Grand Rounds The Great Imitator Patrick Burchell, PGY-3
Grand Rounds The Great Imitator Patrick Burchell, PGY-3 January 11, 2019 Department of Ophthalmology and Visual Sciences Patient Presentation CC Sudden decreased vision in left eye HPI 26 yo AAM presents with a 1 week history of sudden decreased vision in his left eye. Noticed
upon awakening. Non-progressive. Associated flickering in periphery. No recent illness. History (Hx) Past Ocular Hx: Denied Past Medical Hx: Denied Fam Hx: Denied Meds: None Allergies: NKDA Social Hx: Everyday smoker, denied illicits ROS: +Headache External Exam OD
VA sc 20/20 Refraction OS 20/60-2 No improvement Pupils 43mm
43mm IOP 16 mmHg 15 mmHg EOM full full
CVF full full Anterior Segment Exam PLE or SLE OD OS External/Lids
WNL WNL Conj/Sclera WNL WNL Cornea Clear
Clear Ant Chamber Deep and quiet Deep and quiet Iris WNL WNL
OS Optic Nerve Elevation nasally, hyperemic Elevation nasally, hyperemic Vitreous Pigment cells in anterior vitreous
Pigment cells in anterior vitreous WNL Intraretinal creamy dots, blunted foveal reflex Normal caliber Normal caliber White without
pressure nasal to disc Few white dots along arcade Macula Vessels Periphery Color Fundus Photos OD OS
SD-OCT OD OS FAF 12/5 OD OS FA/ICG OS
56.52 1.19.12 FA/ICG OS 2.04.95 5.27.54 Assessment 26 yo AAM with a multifocal choroiditis OS Differential Diagnosis Syphilis
Sarcoidosis Tuberculosis White dot syndrome Idiopathic CBC, CXR, ACE, RPR, TP-PA, Quantiferon, HIV, HSV, CMV Course Pt was lost to follow up for 2 months but returned after an acute decrease in vision OD Stated that vision had improved OS Did not obtain lab work
Exam OD OS VA sc 20/100; PHNI 20/40-2; PH 20/25-2 Pupils
43mm 43mm IOP 7 mmHg 12 mmHg AC 1+ cell
quiet Posterior Segment Exam Fundus OD OS Optic Nerve Elevation nasally, hyperemic
Intraretinal creamy dots, blunted foveal reflex Normal caliber Normal caliber White without pressure nasal to disc Few white dots along arcade
Macula Vessels Periphery SD- OCT OD 10/18 OD12/5 SD-OCT OS 10/18 OS 12/5
FAF 10/18 12/05 Plan Pt left clinic prior to full workup Later called with progression of vision loss and obtained lab studies Outpatient Lab Results RPR+, titer 1:512, TP-PA+ HIV+ CMV IgG+, IgM EBV IgG+, IgM HSV IgG+, IgM Normal CXR
Hospital Course Pt was instructed to go to the ED, where he was admitted for treatment Started on IV Penicillin G 24 million units Neurosyphilis dosing Lumbar Puncture VDRL-, no pleocytosis, normal protein & glucose, Cryptococcus Discharged on IV Penicillin G X 2 weeks Syphilis Multisystem, chronic bacterial infection
caused by spirochete Treponema pallidum Transmission Transplacental (After 10th week) Sexual (Most common) Incidence 9.7/100.000 Men who have sex with men (MSM) African Americans https://labtestsonline.org/ tests/syphilis-tests Congenital Syphilis Hepatosplenomegaly, desquamating rash,
Acquired Syphilis Primary painless chancre Secondary lymphadenopathy, rash on palms/soles Tertiary gummas, neurological/cardiac involvement Ocular involvement at any stage Acquired Syphilis
Ocular involvement 5 - 8% of cases Usually secondary & tertiary stages Great Masquerader Iris Roseola Can involve all structures including pupillomotor pathways and optic nerve Posterior uveitis most
common Multifocal chorioretinitis Posterior Placoid Chorioretinitis Workup and treatment Serologic testing Non-treponemal (RPR, VDRL) + Treponemal (TP-PA) Include HIV Lumbar puncture Ocular syphilis = Neurosyphilis
IV Penicillin G 18-24 million units per day for 10-14 days IM Procaine penicillin 2.4 million units daily + probenecid 500 mg QID for 10-14 days Conclusions Syphilis should always be on your differential With prompt diagnosis it is curable with penicillin! Ocular syphilis = neurosyphilis Commonly coinfected with HIV Thank You
Dr. Wang Dr. Fleissig Dr. Piri References 1. 2. 3. 4. 5. 6. BCSC Section 9, Intraocular Inflammation and Uveitis
Wells J, Wood C, Sukthankar A, Jones NP. Ocular syphilis: the reestablishment of an old disease. Eye (2018) 32: 99-103. Lapere S, Mustak H, Steffen J. Clinical Manifestations and Cerebrospinal Fluid Status in Ocular Syphilis. Ocular Immunology and Inflammation (2018) 00: 1-5. Pichi F, Ciardella AP, Cunningham ET, et al. Spectral domain optical coherence tomography findings in patients with acute syphilitic posterior placoid chorioretinopathy. Retina (2014): 34; 373-384. Davis J. Ocular Syphilis. Ocular Manifestations of Systemic Disease (2014) 25; 513-518. Lima LH, Costa de Andrade G, et al. Multimodal imaging analyses of hyperreflective dot-like lesions in acute syphilitic posterior placoid chorioretinopathy. Journal of Ophthalmic Inflammation and Infection (2017) 7: 1-6.
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