Ocular Syphilis: New Challenges of an Old Disease

Ocular Syphilis: New Challenges of an Old Disease


JANIE GORDON: Good afternoon. My name is Janie Gordon, and
I am the senior coordinator for the Mid-Atlantic Regional
Public Health Training Center here at the Johns
Hopkins Bloomberg School of Public Health. On behalf of the Training
Center and our co-sponsors, the Center for STI Prevention
at the Maryland Department of Health and Mental Hygiene,
the STD/HIV Prevention Training Center at Johns Hopkins, MedChi,
and the Center for Health in Maryland, I want
to welcome everyone to today’s presentation
on Ocular Syphilis– New Challenges of
an Old Disease. Today’s webcast is live,
so you can email questions anytime during the
presentation for the presenter at [email protected] And today’s webcast will also
be archived and available at the website where you
are viewing it now in one to two weeks, hopefully sooner. I’d like to turn that
microphone over now to Dr. Lucy Wilson, who is Chief
of the Center for Surveillance, Infection Prevention, and
Outbreak Response at DHMH. And again, I want to remind
you, please email in questions at [email protected] Lucy? LUCY WILSON: Thank
you, and welcome. Last year, the Centers for
Disease Control and Prevention alerted states to a number
of cases of ocular syphilis that were identified
across the country. The Maryland
Department of Health and Mental Hygiene’s
Center for STI Prevention has identified 14 Maryland
cases that occurred during 2015, against a backdrop of
an increase in cases of primary and
secondary syphilis over the past seven years. Maryland has historically
been the top 10 states for rates of primary
and secondary syphilis. And in 2014, the latest year
for which they are available, Maryland ranked
eighth in the nation. While previous research
supports evidence of neuropathogenic
strains of syphilis, it is still unknown as
some Treponema pallidum strains have a
greater likelihood of causing ocular infections. Today, we’ll hear from
Dr. Anne Rompalo, who will shed some light on
the issues pertaining to ocular syphilis. Dr. Rompalo is a professor of
medicine at the Johns Hopkins University School of
Medicine’s Division of Infectious Diseases. She has joint appointments in
the Department of Gynecology and the Departments of
Epidemiology, Population, Family, and Reproductive
Health and the Department of International Health at the
Johns Hopkins Bloomberg School of Public Health. She’s a noted clinician in the
field of infectious diseases and is an internationally
recognized expert in the field of sexually
transmitted infections. For over 25 years, Dr. Rompalo
has been the medical director of the Regional STD/HIV
Prevention Training Center at Johns Hopkins, and she
serves as a medical consultant to the Center for STI Prevention
at the Maryland Department of Health and Mental Hygiene. Dr. Rompalo, thank you
for being here today. ANNE MARIE ROMPALO: Welcome,
everyone, here and in the web. We’re going to be talking
about ocular syphilis. And again, if you have
questions as I go through this, please, here’s the
email address that you can refer to and
use it and we’ll try to address your
questions as we go. I do not have any disclosures
to reveal, nor do the planners. And here’s the learning
objectives of the next hour. At the end– or,
hopefully, 45 minutes. At the end of this
presentation, you all will be able to assess
all patients who have syphilis,
regardless of stage, for neurologic and ocular
symptoms and signs, recognize the signs and symptoms
of neurologic and ocular syphilis, and refer all patients
with neurologic and/or ocular signs or symptoms for
immediate further evaluation, as recommended by DHMH. And we will go over those
recommendations as we go along. So let’s begin with some case. And these cases have
been shared with me by Dr. Peter Leone at
the University of North Carolina at Chapel Hill
and the people in Denver, Dr. [INAUDIBLE], and
I appreciate those. Although we do have our
cases here in Maryland, I’m going to use
their cases today. This is a 33-year-old
man who presented with no significant
past medical history. Six weeks prior
to his admission, he was diagnosed with
an ear and throat. He said he had a sore
throat and tinnitus, and he was treated with a
week’s course of antibiotics, although his symptoms
never fully resolved. Two weeks prior
to his admission, he developed photophobia
and blurred vision. And he was seen at an outside
hospital, had a CAT scan, and was diagnosed
with sinusitis. He was discharged
on Bactrim, and he was told to follow up
