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Syphilitic placoid chorioretinitis. A case-report
a r c h s o c e s p o f t a l m o l . 2 0 1 6;9 1(5):232–235
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA www.elsevier.es/oftalmologia
Short communication
Syphilitic placoid chorioretinitis. A case-report夽 L. Monje-Fernández a,∗ , E. Martín-García b , M. Cordero-Coma a,c a b c
Servicio de Oftalmología, Hospital Universitario de León, León, Spain Servicio de Oftalmología, Hospital Universitario de Salamanca, Salamanca, Spain Instituto de Biomedicina (IBIOMED), Universidad de León, León, Spain
a r t i c l e
i n f o
a b s t r a c t
Article history:
Clinical case: We report the case of a 45-year-old woman, with unremarkable past medical
Received 27 April 2015
history, who presented with acute visual loss in her left eye due to bilateral posterior uveitis.
Accepted 11 January 2016
After the screening, she was diagnosed with acute syphilitic placoid chorioretinitis and was
Available online 29 March 2016
treated with intravenous penicillin.
Keywords:
mimic several aetiologies. Anti-treponema treatment usually induces a quick and positive
T. pallidum
response in affected patients. Prompt and proper diagnosis of these patients is crucial,
Panuveitis
although anatomical and functional damage may persist.
Discussion: Clinical manifestations of ocular syphilis are extremely heterogeneous and may
Bilateral
˜ © 2016 Sociedad Espanola de Oftalmología. Published by Elsevier España, S.L.U. All rights reserved.
Placoid chorioretinitis Acute
Coriorretinitis placoide sifilítica. Caso clínico r e s u m e n Palabras clave:
˜ Caso clínico: Presentamos el caso de una mujer de 45 anos sin antecedentes de interés y con
T. pallidum
una pérdida súbita de visión en su ojo izquierdo secundaria a una uveítis posterior bilateral.
Panuveítis
Tras despistaje, se diagnosticó de coriorretinitis placoide posterior aguda sifilítica, y recibió
Bilateral
tratamiento con penicilina intravenosa.
Coriorretinitis placoide
Discusión: Existen múltiples manifestaciones oculares de la sífilis que pueden simular
Aguda
cuadros y etiologías muy diversas. El tratamiento anti-treponémico normalmente produce una rápida y positiva respuesta en pacientes afectos. El diagnóstico precoz y certero de estos ˜ anatómicos y funcionales son pacientes es por tanto crucial aunque, en ocasiones, los danos irreversibles. ˜ © 2016 Sociedad Espanola de Oftalmología. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.
夽 Please cite this article as: Monje-Fernández L, Martín-García E, Cordero-Coma M. Coriorretinitis placoide sifilítica. Caso clínico. Arch Soc Esp Oftalmol. 2016;91:232–235. ∗ Corresponding author. E-mail address: [email protected] (L. Monje-Fernández). ˜ 2173-5794/© 2016 Sociedad Espanola de Oftalmología. Published by Elsevier España, S.L.U. All rights reserved.
a r c h s o c e s p o f t a l m o l . 2 0 1 6;9 1(5):232–235
233
Introduction
Clinic case report
The Treponema pallidum spirochaete is the etiological agent of syphilis, a sexual transmission disease through direct contact of an active cutaneous-mucosa syphilitic lesion in the primary or secondary stage.1 The compromise of any ocular structure has been described.2 In what concerns uveitis patterns, anterior, intermediate, posterior or diffuse involvement can be found in one or both eyes, which can be granulomatous or nongranulomatous.3 For this reason, the differential diagnostic comprises a broad range of diseases coursing with ocular inflammation.4 Acute posterior placoid chorioretinitis is an infrequent expression which is clinically and angiographically different to that of other ocular syphilis involvements.5 A female who exhibited acute syphilitic posterior placoid chorioretinitis is described. Despite treatment, both anatomic and functional sequels have remained due to the severity of the condition.
Female, 45, without relevant personal history, who visited due to sudden loss of central vision in the left eye (LE) with 4 days evolution. Best corrected visual acuity (BCVA) was of 20/20 in the right eye (RE) and light perception (LP) in the LE. Intraocular pressure was normal in both eyes, as well as anterior pole examination. Ocular fundus showed +1 vitritis in both eyes (BE) and bilateral papillitis in addition to intense retinal posterior pole edema in the LE. Macular optic coherence tomography (OCT) revealed LE neurosensory detachment at the subfoveal level and discrete granular hyper-reflectiveness of the retina pigment epithelium (RPE). Fluorescein angiography (FAG) revealed non-obstructive bilateral vasculitis, early hypofluorescence in the placoid lesion area with late staining thereof (Fig. 1). Multiple screening tests were carried out, including the main infectious and non-infectious etiologies that could cause uveitis in the posterior segment. The results of all these tests
Fig. 1 – Right eye ophthalmoscopic, angiographic and tomographic findings (first visit) showing placoid lesion with intense chorioretinal edema in LE posterior pole and bilateral vasculitis.
