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Optic neuritis secondary to syphilis
Neuritis óptica secundaria a sífilis
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Ocular ultrasound (B) revealed an attached retina and a vitreous cavity within normal parameters. Microbiological study results (D) of the mussel shell sample taken intraoperatively.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.M. Lopez, M.S. Pighin, M. Picco, I. Jürgens" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J.M." "apellidos" => "Lopez" ] 1 => array:2 [ "nombre" => "M.S." "apellidos" => "Pighin" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Picco" ] 3 => array:2 [ "nombre" => "I." 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Téllez Guzmán, M.C. Atilano Anzaldo, K.P. Delgado Moreno" "autores" => array:3 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "Téllez Guzmán" "email" => array:1 [ 0 => "irasematg43@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.C." "apellidos" => "Atilano Anzaldo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "K.P." "apellidos" => "Delgado Moreno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Hospital Regional Valentín Gómez Farias, Zapopan, Jalisco, Mexico" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Clínica Hospital Constitución, Monterrey, Nuevo León, Mexico" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neuritis óptica secundaria a sífilis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 3601 "Ancho" => 2925 "Tamanyo" => 725419 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Performed 30-2 Humphrey visual field SITA Standard with annular scotoma.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Syphilis is caused by <span class="elsevierStyleItalic">Treponema pallidum</span>, a spirochete transmitted mainly through sexual contact. Syphilis occurs in all ages<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and there has been a re-emergence in recent years, particularly among homosexual males and drug users as a coinfection with HIV.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Syphilis infection can accelerate the progression of HIV<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and can interact in a synergistic manner to enhance transmission and disease virulence·<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The clinical presentation of syphilis can be variable, beside affecting other organs, ocular involvement can occur in any structure, uveitis being the most common manifestation.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Syphilis is divided in four stages: primary, secondary, latent and tertiary. The eye and brain can be involved at any stage.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The presence of optic nerve abnormalities in a patient with syphilis is highly suggestive of central nervous system affection.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Optic neuritis pathogenesis is secondary to an inflammatory process which leads to delayed type IV hypersensitivity reaction.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1025">Case history</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 62-year-old male that had a medical history of type 2 diabetes mellitus, hepatitis B and one-month HIV diagnosis, presented a macular rash on trunk and extremities as well as asthenia and adynamia. The serological examination reported a titer of venereal diseases research laboratory (VDRL) of 1:512 dilutions. Therefore, he was treated with ceftriaxone for twenty-three days, pancreatin, propranolol, antiretrovirals and trimethoprim/sulfamethoxazole.</p><p id="par0020" class="elsevierStylePara elsevierViewall">He presented to the ophthalmologic clinic with decreased vision with myodesopsias in the right eye for the last two months. On examination, visual acuity of the right eye was 20/40 (.) 20/25 and 20/30 (.) 20/20 on the left eye, intraocular pressure of 11- and 9-mm Hg respectively. The anterior segment was normal in both eyes. Direct and consensual reactions of both eyes were normal. Ishihara test on the right eye was 3/8. The posterior segment of the right eye showed an optic disc with peripapillary hemorrhages and retinal pigment epithelium hyperplasia (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a Posterior segment of the right eye with peripapillary hemorrhages and retinal pigment epithelium hyperplasia). Optical coherence tomography (OCT) of the optic nerve showed edema of papilla with significant thickening of the nerve fiber layer of the retina (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> Optic nerve OCT with thickening of the nerve fiber layer of the right eye taken one month after onset of clinical symptoms). We requested a new VDRL, reporting titer of 1:246 dilutions and fluorescent treponemal antibody absorption test (FTA ABS) IgM 1:32 IgG 1:320. After this result, a new evaluation by the Infectious disease department was requested due to the high clinical suspicion of neurosyphilis. The patient was admitted for a lumbar puncture with evaluation of cerebrospinal fluid (CSF), which showed leucocytes 2/mm<span class="elsevierStyleSup">3</span>, glucose 74 mg/dL, proteins 40.67 mg/dL, lactate dehydrogenase (LDH) 25 mg/dL, chloride 125.7 mg/dl, negative Gram, negative Chinese stain, negative culture at 96 h. Treatment was subsequently initiated with ceftriaxone 2 grams every 12 h for 14 days.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We performed 30-2 Humphrey visual field SITA Standard posterior to treatment presenting visual field index (VFI) of 66% with mean deviation (MD) of −17,69 dB (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> performed 30-2 Humphrey visual field SITA Standard with annular scotoma). The patient’s visual acuity did not improve, the optic nerve had a pale appearance (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b) with resolution of edema and the new VDRL titer was 1:32 dilutions. Seven months later a second lumbar punction was performed and reported a negative VDRL. The patient will be followed up for control to avoid relapses.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Optic neuritis secondary to infectious disease is an uncommon clinical presentation. Usually, the most frequent etiologies are demyelinating lesions or autoimmune diseases. Ocular involvement is reported to occur in less than 1%–10% of all cases of syphilis. In a study of 132 patients with optic neuritis, syphilis was responsible for 2.27% of cases of optic neuritis.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> The rate of HIV co-infection with syphilis has been documented to range from 20 to 70%.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In syphilis, optic nerve involvement can be unilateral or bilateral and manifest as perineuritis, anterior or retrobulbar optic neuritis or papilledema<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,8</span></a> and since there is involvement of the central nervous system, it should be considered as neurosyphilis. In anterior optic neuritis the optic nerve head appears inflamed and there is often cellular activity in the posterior vitreous.