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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 13  |  Issue : 4  |  Page : 246-248

Exudative retinal detachment: An unusual ocular manifestation of syphilis


Department of Ophthalmology, Military Hospital Mohammed V, Rabat, Morocco

Date of Submission20-May-2022
Date of Decision19-Jul-2022
Date of Acceptance19-Aug-2022
Date of Web Publication18-Oct-2022

Correspondence Address:
Dr. Belfaiza Soukaina
Military Hospital Mohammed V, Rabat
Morocco
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injms.injms_62_22

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  Abstract 


Ocular syphilis is a disease known as a great simulator.It can affect the structures of the eye. It often manifests by an anterior uveitis. Posterior segment involvement is very rare and it is exceptionally complicated by exudative retinal detachment. We report the case of a patient with bilateral bullous retinal detachment in the context of ocular syphilis with a good evolution after treatment by penicillin G and corticotherapy.

Keywords: Bilateral bullous retinal detachment, exudative retinal detachment, ocular syphilis


How to cite this article:
Soukaina B, Taoufiq A, Issam F, Yassine M, Karim R, Bar OA. Exudative retinal detachment: An unusual ocular manifestation of syphilis. Indian J Med Spec 2022;13:246-8

How to cite this URL:
Soukaina B, Taoufiq A, Issam F, Yassine M, Karim R, Bar OA. Exudative retinal detachment: An unusual ocular manifestation of syphilis. Indian J Med Spec [serial online] 2022 [cited 2022 Dec 1];13:246-8. Available from: http://www.ijms.in/text.asp?2022/13/4/246/358778




  Introduction Top


Ocular syphilis is a disease known as a great simulator.[1] It can affect the structures of the eye.[1] It often manifests by an anterior uveitis. Posterior segment involvement is very rare[1] and it is exceptionally complicated by exudative retinal detachment.[2] We report the case of a patient with bilateral bullous retinal detachment in the context of ocular syphilis.


  Clinical presentation Top


A 50-year-old woman, diabetic on insulin therapy. The patient reported that her husband was treated for genital syphilis a month ago. She had visited the emergency service for a progressive decrease in bilateral visual acuity. It was 15 days since she had the symptomatology. The ophthalmological examination objectified a visual acuity quantified by counting the fingers in both eyes. The anterior segment examination revealed bilateral nongranulomatous synechiae anterior uveitis with anterior synechiae, keratic precipitates, and transparent lens in both eyes. The fundus was inaccessible in both eyes due to the presence of intense hyalitis in both eyes. Ocular ultrasound showed bullous retinal detachment and hyalitis in both eyes [Figure 1]. On the day of examination, she had a healed genital ulcer.
Figure 1: Ocular ultrasound showed bullous retinal detachment and hyalitis in the both eyes (right eye (a) et left eye (b))

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An exhaustive etiological assessment was performed. The inflammatory biological test and the syphilis serology are reported as positive. The rest of the test was normal, including the infectious assessment (viral serologies; tuberculosis assessment, etc.), immunological and cytobacteriological analysis of cerebrospinal fluid. Similarly, orbito-cerebral magnetic resonance angiography was without abnormalities. After the elimination of other etiologies, we retained the diagnosis of ocular syphilis. The patient was treated with penicillin G 24 million units for 15 days and a corticosteroid bolus for 3 days after the start of antibiotic therapy. The evolution was favorable, the disappearance of the inflammatory signs and a subtotal reapplication of the retina were observed on day 10 of treatment. The patient was seen again 2 months after the treatment [Figure 2]. Macular optical coherence tomography objectified a resolution of the subretinal fluid; fundus examination revealed a flat retina on 360, but visual acuity was low; it was 1/10 in both eyes [Figure 3].
Figure 2: Fundus examination found a papillitis and a subtotal reapplication of the retina at day 10 of treatment (right eye (a) and left eye (b))

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Figure 3: Fundus examination after 2 months revealed flat retina in 360 and hyperpigmented chorioretinal scar (arrow) in both eyes characteristic of syphilis (right eye (a) and left eye (b))

