment of syphilis. Seminars in Ophthalmology 20(2005): 161-167.
    23. 23. Syphilis: Ocular  Congenital -pigmentary retinopathy -interstitial keratitis -cataracts
    24. 24. 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
    25. 25. 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)
    26. 26. Syphilis: Ocular
    27. 27. Syphilis: Ocular
    28. 28. Syphilis: Ocular
    29. 29. 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
    30. 30. 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+
    31. 31. Syphilis: workup
    32. 32. 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
    33. 33. 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
    34. 34. 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
    35. 35. 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.
    36. 36. Good luck, applicants!

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