with an ophthalmologist. But he was uninsured
and couldn’t afford to see a doctor,
and his visual loss continued to progress. Two days prior to
his admission, he said he started having worsening
photophobia and new periorbital and frontal headache
and ocular pain. Visual loss had progressed
to almost complete blindness, and he said he couldn’t tell
apart shapes or brightness from darkness. So his friend gave
him money, and he went to see an ophthalmologist,
who immediately sent him to the ED the same day
for further work up. And as a review of systems,
he said he did have eczema, and it was worsening
over the past two months, not responding to
his steroid cream. Typically, it was on his
knuckles and on his knees, but now it was everywhere and
it just wasn’t responding. And he said his
weight was stable. He had eczema in the past
and spontaneous pneumothorax in the remote past. His social history
is listed here. He did smoke. Occasional binge drinking. Marijuana only. No other injection drug use. He lives with his fiance. He had no recent travel
in the past five years. No animal, insect,
or TB exposure. And as sexual history, he
had two female partners in the past year– one
casual and one regular. And he’s an electrician. So here’s his physical exam. His vital signs were stable. He was thin. He was not in any distress. Well appearing. Moist membranes. But on examination
of the mouth, he did have white
patches on his tongue. The eye exam, his pupils were
dilated, they were sluggish, he had conjunctival injection
in the right eye, greater than the left. His visual acuity
was as follows– o the left, he was able to
count fingers at four feet, and in the right eye, he
was able to count fingers at two feet. His visual fields
are shown here. He had no lymphadenopathy. His cardiac, lung, and
abdominal examinations were within normal limits. He had no genital urinary
lesions that were noted. But on his skin, he did have a
hyperkeratotic, scaly plaques on the torso, the buttocks,
and the palms and soles. Neurologically, he had no facial
asymmetry, no meningismus, normal sensation and strength. This is what his skin
examination looked like. I want you to pay attention. And this is his eye examination. So he went for a slit
lamp exam, and he was determined to
have a panuveitis and bilateral acute
retinal necrosis. Quote unquote,
“extensive abnormalities and retinal findings
are suspicious for infectious etiology.” An anterior chamber
paracentesis was performed and aqueous humor was obtained. These are his
laboratory results. And you can see,
with a quick scan, that the pertinent
abnormalities are an increased white
count and an increased neutrophil absolute count. Otherwise, this pretty
much falls within normal. His chest X-ray was normal,
and his test results were as follows– HIV negative; reactive protein
reagent test, positive, at 1 to 512; Treponema
pallidum particulate agglutination confirmatory
test was positive; and he did receive spinal tap. The CSF showed a VDRL, venereal
disease research laboratory test, of 1 to 2. He had 75% white cells,
78% lymphs, 3% neutrophils, 19% monos/macrophages combo,
35 red cells, protein 58, glucose 57. Other tests were done because
of the psoriasis in the work up, and he was ACE
negative, ANA positive, on 1 to 160 speckled
pattern, ANCA negative, HLA B27 positive by
flow of cytometry. His Lyme serology was negative. They gonorrhea and chlamydia
NAATs of the throat and urine, which were negative. And on the aqueous humor that
was sent, the PCR that was done was negative for Herpes,
CMV, Varicella zoster virus, and Toxo. So he was admitted. And due to the acute
retinal necrosis initially– and it was a concern for the
viruses that are listed here and the results weren’t
back, that was high. And so they started
him on IV acyclovir. And intravitreal
ganciclovir was considered, but it was deferred. So once the PCR returned,
acyclovir was stopped. He had the results of this
serologic test for syphilis. He was treated with IV aqueous
penicillin G, 24 million units daily, and Solu-Medrol
for three days, and then steroid eye drops. And he was diagnosed
with secondary syphilis. With that diagnosis, he did
recall a painless chancre. Other points to
solidify the diagnosis is his high RPR
titer, the mucous patches in his mouth, the
hyperkeratotic plaques with “collarette scales”
on the palms and the soles. And you remember,
this is pathognomonic for secondary syphilis. And so he was given a
diagnosis of secondary syphilis with ocular involvement
and, actually, neurosyphilis by the CSF. And as time progressed,
