Article

A mystery retinitis

Careful, candid social history helped us initiate critical and timely therapy.

A 52-year-old male with a past medical history of HIV with noncompliance and AIDS presented with a 1-month history of painful, progressive vision loss in both of his eyes. He began treatment with another retina provider 1 month prior for fungal versus pneumocystis retinitis. Vision at presentation with previous provider was 20/200 OD and 20/25 OS. IOP was normal. Posterior exam was described as diffuse vasculitis with retinitis and 3+ vitritis OU. Herpes simplex virus (HSV), cytomegalovirus (CMV) antibodies were tested, Quant gold and treponemal IgG were sent and returned positive for HSV and treponemal IgG. The following day, he was taken for diagnostic tap of the right eye. Neomycin-polymyxin B-dexamethasone drops were started, but no record of specific systemic medication or intravitreal antibiotics was recorded.

After the first month of treatment with his other provider, the patient denied any improvement in his vision. He stated that his vision acutely worsened in his right eye 2 to 3 days before and began worsening in his left. He had also developed a skin rash on his extremities.

OUR EXAM

Our findings for this patient were as follows:

  • Distance visual acuity was NLP OD and 20/30 OS.
  • IOP was normal.
  • Pupils were minimally reactive OU with a positive afferent papillary defect OD.
  • Anterior exam was notable for a 1+ injection in the right eye. Minimal injection in the left.
  • Posterior exam demonstrated a multifocal retinitis involving both eyes, OD>OS (Figures 1 and 2).

    Figure 1. Multifocal, hypopigmented lesions of the right eye.

    Figure 2. Multifocal, hypopigmented lesions of the left eye.

Other findings: Social history was notable for unprotected sexual activity with men. The patient also demonstrated an erythematous, scaly rash involving both hands (Figure 3). He was being treated with nystatin topically for a fungal rash.

Figure 3. Erythematous, scaly rash of bilateral hands.

THE WORK-UP

Our differential included acute retinal necrosis, CMV retinitis, fungal chorioretinitis, Cat-scratch disease and ocular syphilis. Repeat labs were performed; pertinent laboratory findings included a CD4 count of 240, negative Candida and Cocciodiodes antibodies and negative Cryptococcal antigens.

The patient had a positive rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) test. Given evidence of syphilitic retinitis, the patient underwent lumbar puncture, which was notable for a positive VDRL in his cerebrospinal fluid (CSF). We started the patient on treatment with IV penicillin for ocular and neurosyphilis.

THE DIAGNOSIS

Syphilis is a common cause of uveitis, particularly in men who have sex with men (MSM). According to 2017 Centers for Disease Control and Prevention statistics, MSM constituted 52% of the recorded cases of syphilis in the United States. Interestingly enough, gay and bisexual men also constituted 66% of all U.S. HIV diagnoses in 2017.1,2 Although uveitis, particularly posterior uveitis, accounts for the majority of the cases of ocular syphilis, less common variants can include keratitis and scleritis.3,4

All cases of ocular syphilis should be treated as neurosyphilis with 2 weeks of IV penicillin and lumbar puncture to rule out CSF involvement. These patients require frequent follow-up with RPR or VDRL titers to assure appropriate treatment and response to therapy.4,5

THE LESSON

The appearance of the syphilitic chorioretinitis is highly variable and can be misleading, especially in an immunocompromised individual who may or may not provide a reliable history. This patient had already been treated for possible fungal or CMV retinitis without improvement. However, when treating patients in a high-risk demographic, such as HIV-infected MSM, the clinician should maintain a high index of suspicion not only for CMV and fungal infections but other possible causes of chorioretinitis and retinal necrosis as well.

We saw our patient for another 2 months before he was lost to follow-up. BCDVA was hand motion OD and 20/50 OS at that time. OM

REFERENCES

  1. HIV in the United States and Dependent Areas. Centers for Disease Control and Prevention. https://www.cdc.gov/hiv/statistics/overview/ataglance.html . Published May 9, 2019. Accessed June 17, 2019.
  2. Syphilis statistics — STD information from CDC. Centers for Disease Control and Prevention. https://www.cdc.gov/std/syphilis/stats.htm . Published December 16, 2016. Accessed June 17, 2019.
  3. Durand ML. Infectious causes of uveitis. In: Mandell, Douglas, and Bennett’s Principles and Practices of Infectious Disease. 8th ed. Saunders; 1423-1431.
  4. Furtado JM, Arantes TE, Nascimento H, et al. Clinical manifestations and ophthalmic outcomes of ocular syphilis at a time of re-emergence of the systemic infection. Sci Rep. 2018;8:1271.
  5. 2015 STD Treatment Guidelines. Centers for Disease Control and Prevention. https://www.cdc.gov/std/tg2015/default.htm . Published June 4, 2015. Accessed June 17, 2019.

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