234
a r c h s o c e s p o f t a l m o l . 2 0 1 6;9 1(5):232–235
Fig. 2 – ophthalmoscopic, angiographic and tomographic findings after intravenous antibiotic treatment (15 days after the first visit). Chorioretinal edema and vasculitis have disappeared although a slight papillary contrast subsists in late angiography times.
were within normal limits, with the exception of the syphilis tests which showed positive 1/8 in rapid plasmin reagin (RPR) and 1/1.280 in Treponema pallidum hemagglutination (TPHA). Subsequently, the study was completed with a lumbar puncture that confirmed positive VDRL in the cerebrospinal fluid (CSF). The patient was admitted and administered 24 million UI of intravenous sodium penicillin G during 14 days. After said antibiotic treatment the patient was examined and exhibited persistence of a minimum grade of vitritis and papillitis in BE as well as an atrophy area in RPE corresponding to the area with intense chorioretinal edema in the LE. BCVA was of 0.3. Macular OCT was normal and FAG established the resolution of vasculitis and said lesion, as well as confirming the persistence of bilateral papillitis (Fig. 2). For this reason it was decided to administer oral corticoids in descending amounts, which determined a complete resolution of the condition a few weeks after beginning said treatment. After one year, BCVA has improved to 0.8.
Discussion Ocular compromise secondary to syphilis can be varied and with diverse prognosis. Accordingly, ocular syphilis diagnostic must he considered in the presence of infrequent inflammatory processes. Gass et al.6 coined the term “syphilitic acute posterior placoid chorioretinitis” to describe the large white-yellowish plates at the retina pigment epithelium that appeared in the macular and juxtapapillary areas with characteristic angiographic patterns. It has been proposed that this finding is the direct result of the modification of the host immune response to the syphilis7 and that spontaneous resolution could be due to the immunological reaction of the patient to fight the infection. Due to the similarities found in funduscopy, a differential diagnostic must be established with central serous chorioretinopathy, viral retinitis, Vogt–Koyanagi–Harada or central retinal artery obstruction, the latter being one of the initial
a r c h s o c e s p o f t a l m o l . 2 0 1 6;9 1(5):232–235
diagnostic hypothesis of the authors. In patients with joint HIV infection, syphilis can be accelerated and neuro-syphilis can express rapidly due to the condition of the immune system. The authors wish to emphasize the potential aggressiveness with which ocular syphilis can express and the complications derived thereof, which on some occasions could be irreversible. Accordingly, the highest priority must be given to confirm the condition and initiate adequate treatment.8 In general, visual recovery occurs after completing appropriate antibiotic treatment. It is important to take into account the increased prevalence in the past 5 years,9 and that any diagnostic delay and macular involvement entails permanent visual loss in these patients despite adequate treatment.
Conflict of interests No conflict of interests was declared by the authors.
references
1. Finelli L, Levine WC, Valentine J, Louis ME. Syphilis outbreak assessment. Sex Transm Dis. 2001;28:131–5.
235
2. Gaudio PA. Update on ocular syphilis. Curr Opin Ophthalmol. 2006;17:562–6. 3. Aldave AJ, King JA, Cunningham ET Jr. Ocular syphilis. Curr Opin Ophthalmol. 2001;12:433–41. 4. Fonollosa A, Martínez-Indart L, Artaraz J, Martínez-Berriotxoa A, Aguirrebengoa K, García M, et al. Clinical manifestations and outcomes of syphilis-associated uveitis in northern Spain. Ocul Immunol Inflamm. 2014;14:1–6. 5. Eandi CM, Neri P, Adelman RA, Yannuzzi LA, Cunningham ET Jr. Acute syphilitic posterior placoid chorioretinitis: report of a case series and comprehensive review of the literature. Retina. 2012;32:1915–41. 6. Gass JD, Branunstein RA, Chenoweth RG. Acute syphilitic posterior placoid chorioretinitis. Ophthalmology. 1990;97:1288–97. 7. Zamani M, Garfinkel RA. Corticosteroid-induced modulation of acute syphilitic posterior placoid chorioretinitis. Am J Ophthalmol. 2002;135:891–3. 8. Morandi A, Salek S, Daniel E, Gangaputra S, Ostheimer TA, Leung TG, et al. Clinical features and incidence rates of ocular complications in patients with ocular syphilis. Am J Ophthalmol. 2015;159:334–43.