here actually had no improvement in
his vision at discharge. His prognosis was guarded. Here are the plaques
that were seen, and this is the
“collarette scales.” And this is clipped out of
the New England Journal. You can read a little
bit more about that if you go to that site. But do not miss this. And these were the mucous
patches in the mouth. So here’s another case. It’s going to be shorter. We have a gentleman who says
he has sex with other men. He presents with rash
and blurry vision. He’s 31 years old. He says he’s a man who was
sex with other men, or MSM. He does use methamphetamine. He had symmetric macular
rash on the trunk and palms, one month
of blurry vision, said he felt generally unwell. He had no med allergies. He was on no medications. He had no allergies
and no travel history. He was sent to an
ophthalmologist, and the diagnosis was retinitis. Turns out that his lab
results showed he was, indeed, HIV positive, with
a CD4 count of 50 and a viral load of 75,000. He had normal CBC and
electrolytes and negative PPD. And in this case,
his RPR was negative. Now, the question
that everyone pondered was, what might explain this
patient’s rash and ocular manifestations with
a negative RPR? Could he have an acute
rash with CMV retinitis? Certainly. Could this be a prozone
phenomenon with ocular syphilis and secondary syphilis? Could the rash and the retinitis
have separate etiologies? Or was it none of these? Turns out, what he had was
the prozone phenomenon, which is a false negative RPR,
where have so high antibody titers it prevents the
antibody/antigen lattice formation. And consequently, it
will not precipitate down with a positive RPR test. It’s rare, but we may see it
more commonly in HIV+ than actually with neurosyphilis. So what you do in that case–
and there’s references here on this slide on where to look
if you want more information– but what we do in
this case is we asked the lab to dilute the
serum and then do the test. And what happened with this
was that he, indeed, had a positive RPR at 1 to 1,024. So he was prozone initial
false negative RPR. The retinitis, in this
case, was a manifestation of ocular syphilis. This is his rash and the palms. This is what the
eye looked like. And this, again, is a case
that was shared from Denver. So his lumbar puncture
revealed a CSF VDRL of 1 to 16, eight red cells, 80 white cells,
93% of which were lyphocytes. His glucose was 39. His protein was 100. And indeed, this was
evidence of neurosyphilis. Some questions that
come up in this is, what stages of syphilis
can involve the eye? Well, all stages. Eye involvement tends
to occur, actually, most frequently in
secondary syphilis and then again in late disease,
but it can occur at all stages. What part of the
eye is involved? This is not going to be simple. Every part of the eye
can be involved, again, at any stage of the disease. But the vast majority of
eye problems associated with syphilis are
also associated with many other infectious
and non-infectious diseases. So you have to think about this. In other words,
there’s almost no eye findings that are absolutely
specific for syphilis. I can look like anything,
just like syphilis in general. And these days, we have to
have a high index of suspicion to pursue this as a
differential diagnosis. So here is a cartoon of the eye. And here’s a list,
actually, from 2008, that was in Review
of Ophthalmology about ocular syphilis
and the manifestations. And look. You can see almost anything–
conjunctivitis, scleritis, episcleritis, uveitis, increased
pressure, chorioretinitis. All the way down
the line patients can come in complaining
of redness, and pain, and floaters, flashing
lights, loss of visual acuity, and sometimes, unfortunately,
if it’s let progress too long, even blindness. So the diagnosis
can be confirmed if you can get them to an
ophthalmologist for a split lamp. And that will add
to the findings and increase your
differential diagnosis bent toward neurosyphilis. But you also want
to do serologies. You want to do an RPR or
a VDRL, whatever you have, and the confirm it
with treponemal tests. You also want to do
a lumbar puncture. Now, this is another review– this was in 1983– again, showing the acute
and chronic manifestations of ocular syphilis. And look, it involves
all parts of the eye. And you can go
through all these, but the bottom line is, there’s
protean manifestations of this and not one thing can point
you directly to the diagnosis. This is a review, actually,
in 2015, done here at Hopkins, and it looked at the clinical
