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Syphilitic Uveitis and Outer Retinopathy


History of Present Illness

A 28-year-old Caucasian man with complains of mild redness, floaters, photophobia, and blurred vision in both eyes (OU) that began 2 weeks ago. He previously had excellent visual acuity (VA) with a mild myopic correction. He mentions that he has lost 20 pounds over the past 2 months and has malaise and weakness.

Exam
OD OS
Visual acuity 20/40 20/30
Intraocular pressure (IOP) (mm Hg) 9 8
Purple-red skin lesions on lower lid ( Fig. 42.1 ). Mild ciliary flush. No skin lesions on lids. Mild ciliary flush.
Cornea Nongranulomatous keratic precipitate (KP) in Arlts triangle Nongranulomatous KP in Arlts triangle
Anterior chamber (AC) 1+ flare and 1+ cells 1+ flare and 1+ cells
Iris No posterior synechiae. Argyll Robinson pupil No posterior synechiae Argyll Robinson pupil
Lens Clear Clear
Vitreous cavity 1+ vitreous cells 1+ vitreous cells
Retina/optic nerve Small white dots (<{1/4} disc diameter) scattered throughout the posterior and peripheral retina ( Fig. 42.1A and B ) Small white dots (<{1/4} disc diameter) scattered throughout the posterior and peripheral retina. Optic disc edema

Fig. 42.1, (A) Diffuse, well-circumscribed white dots throughout the outer retina. (B) Optic disc edema OD with perivascular infiltrates and hyperemia.

Questions to Ask

  • Have you been diagnosed with a sexually transmitted disease (STD)?

  • Have you used intravenous (IV) drugs or had sex with high-risk partners?

  • Do you have any skin lesions?

  • Have you been tested for infection with acquired immunodeficiency virus (AIDS)?

He responds that no, he has not been diagnosed with an STD, and he denies IV drug use, but he is a man who has sex with other men (MSM). He recently noticed a subconjunctival hemorrhage inside his left lower eyelid, which has been present for over 2 months ( Fig. 42.2A ), and he has been bothered by a rash on his hands for over 3 months ( Fig. 42.2B ).

Fig. 42.2, (A) Chronic subconjunctival hemorrhage in the left lower cul-de sac suspicious for Kaposi sarcoma. (B) Chronic rash on the palms of both hands.

Assessment

  • Nongranulomatous (NG) panuveitis with chorioretinitis, OU, with Kaposi sarcoma of right lower lid (RLL)

  • Systemic malaise and weight loss, possibly secondary to HIV infection

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