1. Skin Rash and Visual Loss: “Looking for Love in All the Wrong Places” Clinical Conference July 28, 2004 Edward L. Goodman, MD

2. Case 1 History 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.

3. Exam VS were normal. Skin had generalized reticular rash not involving palms or soles Bilateral shoddy axillary nodes Normal heart, lungs, abdomen, neurologic

4. 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

5. 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

6. Sequential Serology’s DateSerum RPR 10/1/031:128 1/27/041:4 5/05/041:1

7. Case 2 History 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

8. Exam Temp 100.2, HR 104 Cloudy vitreous, white patches in pharynx Skin rash all over including palms and soles Penile ulcer

10. 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

11. 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!

12. Clinical Stages and Presentation of Syphilis

13. Typical Rash of Secondary Syphilis

14. Plantar Syphilid in Secondary Syphilis

15. Mucous Patch

16. CSF in Syphilis Kinghorn in Cohen and Powderly 2004

17. 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

18. Ocular Syphilis Can involve all areas of the eye –Conjunctiva –Iritis/iridocyclitis –Chorioretinitis –Posterior uveitis –Neuroretinitis Evolving syndromes associated with HIV

20. Ocular Syphilis Aldave AJ et al. Curr Opin Opthalmol 2001 Dec;12(6):433-41 SecondaryTertiary ConjunctivaPapillaryGranulomatous ScleraEpiscleritisScleritis CorneaMarginal infiltrates, precipitates Stromal keratitis, precipitates LensCataracts

21. Ocular Syphilis Aldave et al SecondaryTertiary Uveal tractIridocyclitis, vascularized iris nodules,isolated vitritis, chroioretinitis Chorioretinitis, gummas

22. Ocular Syphilis SecondaryTertiary RetinaNecrotizing neuroretinitis, retinochoroid, vasculitis, serous retinal detachment same Optic NerveDisc edema, Papilledema Same plus atrophy, gumma

23. Ocular Syphilis SecondaryTertiary IOPGlaucomaglaucoma PupilsArgyl Robertson EOMVarious palsies

24. Optic Neuritis

26. Differential Dx of Acute Unilateral Optic Neuropathy

27. Specific Causes of Neuroretinitis Viral and post viral Sarcoidosis Systemic Lupus and other vasculitides Syphilis Lyme Disease OI’s complicating HIV/AIDS

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

29. Interaction between Syphilis and HIV Cohen and Powderly 2004

30. Syphilis in MSM San Francisco

31. Syphilis in MSM Los Angeles

32. CDC 2002 STD Guidelines

33. 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, 2 nd 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.

34. 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