features and incidence rates of ocular complications in
patients with ocular syphilis. Now, mind you, this was a
review from 1984 to 2014. I’m going to come back to this. It was 35 patients,
or in 61 eyes. And the gave comparison to
HIV positive to negative, and the only real difference was
that the HIV negative patients had a higher percent of
cataracts than the positives, and the HIV positive
patients were more likely to have
optic nerve involvement than were the negatives. Otherwise, everything
was pretty much the same. So are ocular syphilis and
neurosyphilis the same thing. Well, actually, no. They are separate entities. But there’s a lot
of overlap, and it has to do with embryologic
development of the eye and the connection to the CNS,
or central nervous system. But the bottom line is
that it’s very difficult to tell and to say one isn’t
involved with the other. So important points to remember. One, all stages of syphilis
can involve the eye. And the second
one to remember is neurosyphilis can occur at
any stage of the disease. So again, this is
a little cartoon trying to review for you
how syphilis would progress if it read the textbook. The problem is, it doesn’t
always read the textbook. So quickly, you
may have exposure. Someone will be
exposed to syphilis. Their partner has syphilis,
and they have sex, and they’re exposed. And at the site of
inoculation, where they had sex, maybe in
three to four weeks, or we we call it
nine to 90 days, people can develop
primary chancre. Now, not all develop
a primary chancre. 30% to 50% do. And you have the chancre. You do nothing about. Two to six weeks, you
may go into secondary. But not everyone
goes into secondary. Secondary can the progress,
if not treated, into latency. And among 30% of those
patients with latent disease, they can go on to tertiary
or end-stage manifestations– destruction of end-organs by,
perhaps, even the footprint of this heirarchy. Bottom line is, syphilis can go
from exposure into a latency, not manifesting with
primary-secondary disease. But here’s the
take home message. We used to be told, a
long time ago, or at least thought we had been
told that neurosyphilis is a late manifestation
of syphilis. It’s not. It can occur at any
stage along this cartoon. So keep that in mind. So what do we do to diagnose
ocular syphilis specifically? Well, ocular signs and symptoms
in a person who has syphilis should trigger you to think
about this, because most diagnoses are presumptive. And most patients will help
positive serologic tests if we look for them. So in patients with late
ocular syphilis, honestly, 30% may have a negative serum
RPR or VDRL, heart but all of them will have a positive
serum treponemal test. So if you’re doing
the reverse algorithm you’re going to pick this up. Don’t be surprised
if the VDRL, RPR, whatever you’re using as
the non-treponemal test is negative, because some
people in late stage lose that. Very rarely, someone with early
syphilis, in the primary stage, will also have negative syphilis
serologies and eye problems. So again, you’ve got
to talk to you patients and put the whole picture
together and keep syphilis in mind. Do you need to do
an LP in someone who only has eye symptons and
no other neurologic symptoms? Yes, and here’s why. If the CFS VDRL, which
is the test we do, is positive in someone
who has eye symptoms, you can make a definitive
diagnosis of ocular syphilis. And that’s really the only way
to make a definitive diagnosis. Let me remind you, up to 70% of
patients with ocular syphilis will have evidence of
neurosyphilis on LP. Some won’t. Some will. But you’re looking for
that, because if they do have evidence
of neurosyphilis, clinicians really should follow
them with LPs maybe every six months to make sure that
they responded to therapy. Also, if you have an LP at
the beginning of therapy, you’re hopefully pretty
clear that you ruled out other causes of this,
and it gives you a more complete picture of
what you’re dealing with. So here are some symptom
questions to ask, and the DHMH is
putting this out. You can see this. Symptoms of ocular
syphilis, simply to remind you to ask the
questions– have you, the patient, had a change
or blurring in your vision? Do you see flashing lights? Do you see spots that move or
float in your visual field? Have you recently had pain
or retinus in the eyes? All good screening questions. Other questions
of neurosyphilis– have recently started
to have headaches? Have you had new weakness
in any part of the body– arms, legs, facial droop? Have you had problems walking? Have you had problems