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA www.elsevier.es/oftalmologia
Short communication
Syphilitic placoid chorioretinitis. A case-report夽 L. Monje-Fernández a,∗ , E. Martín-García b , M. Cordero-Coma a,c a b c
Servicio de Oftalmología, Hospital Universitario de León, León, Spain Servicio de Oftalmología, Hospital Universitario de Salamanca, Salamanca, Spain Instituto de Biomedicina (IBIOMED), Universidad de León, León, Spain
a r t i c l e
i n f o
a b s t r a c t
Article history:
Clinical case: We report the case of a 45-year-old woman, with unremarkable past medical
Received 27 April 2015
history, who presented with acute visual loss in her left eye due to bilateral posterior uveitis.
Accepted 11 January 2016
After the screening, she was diagnosed with acute syphilitic placoid chorioretinitis and was
Available online 29 March 2016
treated with intravenous penicillin.
Keywords:
mimic several aetiologies. Anti-treponema treatment usually induces a quick and positive
T. pallidum
response in affected patients. Prompt and proper diagnosis of these patients is crucial,
Panuveitis
although anatomical and functional damage may persist.
Discussion: Clinical manifestations of ocular syphilis are extremely heterogeneous and may
Bilateral
˜ © 2016 Sociedad Espanola de Oftalmología. Published by Elsevier España, S.L.U. All rights reserved.
Placoid chorioretinitis Acute
Coriorretinitis placoide sifilítica. Caso clínico r e s u m e n Palabras clave:
˜ Caso clínico: Presentamos el caso de una mujer de 45 anos sin antecedentes de interés y con
T. pallidum
una pérdida súbita de visión en su ojo izquierdo secundaria a una uveítis posterior bilateral.
Panuveítis
Tras despistaje, se diagnosticó de coriorretinitis placoide posterior aguda sifilítica, y recibió
Bilateral
tratamiento con penicilina intravenosa.
Coriorretinitis placoide
Discusión: Existen múltiples manifestaciones oculares de la sífilis que pueden simular
Aguda
cuadros y etiologías muy diversas. El tratamiento anti-treponémico normalmente produce una rápida y positiva respuesta en pacientes afectos. El diagnóstico precoz y certero de estos ˜ anatómicos y funcionales son pacientes es por tanto crucial aunque, en ocasiones, los danos irreversibles. ˜ © 2016 Sociedad Espanola de Oftalmología. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.
夽 Please cite this article as: Monje-Fernández L, Martín-García E, Cordero-Coma M. Coriorretinitis placoide sifilítica. Caso clínico. Arch Soc Esp Oftalmol. 2016;91:232–235. ∗ Corresponding author. E-mail address: [email protected] (L. Monje-Fernández). ˜ 2173-5794/© 2016 Sociedad Espanola de Oftalmología. Published by Elsevier España, S.L.U. All rights reserved.
a r c h s o c e s p o f t a l m o l . 2 0 1 6;9 1(5):232–235
233
Introduction
Clinic case report
The Treponema pallidum spirochaete is the etiological agent of syphilis, a sexual transmission disease through direct contact of an active cutaneous-mucosa syphilitic lesion in the primary or secondary stage.1 The compromise of any ocular structure has been described.2 In what concerns uveitis patterns, anterior, intermediate, posterior or diffuse involvement can be found in one or both eyes, which can be granulomatous or nongranulomatous.3 For this reason, the differential diagnostic comprises a broad range of diseases coursing with ocular inflammation.4 Acute posterior placoid chorioretinitis is an infrequent expression which is clinically and angiographically different to that of other ocular syphilis involvements.5 A female who exhibited acute syphilitic posterior placoid chorioretinitis is described. Despite treatment, both anatomic and functional sequels have remained due to the severity of the condition.
Female, 45, without relevant personal history, who visited due to sudden loss of central vision in the left eye (LE) with 4 days evolution. Best corrected visual acuity (BCVA) was of 20/20 in the right eye (RE) and light perception (LP) in the LE. Intraocular pressure was normal in both eyes, as well as anterior pole examination. Ocular fundus showed +1 vitritis in both eyes (BE) and bilateral papillitis in addition to intense retinal posterior pole edema in the LE. Macular optic coherence tomography (OCT) revealed LE neurosensory detachment at the subfoveal level and discrete granular hyper-reflectiveness of the retina pigment epithelium (RPE). Fluorescein angiography (FAG) revealed non-obstructive bilateral vasculitis, early hypofluorescence in the placoid lesion area with late staining thereof (Fig. 1). Multiple screening tests were carried out, including the main infectious and non-infectious etiologies that could cause uveitis in the posterior segment. The results of all these tests
Fig. 1 – Right eye ophthalmoscopic, angiographic and tomographic findings (first visit) showing placoid lesion with intense chorioretinal edema in LE posterior pole and bilateral vasculitis.
