Syphilis: Management Challenges

Transcription

1 Syphilis: Management Challenges Khalil Ghanem & Susan Tuddenham Johns Hopkins University School of Medicine Baltimore, MD USA uwptc.org

2 Patient 1 36 year old gay man with sudden onset of fluctuating bilateral hearing loss and tinnitus - Sensorineural with poor word discrimination - Diffuse maculopapular rash on trunk sparing palms and soles - Serum CIA reactive; RPR 1:2048

3 Poll 1: Would you perform a lumbar puncture in this patient? A. Yes B. No

4 Patient 1 Continued IV aqueous crystalline penicillin G 4,000,000 units IV q 4 hours + steroids X 10 days JH reaction after 1st dose of penicillin Complete resolution of symptoms 1 month after therapy

5 Otosyphilis Diagnostic criteria: cochleovestibular dysfunction and syphilis infection without an alternate diagnosis; ~50% bilateral - Diagnosis is presumptive; CSF examination is normal in 90% of cases Therapy: IV penicillin (+ corticosteroids) Prognosis: 23% experience improvement in hearing; up to 80% experience improvement in tinnitus and vertigo - Absence of hearing fluctuations, longer duration of symptoms, and age >60 years are bad prognostic indicators Laryngoscope 1973; 83: Laryngoscope 1983; 93:154 Laryngoscope 1977; 87: Laryngoscope 1984; 94: Laryngoscope 1992; 102:1255-9

6 Patient 2 48 year old man with a history of Hepatitis C infection and alcohol abuse presents to ED with a pustular rash, decreased PO intake, and nausea - Pustular rash on arms, back, and abdomen; no stigmata of chronic liver disease - AST 52 U/L; ALT 58 U/L; AP 1260 U/L; t-bili 1.2 mg/dl - Serum CIA reactive; RPR 1:128

7 Syphilitic Hepatitis Involvement of the liver in late stages of the disease as fibrosis, gumma, and hepar lobatum well documented in the pre-antibiotic era Early stage asymptomatic involvement usually as a disproportionally elevated alkaline phosphatase in the setting of secondary syphilis is a more recent observation- but is not universal - Clinical:? Association with rash and anorectal lesions - Histology: pericholangiolar inflammation; mild (proliferation of sinus endothelial cells and Kupffer cells, eosinophils, and lymphocytes) to severe (diffuse necrosis especially in periportal region and central vein) - In half of the cases spirochetes were found in the necrotic foci, walls of sinusoids, and in the endothelial cells Incidence of LFT abnormalities in both immunocompetent and HIVinfected persons in secondary syphilis noted in up to 38% -but majority are asymptomatic Lancet. 1975;2(7941):896-9 Treatment: 2.4 MU of BPG IM X1 Int J STD AIDS. 2009;20(4): Int J STD AIDS. 2012;23(8):e4-6 West J Med. 1978;128(1):64-7

8 Patient 2 continued 48 year old man with a history of Hepatitis C infection and alcohol abuse presents to ED with a pustular rash, decreased PO intake, and nausea - Pustular rash on arms, back, and abdomen; no stigmata of chronic liver disease - AST 52 U/L; ALT 58 U/L; AP 1260 U/L; t-bili 1.2 mg/dl - Serum CIA reactive; RPR 1:128 - BPG 2.4 MU IM X1 - Sent to ultrasound for HCC screening and discharged after PCN therapy 12 cm mass in liver consistent with HCC Follow-up appointment with IR scheduled 1 week later for CT-guided biopsy At follow-up with IR, mass had disappeared

9 Am J Surg Pathol 2014; 38 (12): Liver Abscesses and Tumors

10 Patient 3 58 y/o man R eye pain and redness X 4 days - No medical care X 20 years - No sex in the past 4 years - Right eye: Panuveitis - Serum CIA reactive; RPR 1:128

11 Poll 2: Would you perform a lumbar puncture in this patient? A. Yes B. No

12 Poll 3: If the lumbar puncture in this patient is normal, what would you treat him with? A. BPG 2.4 MU X1 B. BPG 2.4 MU X3 doses one week apart C. Aqueous Penicillin G 24 MU per day X 10 days D. Prednisone 60mg PO daily X 10 days

13 Prevalence of ocular syphilis No national estimates (passive reporting) Antibiotic era: - Up to 8% of patients with secondary syphilis % of patients with neurosyphilis - 7.9% of syphilis patients reported new onset of visual or hearing disturbances British Ocular Syphilis Study ( ): per 1 million adults - This compares to approximately 50 per 1 million cases of syphilis diagnosed annually in the United Kingdom health clinics during the same period Sex Transm Dis 1980; 7: Int J Dermatol 1987; 26: J Clin Neuroophthalmol 1983; 3: Sex Transm Dis 2015; 42: Invest Ophthalmol Vis Sci 2014;55: Arch Neurol 1993; 50:243-9

14 What stage(s) of syphilis involves the eye? What part(s) of the eye is/are involved? Every part of the eye can be involved during any stage of the infection Majority of eye manifestations associated with syphilis are also associated with many other infectious and noninfectious diseases. Semin Ophthalmol 2005; 20: AJO 1930; 13:

15 Diagnostic Criteria Ocular signs and symptoms in a person who has syphilis - Most diagnoses are presumptive - Most will have positive serological tests In patients with late ocular syphilis, up to 30% may have a nonreactive serum RPR/VDRL but will have a reactive serum treponemal test - Implications of the RSA Rarely, with early primary syphilis, persons will have nonreactive syphilis serologies (both treponemal and RPR/VDRL) and eye symptoms 30% of persons with ocular syphilis will have a normal CSF examination A CSF examination is NOT necessary to make a diagnosis of ocular syphilis

16 Role of CSF examination in the absence of neurological signs/symptoms Up to 70% of patients with ocular syphilis will have CSF abnormalities which need to be followed If the CSF VDRL is reactive (in up to 35% of patients with ocular syphilis), a DEFINITIVE diagnosis of ocular syphilis can be made Objective measure in persons with fluctuating symptoms The CDC recommends a CSF examination in all persons with syphilis and ocular signs/symptoms Arch Dermat Syph 1921; 3:272

17 Role of adjunctive corticosteroid therapy No clear evidence for benefit or harm Topical corticosteroids have been used as treatment adjuncts for syphilitic interstitial keratitis and anterior uveitis Oral and intravenous corticosteroids have been used as treatment adjuncts for posterior uveitis, scleritis, and optic neuritis Intravitreal injections of triamcinolone may be harmful Retina 2012; 32:

18 End