with memory or confusion? And do you feel or have been
told that your personality has changed? All of these,
again, may lead you to think about neurosyphilis
or put the differential higher in the list. Now, what should you
do if you suspect someone has ocular involvement? Well, here’s the problem. In rare cases, syphilis of the
eye can progress very rapidly and cause blindness, so you
want to act relatively quickly. It’s someone suspects that eye
symptoms are due to syphilis, the patient should be evaluated
by an ophthalmologist. Now, that’s great, but
if you don’t have access to an ophthalmologist– AUDIENCE: I’ll see
all the patients. ANNE MARIE ROMPALO:
–then the patient needs to be referred to the local ER. And we have an ophthalmologist
sitting here in the room, and he’ll see them. If the ophthalmologist finds
any evidence of eye involvement, then the patient will
most likely need an LP. How do we treat ocular syphilis? Use the same regimen
as neurosyphilis, even if the lumbar
puncture is normal. Even if the lumbar
puncture is normal. Remember, 30% of patients
with ocular syphilis will have a normal LP. Now, listen, if you can’t get
them to see an ophthalmologist, if you can’t get
them in immediately, if you can’t get the
LP done immediately, don’t delay antibiotics. One should be careful
not to delay antibiotics while waiting for the LP
or further evaluation. So if you think this
is eye involvement, set everything up
with neurosyphilis. Set everything up. And if you can’t get the
work up rolling quickly, then start antibiotics. Because the whole point is
to start Aqueous Procaine penicillin, short-acting IV
penicillin, to get into the CSF and hopefully get the eye
some treatment as quickly as possible so it
doesn’t progress. Now, here you go. Ocular neurosyphilis treatment,
as recommended by the CDC 2015 Treatment Guidelines,
is listed here. Aqueous Crystalline
Penicillin G. That’s not the long-acting
benzathine penicillin that you give in shots. This is the aqueous form,
so it gets good absorption into the CFS. And you give it 18.4 to 24
million units, intravenously. You can give it as three to
four million units IV every four hours, and you give
it for 10 to 14 days. Now, some people have
given daily injections. It’s hard to tolerate them. But in Britain, they do this. And I put this up
for completeness, along with probenecid, to
keep the penicillin levels in the serum high. And again, that’s
for 10 to 14 days. So experts say that
after you give this IV therapy for 10 to 14
days, you should then give long-acting bicillin,
2.4 million unit shots once a week, up to three weeks. Some only give one shot. Other clinicians
say, maybe we should give three additional shots. Again, the key is to get
10 to 14 days of IV Aqueous procaine penicillin on board. And then, if you want
to, you can email us and we can talk
to you about where you want to go with the shots. Get the IV penicillin started. Will patients with
ocular syphilis get better with
antibiotic treatment? Yes, the majority of
patients will actually get better if the antibiotics
are not significantly delayed. But you’re going to find
some patients, particularly those with late ocular
syphilis, they may not improve. Remember, the goal of
therapy in late syphilis is to stop further
progression of the disease. Whether it causes a major
improvement in the signs or symptoms is great,
but it may not. But we don’t want it to
progress any further. So all of this is predicated
on a 2015 clinical advisory that came out in April. And it was Ocular
Syphilis Alert. And it was from
California, Washington, and a few other states. And it was in the
MMWR, as you can see. There were 24 cases that
were reported to the CDC. The majority were HIV
infected, and they were men who had sex with men. Few, however, were
not infected, and they were both men and women,
which made us stop and think. There’s significant sequelae
that were reported, also including blindness. So the CDC admonished
us all, at that time, to be aware of ocular syphilis. And again, I’m going
to go through this. The symptoms that they
wanted us to pay attention to is loss of vision, floaters,
blue tinge in vision, flashing lights, and
blurring of vision. And be sure that you do a
careful neurological exam in these syphilis patients. And patients with syphilis
and ocular complaints should really be sent
to the ophthalmologist as quickly as you
can get them in. You should perform
and LP in these cases. And then question came up–
is this because we’re seeing more syphilis in general? The rates of
syphilis are, indeed, increasing among
