臨床感染症と実践

抽象的な

Ocular syphilis: when love blinds-Epidemiological, Clinical, Biological and Evolutionary Aspects of 14 Patients-22 Eyes Cohort (2008-2015)

Rostane Gaci

Introduction: Ocular Syphilis is a rare and poorly described pathology. Syphilis renewal of activity leads ophthalmologists, internal medicine and infectious diseases experts to consider this diagnosis in front of various symptoms, among which ocular proteiform involvement.
Objective: Describe epidemiological, clinical, paraclinical and evolutionary aspects of syphilis with ocular involvement. Seek out any differences between HIV-positive and HIV-negative populations.
Material and methods: Retrospective, descriptive, non-comparative study about all the cases of ocular syphilis diagnosed in a tertiary academic hospital in Nancy, France, from 2008 to 2015.
Results: 14 patients among which 10 HIV-free and 4 HIV co-infected patients, representing 22 eyes, were diagnosed for ocular involvement, all in the secondary stage of syphilis. Mean age was 46.2 ± 6.2 years (Range: 39-61 years) and 86% were male (n=12). 65% reported having multiple sex partners (n=9), 14.3% using intravenous drug (n=2). 29% were known co-infected with HIV at syphilitic uveitis diagnosis (n=4). At the time of uveitis diagnosis, none of the HIV-positive patients were treated with HAART. Only one patient had a CD4 LT count less than 250 mm^-3. Ocular involvement was inaugural of syphilis in 71.4% of cases (n=10). The average diagnosis time was 63.1 ± 70, 3 days (Median=33.5 days, Range: 4-207 days). 57.1% of cases had an extra-ocular involvement at initial presentation. Meningitis was identified in 92.1% of cases (n=11 of 12 tested). The average cephalospinal fluid (CSF) cellularity was 54 ± 73.4 cells/mm³ (Range: 4-260 cells/mm³). CSF was mostly lymphocytic in all cases, up to 72 ± 19.1% (Range: 16.1-89.3%), except for an HIV co-infected patient who presented a majority of neutrophils. 92.9% of patients showed a decrease in Best Corrected Visual Acuity (Mean=0.51 ± 0.61 LogMAR; about 4.8/10 on Monoyer scale). All patients presented with uveitis, bilateral in 57% cases (n=8) with anterior, intermediate and posterior involvement in respectively 43% (n=6), 50% (n=7) and 93% of cases (n=13). 36% of patients had panuveitis (n=5). No isolated anterior or intermediate uveitis was observed. 43% of patients had an isolated posterior uveitis (n=6). Macular edema and retinal vasculitis were reported in 21% (n=3) and 29% of patients (n=4). 21% of patients had optic nerve damage papillitis type (n=3). 2 patients showed scleritis and one patient was diagnosed after onset of hypopion revealing anterior uveitis. Median follow up time was 3 months ± 488 days (Range: 21-1825 days). Ocular inflammation and visual acuity improved after a neurosyphilis-like parenteral antibiotherapy regimen for all patients when diagnosis was made promptly (Mean=0.39 ± 0.71 LogMAR; about 7/10 on Monoyer scale). Comparison according to HIV co-infection status did not show any clinical presentation, severity or outcome significant differences. VDRL in cephalospinal fluid was more likely to be positive in HIV patients with ocular involvement.
Conclusion: Ocular syphilis should, because of its potential gravity, its accessibility to a simple and effective treatment be considered in range of the uveitis causes and in the assessment of any new syphilis whatever the patient’s status toward an HIV co-infection.