234
a r c h s o c e s p o f t a l m o l . 2 0 1 6;9 1(5):232–235
Fig. 2 – ophthalmoscopic, angiographic and tomographic findings after intravenous antibiotic treatment (15 days after the first visit). Chorioretinal edema and vasculitis have disappeared although a slight papillary contrast subsists in late angiography times.
were within normal limits, with the exception of the syphilis tests which showed positive 1/8 in rapid plasmin reagin (RPR) and 1/1.280 in Treponema pallidum hemagglutination (TPHA). Subsequently, the study was completed with a lumbar puncture that confirmed positive VDRL in the cerebrospinal fluid (CSF). The patient was admitted and administered 24 million UI of intravenous sodium penicillin G during 14 days. After said antibiotic treatment the patient was examined and exhibited persistence of a minimum grade of vitritis and papillitis in BE as well as an atrophy area in RPE corresponding to the area with intense chorioretinal edema in the LE. BCVA was of 0.3. Macular OCT was normal and FAG established the resolution of vasculitis and said lesion, as well as confirming the persistence of bilateral papillitis (Fig. 2). For this reason it was decided to administer oral corticoids in descending amounts, which determined a complete resolution of the condition a few weeks after beginning said treatment. After one year, BCVA has improved to 0.8.
Discussion Ocular compromise secondary to syphilis can be varied and with diverse prognosis. Accordingly, ocular syphilis diagnostic must he considered in the presence of infrequent inflammatory processes. Gass et al.6 coined the term “syphilitic acute posterior placoid chorioretinitis” to describe the large white-yellowish plates at the retina pigment epithelium that appeared in the macular and juxtapapillary areas with characteristic angiographic patterns. It has been proposed that this finding is the direct result of the modification of the host immune response to the syphilis7 and that spontaneous resolution could be due to the immunological reaction of the patient to fight the infection. Due to the similarities found in funduscopy, a differential diagnostic must be established with central serous chorioretinopathy, viral retinitis, Vogt–Koyanagi–Harada or central retinal artery obstruction, the latter being one of the initial
a r c h s o c e s p o f t a l m o l . 2 0 1 6;9 1(5):232–235
diagnostic hypothesis of the authors. In patients with joint HIV infection, syphilis can be accelerated and neuro-syphilis can express rapidly due to the condition of the immune system. The authors wish to emphasize the potential aggressiveness with which ocular syphilis can express and the complications derived thereof, which on some occasions could be irreversible. Accordingly, the highest priority must be given to confirm the condition and initiate adequate treatment.8 In general, visual recovery occurs after completing appropriate antibiotic treatment. It is important to take into account the increased prevalence in the past 5 years,9 and that any diagnostic delay and macular involvement entails permanent visual loss in these patients despite adequate treatment.
Conflict of interests No conflict of interests was declared by the authors.
references
1. Finelli L, Levine WC, Valentine J, Louis ME. Syphilis outbreak assessment. Sex Transm Dis. 2001;28:131–5.
235
2. Gaudio PA. Update on ocular syphilis. Curr Opin Ophthalmol. 2006;17:562–6. 3. Aldave AJ, King JA, Cunningham ET Jr. Ocular syphilis. Curr Opin Ophthalmol. 2001;12:433–41. 4. Fonollosa A, Martínez-Indart L, Artaraz J, Martínez-Berriotxoa A, Aguirrebengoa K, García M, et al. Clinical manifestations and outcomes of syphilis-associated uveitis in northern Spain. Ocul Immunol Inflamm. 2014;14:1–6. 5. Eandi CM, Neri P, Adelman RA, Yannuzzi LA, Cunningham ET Jr. Acute syphilitic posterior placoid chorioretinitis: report of a case series and comprehensive review of the literature. Retina. 2012;32:1915–41. 6. Gass JD, Branunstein RA, Chenoweth RG. Acute syphilitic posterior placoid chorioretinitis. Ophthalmology. 1990;97:1288–97. 7. Zamani M, Garfinkel RA. Corticosteroid-induced modulation of acute syphilitic posterior placoid chorioretinitis. Am J Ophthalmol. 2002;135:891–3. 8. Morandi A, Salek S, Daniel E, Gangaputra S, Ostheimer TA, Leung TG, et al. Clinical features and incidence rates of ocular complications in patients with ocular syphilis. Am J Ophthalmol. 2015;159:334–43.