A Man with Cloudy Vision

Posted by • July 1st, 2016

2016-06-27_11-38-42Syphilis can cause uveitis and retinitis. The uveitis can be anterior, posterior, or both (panuveitis) and can occur with or without a hypopyon (usually without).

A 50-year-old man with psoriatic arthritis and HIV infection presented with cloudy vision, decreased hearing, and gait instability. Two months earlier, the patient had begun taking antiretroviral medications. A diagnostic test result was received. A new Case Record of the Massachusetts General Hospital summarizes.

Clinical Pearl

• What is the most common retinal infection in patients with human immunodeficiency virus (HIV) infection?

Cytomegalovirus retinitis is the most common retinal infection in patients with HIV infection and is manifested by hemorrhagic or granular areas of retinitis with very slow progression.

Clinical Pearl

• What type of uveitis is associated with psoriatic arthritis?

Uveitis is a common finding in patients with psoriatic arthritis; such patients typically have nongranulomatous anterior uveitis (confined to the anterior chamber). Posterior-segment findings occasionally occur and include macular edema.

Morning Report Questions

Q: Describe some of the features of ocular syphilis.

A: Syphilis can affect every part of the eye and can result in a multitude of findings. It can cause retinal vasculitis, serous retinal detachment, posterior placoid chorioretinopathy, neuroretinitis, multifocal retinitis, and other findings, including ground-glass retinitis. Superficial retinal precipitates can also be present; they are presumed to be focal inflammatory accumulations on the retinal surface. In fact, superficial retinal precipitates are strongly suggestive of syphilis.

Figure 2. Imaging Studies of the Right Eye.

Q: How is ocular syphilis managed? 

A: In patients with ocular syphilis, especially those who present with an acute onset of symptoms, prompt initiation of antibiotic treatment is essential to prevent irreversible vision loss. A lumbar puncture is recommended for all patients with ocular syphilis or otosyphilis to determine whether there is concomitant involvement of the central nervous system, but antibiotic treatment should not be delayed if the patient declines to undergo a lumbar puncture or if the procedure cannot be performed promptly. Normal results of a cerebrospinal fluid analysis do not rule out ocular syphilis, because Treponema pallidum may infect the eye without infecting the brain or meninges. Immediate treatment for ocular syphilis should be given regardless of the results of cerebrospinal fluid analysis. Ocular syphilis, otosyphilis, and neurosyphilis (i.e., syphilis with brain or meningeal involvement) all require treatment with a 10-to-14-day course of high-dose intravenous penicillin. Glucocorticoids, such as prednisone, are often given concurrently with intravenous penicillin in patients with acute ocular syphilis or otosyphilis to reduce inflammation. After the course of intravenous penicillin is completed, some clinicians also give intramuscular penicillin G benzathine. Patients whose initial results of cerebrospinal fluid analysis are consistent with neurosyphilis should undergo a repeat lumbar puncture 6 months later to assess the response to treatment; some cases of neurosyphilis require retreatment.

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