the MSM population. And now, we’re seeing
more in females, and also, we’re seeing more
congenital syphilis cases. Is this merely because
we’re seeing more syphilis, and this is something
that we’ll see because we have greater numbers? Or is there some sort of
neuropathogenic strain emerging? And the answer to that
is, we really don’t know. So let’s talk a little bit
about what we’re seeing here Maryland in the past year. And if you recall that the
Hopkins review ended in 2014– it was like 1984,
30 years, to 2014– well, this is what’s
happened in 2015. And these are
preliminary findings. In this slide, we had
a total of 14 cases. Most of them, 79%, almost
80% were among men, and 20% were among females. So it’s not only men. Two cases counted in
the total but couldn’t be located for a follow up. And here among the men,
we had six MSM, three men who said they had
sex only with women, and two who did not
tell us or we couldn’t find their sexual preference. Here’s the– it came up wrong. But here’s the distribution. And unfortunately, this came up. And I will put up the Anne
Arundel county and each county on here as it came up. I believe, of the 14 cases– and I apologize– Anne Arundel County
had the highest number. But we’ll put this up here
with the exact percentages. All right. The age at diagnosis. Ages ranged here in
Maryland, from 22 to 64. The mean was about 50 years old. And you can see their racial
ethnicity distribution listed here in the bar graph. The majority of eight of
the 13 were Caucasian. HIV status– one
unknown, three diagnosed with HIV simultaneously,
three had previous HIV, and seven were HIV negative. So it was almost neck and neck
between HIV positive and non. And here’s how they
fill out in stages. And you can see that
secondary is on there, but early latent and
late latent also made up a good chunk of our
ocular syphilis cases. In the state of Maryland,
the reported symptoms and the diagnose conditions
were as follows– we had patients come
in with blurry vision, painful eye, the whole gamut. Loss of vision, eye pressure,
one photosensitivity, and quote unquote,
“eye infection” in one. And the diagnosis
that was made was three had uveitis, one
scleritis, one swelling of the optic nerve, one “leaking
optic nerve,” quote unquote, and one retinitis. Nine people reported
visiting an ophthalmologist, and three reported extra-ocular
neurologic symptoms of hearing loss and headache. So of the 13, we were
able to document treatment in 12 patients. And this is what we know. One didn’t have any improvement,
one improved completely, and we have seven that
are still out there, we’re trying to locate and find. So here’s the big question
that we contemplate. Is this increase
in ocular syphilis indicative of a more virulent
form of neurosyphilis? Or is it because,
as I said before, we’re seeing increase in cases
and more protean manifestations of an old disease? Well, the people in Seattle
have done some studies on Treponema pallidum strains
associated with neurosyphilis, and this is what they reported. And you can see that it’s in the
Journal of Infectious Disease, 2005 and 2010. And they continue
to do work on this. Treponema pallidum
DNA from 83 patients were evaluated
for neurosyphilis. Most of these LP specimens
came from Seattle. 21, or 50%, of the 42
patients with one strain, and that’s the 14d/f,
had neurosyphilis. And then, 24 of 41 patients
with seven other strains had neurosyphilis. So it looked as if the 14d/f
strain was more frequently associated with
invasive disease. Now, in rabbit studies,
which they do in Seattle, animals infected with the 14a/a
strain and this d/f strain actually had the greatest
degree of neuroinvasion. Further studies are needed. We don’t know
what’s causing this or if it has anything
to do with the strain. But the [INAUDIBLE] are
interested, along with the CDC, in pursuing the question. So the ocular syphilis
specimen protocol, as published on the CDC
website, is as follows– CDC’s study of strain types
associated with ocular syphilis is what they’re trying to do. Again, University of Washington
lab is doing the strain typing. So what do they need? Ideally, they need specimens
before antibiotics are given. But again, I’m telling you,
don’t delay antibiotics until you get the spinal tap. That’s just not the way to go. But if you can, before
you start the antibiotics, if everything lines
up appropriately, think about this. They need 3 milliliters of
blood in a purple top EDTA tube. Hopefully, they
need, if the person has primary or
secondary lesions, a sterile Dacron swab