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  Discussion Top


Syphilis is a chronic and infectious disease, it is sexually transmitted and it is caused by the spirochete Treponema pallidum. It can affect the structures of the eye in the secondary and tertiary stages.[3] Anterior uveitis is the mode of the revelation of ocular syphilis,[3] while posterior segment involvement during syphilis is rare, representing only 8% of syphilitic uveitis.[3] The most common ocular manifestations are represented by interstitial keratitis, conjunctivitis, hypertensive anterior uveitis, roseola iris, intermediate and posterior uveitis, vasculitis, serous retinal detachment, and diffuse retinal epitheliopathy.[3] The latter manifests as punctate internal retinitis, chorioretinitis, or acute syphilitic posterior placoid chorioretinitis. Acute syphilitic posterior placoid chorioretinitis is a distinct form of syphilitic retinitis, characterized by the presence of a placoid lesion with a round or oval shape and yellowish color, it involves the macula or a spot very close to the macula.[4] Chorioretinitis may be complicated by bullous exudative retinal detachment. It is rarely described in the literature.[5] The first description of it dates back to 1996 and only a few cases have been described in the literature. It is clinically manifested by a profound progressive visual acuity decline.[5] It is often associated with retinitis, hyalitis, and uveitis.[6],[7] It is the consequence of an alteration of retina function including the internal and external blood barriers of the retina. A study by Pichi et al., who performed B-scans on patients with DRE associated with syphilis, revealed thickening of the choroid, which indicates the presence of choroidal vascular leakage, that causes the bullous exudative retinal detachment.[8] The exudative retinal detachment is often bilateral and it is associated with hyalitis in all cases. Syphilitic uveitis is confirmed by both sensitive and specific serological tests such as fluorescent treponemal antibody absorption and by a nonspecific test such as Venereal Disease Research Laboratory or rapid plasma reagin, which are complementary. Treponema can be found in subretinal fluid analysis of retinal detachment. The test of anti-treponeme antibody titration in cerebrospinal fluid is required to look for associated neurosyphilis.[6]

Patients with syphilitic posterior uveitis should be treated as neurosyphilis. Treatment for syphilitic posterior uveitis is with penicillin G at 18–24 million units daily, given 3–4 million units intravenously every 3–4 h for 10–14 days. Oral corticosteroids can be used to treat inflammatory complications. Treatment prevents disease progression but is not restorative. Jumper et al. used penicillin IV (400 million units every 4 h) for 10–14 days with oral corticosteroids in escalating doses on three patients with exudative retinal detachment.[2] They reported complete resolution of the bullous exudative retinal detachment, but, as in our case, the visual prognosis was poor in eyes where the macula was detached. Even after appropriate systemic treatment, retinal detachment surgery is sometimes required in the absence of reapplication of the retina.[5],[6] Chorioretinitis heals toward retinal hypo or hyperpigmentation and atrophy of the retinal pigment epithelium, this chorioretinal scar is characteristic of syphilis.


  Conclusion Top


Although the prevalence of syphilis had increased in recent years, bullous exudative retinal detachment remains an exceptional ocular manifestation of syphilis. The ophthalmologist must always know how to evoke this diagnosis because syphilis is a great simulator and early diagnosis is the only way to improve the visual prognosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Amaratunge BC, Camuglia JE, Hall AJ. Syphilitic uveitis: A review of clinical manifestations and treatment outcomes of syphilitic uveitis in human immunodeficiency virus-positive and negative patients. Clin Exp Ophthalmol 2010;38:68-74.  Back to cited text no. 1
    
2.
Jumper JM, Machemer R, Gallemore RP, Jaffe GJ. Exudative retinal detachment and retinitis associated with acquired syphilitic uveitis. Retina 2000;20:190-4.  Back to cited text no. 2
    
3.
Kiss S, Damico FM, Young LH. Ocular manifestations and treatment of syphilis. Semin Ophthalmol 2005;20:161-7.  Back to cited text no. 3
    
4.
Eandi CM, Neri P, Adelman RA, Yannuzzi LA, Cunningham ET Jr., International Syphilis Study Group. Acute syphilitic posterior placoid chorioretinitis: Report of a case series and comprehensive review of the literature. Retina 2012;32:1915-41.  Back to cited text no. 4
    
5.
Yogo N, Nichol AC, Campbell TB, Erlandson KM. Syphilis presenting as retinal detachment and orchitis in a young man with HIV. Sex Transm Dis 2014;41:114-6.  Back to cited text no. 5
    
6.
Williams JK, Kirsch LS, Russack V, Freeman WR. Rhegmatogenous retinal detachments in HIV-positive patients with ocular syphilis. Ophthalmic Surg Lasers 1996;27:699-705.  Back to cited text no. 6
    
7.
Díaz-Valle D, Allen DP, Sánchez AA, Aguado CB, Benítez Del Castillo JM, Aceñero MJ. Simultaneous bilateral exudative retinal detachment and peripheral necrotizing retinitis as presenting manifestations of concurrent HIV and syphilis infection. Ocul Immunol Inflamm 2005;13:459-62.  Back to cited text no. 7
    
8.
Pichi F, Ciardella AP, Cunningham ET Jr., Morara M, Veronese C, Jumper JM, et al. Spectral domain optical coherence tomography findings in patients with acute syphilitic posterior placoid chorioretinopathy. Retina 2014;34:373-84.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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