skin rash and visual loss: “looking for love in all the wrong places” clinical conference july...

Skin Rash and Visual Loss:“Looking for Love in All the Wrong Places”

Clinical Conference

July 28, 2004

Edward L. Goodman, MD

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.

Exam

• VS were normal.

• Skin had generalized reticular rash not involving palms or soles

• Bilateral shoddy axillary nodes

• Normal heart, lungs, abdomen, neurologic

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

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

Sequential Serology’s

Date Serum RPR

10/1/03 1:128

1/27/04 1:4

5/05/04 1:1

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

Exam

• Temp 100.2, HR 104

• Cloudy vitreous, white patches in pharynx

• Skin rash all over including palms and soles

• Penile ulcer

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

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!

Clinical Stages and Presentation of Syphilis

Typical Rash of Secondary Syphilis

Plantar Syphilid in Secondary Syphilis

Mucous Patch

CSF in SyphilisKinghorn in Cohen and Powderly 2004

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

Ocular Syphilis

• Can involve all areas of the eye– Conjunctiva– Iritis/iridocyclitis– Chorioretinitis– Posterior uveitis– Neuroretinitis

• Evolving syndromes associated with HIV

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

Ocular SyphilisAldave et al

Secondary Tertiary

Uveal tract Iridocyclitis, vascularized iris nodules,isolated vitritis, chroioretinitis

Chorioretinitis,

gummas

Ocular SyphilisSecondary Tertiary

Retina Necrotizing neuroretinitis,

retinochoroid, vasculitis, serous retinal detachment

same

Optic Nerve Disc edema, Papilledema

Same plus atrophy, gumma

Ocular Syphilis

Secondary Tertiary

IOP Glaucoma glaucoma

Pupils Argyl Robertson

EOM Various palsies Various palsies

Optic Neuritis

Differential Dx of Acute Unilateral Optic Neuropathy

Specific Causes of Neuroretinitis

• Viral and post viral

• Sarcoidosis

• Systemic Lupus and other vasculitides

• Syphilis

• Lyme Disease

• OI’s complicating HIV/AIDS

Optic Disc Edema and Macular Star in 13 yo girl with Bartonella

Neuroretinitis

Interaction between Syphilis and HIV Cohen and Powderly 2004

Syphilis in MSM San Francisco

Syphilis in MSM Los Angeles

CDC 2002 STD Guidelines

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.

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