from these lesions. And then, if you can put
it in a glass container and put it in the freezer,
that’s great, or plastic and get it into a negative
80 degree freezer. If you do a spinal tap,
2-3 milliliters of CSF would be ideal. And ocular fluid,
if for some reason there is an aspirate
done of the chambers. Freeze the specimens at negative
80 degrees, as we talked about. If you don’t have a
negative 80 degrees, negative 70 will be fine. And hopefully, let them know
to call up the numbers that are indicated on
the CDC website, and let them know, and
they’ll tell you how to ship these specimens on dry ice. Here’s the recent
contact that’s listed on the website with a phone
number, if it comes up. So ocular syphilis– the ongoing
questions and challenges is that there is a lack of clarity
whether this truly represents an outbreak of a more
neuro/ocular-tropic strain of syphilis, versus increased
awareness of a known complication of syphilis in the
setting of increasing numbers of syphilis cases. Again, there’s limitation of
current surveillance system, unfortunately, to detect or
record ocular syphilis cases. So we depend on
all clinicians that are out there to let
us know that this is what you’re seeing. So in summary, clinicians should
be aware of ocular syphilis and screen for visual complaints
in any patient at risk for syphilis. And the risk
factors for syphilis include having sex with
anonymous or multiple partners, sex in conjunction
with illicit drug use, or having a partner who
engages in these behaviors. Assure that all patients
diagnosed with syphilis or suspected of having syphilis
are evaluated for ocular and neurological symptoms. So ask the questions. Refer patients with positive
syphilis serology and either ocular or neurologic signs
or symptoms immediately, either for ophthalmologic
evaluation or evaluation for an LP with a
CSF examination– that may be to the ED– and even for possible hospital
admission and IV therapy. When referring a
patient for evaluation, communicate the need to
evaluate specifically for ocular or
neurosyphilis using– we have the Maryland Ocular
Syphilis and Neurosyphilis Screening Guide, which I
believe was shot out last week. But you can get it, and
I’ll show you on the website where you can download that. Send the patient
with something– if you’re sending them to the
ED– that indicates that this is what you’re thinking
about, and this is what they need to
consider and work on. So obtaining a lumbar
puncture, as I said, is ideal, but treatment should
not be delayed while waiting for an LP. Manage ocular syphilis according
to the current CDC treatment guidelines for neurosyphilis. So eye involvement
that you think is due to syphilis, regardless
of the CSF findings, gets the treatment IV
aqueous procaine pencillin– I’m sorry. aqueous crystalline penicillin
G for 10 to 14 days, ideally. Test all patients
with syphilis for HIV. Always co-test patients
with syphilis for HIV if the status is unknown or
they were previously negative. Report all cases of ocular
syphilis to your local health department, ideally within
24 hours of diagnosis. So the case definition for
an ocular syphilis case is as follows– it’s a person
with clinical symptoms or signs consistent with ocular disease– and we talked about all
that are listed here– with syphilis of any stage. This is the more
confidential morbidity reporting instructions
that are available. It’s the morbidity card, and you
can see where it’s available. And what is listed
here is the reporting. And what you can see is we
have Syphilis Stage, Other, which you can actually
write optic on there if you think that’s part of it. So Syphilis Stage is what it is. And then the Symptoms, you
can indicate here under Other, you could do Neurological
or Other, Optic, which would be very helpful to
the state to see how many cases they’re actually seeing. There’s a lot of this out
there and in many other cities and states besides ours. And you can see some of
them are listed here– Washington, Philly, LA. But we want to be
on top of this. So I’m going to– I stopped early, which we have
a lot of time for questions. If you need to receive
technical assistance, it’s on here, with the treatment
guidelines, ocular syphilis, neurosyphilis, specific
case consultations, you can get to us
through this address or you can call, 410-767-6690. And for additional information,
the website is listed here. There’s also a lot of
information at the CDC website. So I will see if we have any
questions floating about. These are our sponsors. And email questions to