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The diagnosis of neurosyphilis is based on clinical and laboratory tests. Nontreponemal test are used to correlate activity and the treponemal are used as confirmatory tests and remain positive for life<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and in the HIV-infected patient is based on positive serologic tests for syphilis, plus one or more of the following<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0035" class="elsevierStylePara elsevierViewall">A positive CSF VDRL or positive CSF FTA-ABS</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0040" class="elsevierStylePara elsevierViewall">CSF pleocytosis</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0045" class="elsevierStylePara elsevierViewall">A CSF protein level greater than 50 mg/dL</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">Our patient was treated at first with intravenous and oral antibiotics, however titers of VDRL persisted high until a new antibiotic regimen was started. The treatment of choice for neurosyphilis when HIV is positive is aqueous crystalline penicillin G 3-4 × 10 U<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> IV 6 × daily for 14 days. As an alternative, especially in patients allergic to penicillin, intravenous or intramuscular ceftriaxone can be used at a dose of 2 grams every 24 h for 14 days. Due to the hospital's shortage of penicillin, we decided to start treatment with ceftriaxone. The follow-up must be done through non-treponemal test titers.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">There is a higher risk of relapse with an inadequately treatment, mainly if there is concurrent HIV infection. Therefore, patients must always receive a multidisciplinary management, in collaboration with infectologists for better and successful outcomes.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Also lumbar puncture should be repeated every six months for the next two years in patients who have had neurosyphilis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Toxoplasmosis is an important differential diagnosis, it was ruled out because generally the involvement of the optic nerve in this disease can present a juxtapapillary chorioretinitis, neuroretinitis or pure papillitis but typically occurs next to or far from an active necrotizing retinochoroiditis lesion.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Trimethoprim/sulfamethoxazole was indicated by the infectologist as prophylaxis to opportunist infections as the recent diagnosis with HIV and the low count of CD4.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The clinical case illustrates the importance of a proper approach in the context of a patient with optic neuritis, having in mind that this may be the only manifestation of neurosyphilis. Also, risk factors and associated infectious diseases such as HIV must always be ruled out in the presence of optic neuritis.</p><p id="par0070" class="elsevierStylePara elsevierViewall">We must use laboratory tests to confirm our diagnosis and to a correct follow up, as well as a multidisciplinary management.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflict of interests</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres2157684" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1830890" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2157683" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1830891" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0001" "titulo" => "Case history" ] 6 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-10-08" "fechaAceptado" => "2024-02-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1830890" "palabras" => array:4 [ 0 => "Syphilis" 1 => "Neurosyphilis" 2 => "Optic neuritis" 3 => "Cerebrospinal fluid analysis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1830891" "palabras" => array:4 [ 0 => "Sífilis" 1 => "Neurosífilis" 2 => "Neuritis óptica" 3 => "Análisis líquido cefalorraquídeo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Optic neuritis is a rare manifestation of syphilis, and the involvement of the central nervous system should be considered synonymous with neurosyphilis. This infectious disease, well known as the great imitator, can affect any structure and produce multiple clinical symptoms. Here, we report a case of a 62- year-old male patient who presented to our service with decreased vision and myodesopsias in right eye. The posterior segment showed a hyperemic nerve with peripapillary hemorrhages and retinal pigment epithellium hyperplasia. The patient was recently diagnosed with HIV. Serology for syphilis was positive with posterior decreased levels of nontreponemal test following treatment with ceftriaxone. Optic neuritis can occur at any stage of syphilis and must always be considered a differential diagnosis.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La neuritis óptica es una manifestación poco común de la sífilis, la afectación del sistema nervioso central debe considerarse sinónimo de neurosífilis. Esta enfermedad infecciosa, conocida como "la gran imitadora", puede afectar cualquier estructura ocular y producir múltiples manifestaciones clínicas. Presentamos el caso de un varón de 62 años que acudió a nuestro servicio con disminución de visión y miodesopsias en ojo derecho. El segmento posterior mostraba un nervio hiperémico con hemorragias peripapilares e hiperplasia del epitelio pigmentario de la retina; además, el paciente había sido diagnosticado recientemente de VIH. La serología para sífilis fue positiva con disminución posterior de los niveles de la prueba no treponémica tras el tratamiento con ceftriaxona. La neuritis óptica puede aparecer en cualquier estadio de la sífilis y debe considerarse siempre un diagnóstico diferencial.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 346 "Ancho" => 1258 "Tamanyo" => 42857 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Posterior segment of the right eye with peripapillary hemorrhages and retinal pigment epithelium hyperplasia. (b) Posterior segment of the right eye with a pale optic nerve, an artifact is presented, clinical photograph taken posterior to treatment.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 4237 "Ancho" => 2925 "Tamanyo" => 1225356 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Optic nerve OCT with thickening of the nerve fiber layer of the right eye taken one month after onset of clinical symptoms.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 3601 "Ancho" => 2925 "Tamanyo" => 725419 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Performed 30-2 Humphrey visual field SITA Standard with annular scotoma.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The many faces of ocular syphilis: case-based update on recognition, diagnosis, and treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D.C. 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