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![Page 1: Skin Rash and Visual Loss: “Looking for Love in All the Wrong Places” Clinical Conference July 28, 2004 Edward L. Goodman, MD.](https://reader035.fdocuments.us/reader035/viewer/2022070409/56649e895503460f94b8eaa5/html5/thumbnails/1.jpg)
Skin Rash and Visual Loss:“Looking for Love in All the Wrong Places”
Clinical Conference
July 28, 2004
Edward L. Goodman, MD
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Case 1History
• 57 year old divorced man referred to evaluate optic neuritis and skin rash.
• He became ill three weeks earlier with febrile illness, myalgias and skin rash. His internist evaluated him and obtained normal CBC, CMP.
• Shortly after, he had visual symptoms and saw an opthalmologist who diagnosed unilateral optic neuritis with visual field loss
• Fever resolved but rash, fatigue, myalgias and visual loss persisted.
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Exam
• VS were normal.
• Skin had generalized reticular rash not involving palms or soles
• Bilateral shoddy axillary nodes
• Normal heart, lungs, abdomen, neurologic
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Lab
• Normal CBC, CMP, CRP
• Negative Toxo, HCV, HBV, CMV, HIV serologies
• Negative blood culture
• RPR 1:128
• CSF: 48 WBC (80% LM), protein 96, VDRL negative
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Course
• Hospitalized overnight to obtain CSF and start intravenous penicillin
• Completed 14 days IV penicillin as outpatient - 3 mu IV Q4H followed by one dose of Bicillin 2.4 mu
• Complete resolution of rash and visual sx• Asymptomatic permanent isolated field loss• Refused follow-up LP
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Sequential Serology’s
Date Serum RPR
10/1/03 1:128
1/27/04 1:4
5/05/04 1:1
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Case 2History
• 33 year old man referred 2/18/04 for rash and visual loss
• 10/03 diagnosed as uveitis; + RPR and referred to Ft Worth ID physician; never went (couldn’t afford)
• Fever, skin rash, progressive visual loss
• Seen in office and admitted
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Exam
• Temp 100.2, HR 104
• Cloudy vitreous, white patches in pharynx
• Skin rash all over including palms and soles
• Penile ulcer
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Lab
• Normal CBC, low albumin
• RPR 1:128; HIV and Western Blot +
• CSF: 178 WBC (98% mononuclear), protein 79, glucose 33, VDRL 1:16
• Penile lesion: grew HSV
• CD4 259, HIV viral load 190,000
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Course
• Admit to hospital for CSF and penicillin • 14 days of IV penicillin in hospital (self pay)
– Herxheimer reaction first night• Rash transiently worsened• Fever transiently higher
– Bicillin at end of 14 days
• Valtrex for HSV: resolved• Defer HAART for fear of IRIS• LOST TO FOLLOW UP!
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Clinical Stages and Presentation of Syphilis
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Typical Rash of Secondary Syphilis
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Plantar Syphilid in Secondary Syphilis
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Mucous Patch
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CSF in SyphilisKinghorn in Cohen and Powderly 2004
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CSF in Posterior Segment Ocular Syphilis
Browning.Opthalmology Nov 2000.
• 14 patients with posterior segment ocular syphilis
• 12/14 positive RPR (14/14 + FTA-ABS)
• CSF examined in 10– VDRL: + 3/9 – Pleocytosis: 4/9 – Protein elevated: 4/9
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Ocular Syphilis
• Can involve all areas of the eye– Conjunctiva– Iritis/iridocyclitis– Chorioretinitis– Posterior uveitis– Neuroretinitis
• Evolving syndromes associated with HIV
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Ocular SyphilisAldave AJ et al. Curr Opin Opthalmol 2001 Dec;12(6):433-41
Secondary Tertiary
Conjunctiva Papillary Granulomatous
Sclera Episcleritis Scleritis
Cornea Marginal infiltrates, precipitates
Stromal keratitis, precipitates
Lens Cataracts Cataracts
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Ocular SyphilisAldave et al
Secondary Tertiary
Uveal tract Iridocyclitis, vascularized iris nodules,isolated vitritis, chroioretinitis
Chorioretinitis,
gummas
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Ocular SyphilisSecondary Tertiary
Retina Necrotizing neuroretinitis,
retinochoroid, vasculitis, serous retinal detachment
same
Optic Nerve Disc edema, Papilledema
Same plus atrophy, gumma
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Ocular Syphilis
Secondary Tertiary
IOP Glaucoma glaucoma
Pupils Argyl Robertson
EOM Various palsies Various palsies
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Optic Neuritis
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Differential Dx of Acute Unilateral Optic Neuropathy
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Specific Causes of Neuroretinitis
• Viral and post viral
• Sarcoidosis
• Systemic Lupus and other vasculitides
• Syphilis
• Lyme Disease
• OI’s complicating HIV/AIDS
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Optic Disc Edema and Macular Star in 13 yo girl with Bartonella
Neuroretinitis
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Interaction between Syphilis and HIV Cohen and Powderly 2004
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Syphilis in MSM San Francisco
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Syphilis in MSM Los Angeles
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CDC 2002 STD Guidelines
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Bibliography
• Aldave A, King J, Cunningham E. Ocular Syphilis. Curr Opin Opthalmol. 2001 Dec;12(6):433-41.
• Balcer L, Beck R. Inflammatory Optic Neuropathies and Neuroretinitis. Yanoff Opthalmology, 2nd ed. 2004; pp. 1263-74.
• Browning DJ. Posterior Segment Manifestations of Active Ocular Syphilis, Their Response to a Neurosyphilis Rgimen of Penicillin Therapy, and the Influence of HIV Status on Response. Ophthalmology 2000;107:2015-2023.
• CDC.STD Treatment Guidelines 2002. MMWR 2002;51 (No RR-6): 18-29.
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Bibliography
• CDC. Trends in Primary and Secondary Syphilis and HIV Infection in MSM – San Francisco and Los Angeles, California. MMWR 2004;53:575-578
• Dugel P, Thach A. Syphilitic Uveitis. Yanoff: pp. 1135-44.
• Kinghorn GR. Syphilis in Cohen and Powderley. Infectious Diseases 2004: Elsevier, pp. 807-816