title: [Clinical and paraclinical features of syphilitic uveitis].
abstract: BACKGROUND
  Syphilis, caused by Treponema pallidum agent, results in polymorphic and non-specific ocular manifestations. Early diagnosis and institution of individualized treatment play a large role in the prognosis. The increase in syphilis over the past several years requires the ophthalmologist to consider this diagnosis in the setting of any intraocular inflammatory involvement.
  
  
  OBJECTIVE
  To describe epidemiological, clinical and paraclinical features and natural history of syphilitic uveitis.
  
  
  METHODS
  Retrospective, descriptive and non-comparative study of a series of patients hospitalized between 2007 and 2013 in our department of ophthalmology for management of ocular inflammation associated with a positive syphilitic serology.
  
  
  RESULTS
  Thirteen patients of mean age 52.5 years ± 12.9 (33-82 years) were included. All were male and were followed for six months. Co-infection with human immunodeficiency virus (HIV) was present in four of them. Other risk factors discovered on history were unprotected sexual relations, multiple partners, homosexual relations, co-infection with another sexually transmitted disease (STD) or an occupational risk. Decreased visual acuity (VA) was present in all patients, with an average initial VA of 0.71 ± 0.81 LogMAR, i.e. 2/10. Involvement was bilateral in 38% (n=5) of cases. Papilledema was present in 10 patients. Seven patients exhibited vasculitis, 6 patients a necrotizing retinitis, 2 patients with placoid lesions, 7 patients with panuveitis and 2 patients with macular edema. We did not find any patients with isolated anterior uveitis. Three patients exhibited concomitant extraocular involvement with cutaneous palmoplantar lesions. Spectral domain optical coherence tomography (SD-OCT) found a fragmentation of the external limiting membrane and a disorganization of the ellipsoid line in two patients. Cerebrospinal fluid was studied for all patients. Eight of them exhibited lymphocytic meningitis, and we found the presence of anti-Treponema pallidum hemagglutination assay antibody (TPHA) in 9 patients and anti-veneral disease research laboratory antibody (VDRL) in 1 patient. Syphilis polymerase chain reaction (PCR) in the aqueous humor was positive in 50% (n=6) of studied cases and the PCR for Epstein Barr virus came back positive in four specimens out of eight. False positive reactions were observed for Lyme disease in eight patients. The four HIV-positive patients showed bilateral lesions more frequently, but less severe and with a favorable outcome. Antibiotic treatment with ceftriaxone (2 grams per day intramuscularly for 15 to 21 days) and local treatment (corticoids and mydriatics) in the case of inflammation of the anterior segment, allowed a regression of the inflammation in all of our patients as well as an improvement in VA (average final VA 0.09 ± 0.17 LogMAR, i.e. approximately 8/10). One Jarisch Herxheimer reaction occurred and was resolved with systemic corticosteroid therapy. A change in the retinal pigment epithelium was the main sequela in 44% of cases (n=8 eyes).
  
  
  CONCLUSIONS
  Every structure of the eye may be involved with syphilis; therefore, syphilis must be systematically sought during the etiologic assessment of ocular inflammation even in the absence of historical risk factors. HIV-positive patients must be handled in the same way as immunocompetent patients. Collaboration with the internist is essential for the diagnosis, monitoring, and staging, especially in search of neurosyphilis. The clinical course is favorable with early treatment.
authors: Service d'ophtalmologie, hôpital Édouard-Herriot, 5, place d'Arsonval, 69003, Lyon, France. Electronic address: marty.anneso@sfr.fr.
authors: A-S
authors: AS
authors: Marty
authors: Centre ophtalmologique pôle vision, clinique du Val-d'ouest, 39, chemin de la Vernique, 69130, Écully, France.
authors: P-L
authors: PL
authors: Cornut
authors: Service d'ophtalmologie, hôpital Édouard-Herriot, 5, place d'Arsonval, 69003, Lyon, France.
authors: H
authors: H
authors: Janin-Manificat
authors: Service de médecine interne, hôpital Édouard-Herriot, 5, place d'Arsonval, 69003, Lyon, France.
authors: L
authors: L
authors: Perard
authors: Hôpital de la Croix-Rousse, service d'ophtalmologie, 103, Grande rue de la Croix-Rousse, 69004, Lyon, France.
authors: F
authors: F
authors: Debats
authors: Service d'ophtalmologie, hôpital Édouard-Herriot, 5, place d'Arsonval, 69003, Lyon, France.
authors: C
authors: C
authors: Burillon
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000175:diagnosis / Q000188:drug therapy; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002443:Ceftriaxone / Q000008:administration & dosage; D015897:Comorbidity; D004359:Drug Therapy, Combination; D042241:Early Diagnosis; D005602:France; D006801:Humans; D007273:Injections, Intramuscular; D008297:Male; D008875:Middle Aged; D009184:Mydriatics / Q000008:administration & dosage; D012189:Retrospective Studies; D041623:Tomography, Optical Coherence; D014605:Uveitis / Q000175:diagnosis* / Q000188:drug therapy
chemical_list: D000305:Adrenal Cortex Hormones; D009184:Mydriatics; D002443:Ceftriaxone
keywords: Ceftriaxone; Human immunodeficiency virus; Polymerase chain reaction; Syphilis; Uveitis; Uvéite; Virus de l’immunodéficience humaine