the presenter, again, and you can get C1
credits for this. So if we have any
questions in the audience. Yes, ma’am? LUCY WILSON: I’m sorry. We’re having a
microphone problem. Could you go up and
share the microphone and ask the question? We’re trying to get
a new mic in here. Just so people– ANNE MARIE ROMPALO: We are
writing our questions up so you can see them too. Thank you for being brave
and asking a question. AUDIENCE: So my question
is, if the LP doesn’t direct the course of treatment,
what’s the reason for doing it? ANNE MARIE ROMPALO:
That’s a great question, and it’s come up
multiple, multiple times. The reason for doing the LP
is that you have a baseline. So you don’t know
whether it’s going to be positive or
negative when you start. And also, when you’re
working up the patient you think it’s syphilis, but
there’s many, many other things that could be involved. I mean, what if
it’s CMB retinitis? What if it’s any of the HSU, the
things that were listed there? You’d like to have a complete
picture of what’s going on. The other thing is
that if you have a CSF abnormality, either a
VDRL positive or white cells, over time, if the person
is not getting better, you’ll be able to go
back, do another tap, and see what is happening. Is it getting worse
on those parameters, or, indeed, is it getting
better and we just have to buy more time? Or is it something
completely different? So some people
would say, oh, you don’t need to have that done. But I’m saying that if
you can do it, do it, because you have a baseline, and
you have something to follow, and you have more data that will
either say it’s neurosyphilis or something else. We have no– oh, we
have one question. Come up. AUDIENCE: I’m Alex [INAUDIBLE]. I’m an ophthalmologist
and retina and [INAUDIBLE] specialist, with a special
interest in infections. And I’d very much like to
participate in this study. Does someone pay
you for these tests? ANNE MARIE ROMPALO:
Of course not. This is a CDC study. So right now,
there’s no payment. It’s the good will. But if someone–
you’d be surprised. Sometimes they’ll say,
yeah, if you have extra CSF or you have extra fluid,
sure, you can send it. It’s nice to know. But right now, there
is no payment for this. AUDIENCE: And are
your slides available? ANNE MARIE ROMPALO:
Yes, they are. And you can have them. And thank you for coming. I love when
ophthalmologists come. LUCY WILSON: Anne, can you
note that the PowerPoint will be up within a few days? ANNE MARIE ROMPALO:
The PowerPoint will be up within a few days. LUCY WILSON: Thank you. ANNE MARIE ROMPALO:
And the percentages and the correct county
distribution will also be done. Do we have that? SPEAKER: Yes, it’s here. ANNE MARIE ROMPALO:
May I see it? I apologize. You know, when you put
things up on the web, sometimes it gets a
little bit different. Here we go. LUCY WILSON: Anne, can
you clarify the CDC doesn’t charge for those tests. ANNE MARIE ROMPALO: The CDC
doesn’t charge for those tests, but there’s no payment to
reimburse the investigators or the patient. So it’s like working
on good will. I will say, here is how this all
in that geographic distribution of ocular syphilis–
in Anne Arundel, we had five cases, which
made up 36% of the total; Baltimore City had four
for 29%; Prince George’s had two for 14%; and Frederick,
Dorchester, and Howard each had one, which makes up 7%. AUDIENCE: More questions? ANNE MARIE ROMPALO: Yes. Come up. LUCY WILSON: Oh,
we have a mic now. ANNE MARIE ROMPALO: Well,
she’s coming up anyway. AUDIENCE: Maybe everybody
else already knows this, but I don’t know. What is a leaky optic nerve? I’ve never heard of it. ANNE MARIE ROMPALO: One of
our ophthalmologists here. The question was, what
is a leaky optic nerve? Do you want to answer that? AUDIENCE: I can guess. AUDIENCE: Excuse me. ANNE MARIE ROMPALO:
I was a little intrigued with that myself. But hey. AUDIENCE: The truthful
answer is, I don’t know. But most likely, they meant,
on fluorescein angiography, the optic nerve
leaked fluorescein. And that’s an indication
of inflammation and loss of the retinal blood-brain
barrier at the optic nerve. And that could be
indicative of many things– ANNE MARIE ROMPALO: And I
will say that treponemes are notorious for getting
stuck in the end arterioles and causing damage
and inflammation, so I’m not surprised. All right, everyone. If there are no other questions,
we’re going to finish early. I’ll let you get to your lunch. And thank you for listening. Thank you for coming, and
thank you for being on the web. [APPLAUSE]

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