Last additions - Unknown - Possible Syphilitic Visit 1: 12-06-12
74-year-old man was seen in the office on December 3, 2012. He was doing fine until just a few months ago when he started noticing vision loss, first in the right eye than the left. Then the left eye had cataract surgery done back in July. He has noticed recently he is getting tired easily. He gets weak. He can’t walk for a long distance. He has lost five pounds within the last month and he also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. He does have a positive FTA-ABS, suggesting he might have syphilis, however, he had a spinal tap, which was negative. MRI initially revealed a mass lesion of the occipital lobe however repeat
scanning with contrast showed the suspect area simply to be artifact. Further testing was ordered
including lumbar puncture and blood testing which revealed a negative RPR, VDRL,
Toxo titre, Cryptococcus and lyme titre. A vitreous sample (PPV) had negative PCR for lyme, toxo, HSV, HS and DNA for TP all of which were
negative.
VISUAL ACUITY: OD 1/200, OS 20/63. IOP: OD 14, OS 12. The right eye has 1+ cell and flare of the anterior chamber and a ReSTOR intraocular lens in good position. He also has corneal incisions. The left eye has a trace cell and flare of the anterior chamber and a ReSTOR intraocular lens in good position.
EXTENDED OPHTHALMOSCOPY:
OD: Vertical C/D ratio is 0.2. There is a white intraretinal mass surrounding the optic nerve.
OS: Vertical C/D ratio is 0.4. There are leopard spots temporal to the fovea.
PHOTOS: The color photo in the right eye shows the white retinal mass and the left eye shows the leopard spots temporal to the fovea.
SPECTRALIS-SD-OCT SCAN: The OCT scan through the macula in the right eye shows the mass to be intraretinal and in the left eye there are irregularities at the level of the pigment epithelium.
FUNDUS PHOTOGRAPHY - AUTO FLUORESCENCE: The image in the right eye shows white hyper auto fluorescence centrally where the white reflective lesion is. In the left eye those little leopard spots are hyper auto fluorescencent.
FLUORESCEIN ANGIOGRAPHY: Fluorescein angiography in the right eye shows leakage from the area of retinal infiltrate. In the left eye there is hypo and hyper auto fluorescence corresponding to the leopard spots.
INDOCYANINE GREEN ANGIOGRAPHY: The indocyanine green angiogram similarly shows the leopard spots in the left eye and leakage from the lesion in the right eye.
IMPRESSION:
1. DIFFUSE CHORIORETINITIS – BOTH EYES
2. PROBABLE SYPHILITIC RETINITIS – RIGHT EYE AND CHOROIDITIS IN THE LEFT EYE
3. POSSIBLE OCULAR LYMPHOMA, TUBERCULOSIS, LYME DISEASE, AND GRANULOMATOUS CHOROIDITIS
DISCUSSION: As I discussed on the phone with you, given the positioning FDABS and the classic signs in the retina for syphilis, I think even with the presence of a negative spinal tap, this is in all likelihood syphilitic choroiditis and retinitis and at the moment I don’t see the reason not to try an antibiotic treatment trial prior to other invasive testing.
If he is on the appropriate treatment for neurosyphilis and he doesn’t show improvement within a week or two, then I don’t think there is any harm in doing vitreous biopsy in the right eye looking for PCR and for cytology and even for possible flow cytometry and then ultimately if that is negative, a retinal biopsy could be considered in the right eye, which may not have much visual potential depending on what happens to the optic nerve lesion.
Visit 2: 02-06-13
74-year-old man was seen in the office on February 6, 2013. He has had decreasing vision in both eyes starting prior to his cataract surgery, which is in July of 2012. Since then he has had a sort of steady gradual downhill course, especially in the right eye, which unfortunately completely lost vision to no light perception not too long ago from possibly optic nerve related swelling, retinal vascular occlusion. His left eye unfortunately has continued inflammation. He has had vitrectomies as well as taps sent for his multiple tests. He has had PCR tests sent for toxoplasmosis and he has also had vitreous samples sent for possible lymphoma.
Recently there is a suspicion he may have lymphoma. He was initially treated with a twenty one day course of penicillin, because of his positive FDABS and the possibility of syphilis. He was subsequently put on fluconazole forty one days of infusion and now he is getting IGG infusions. The right eye which was previously quite painful does feel a lot better now with the treatments.
He has been on 20 mg of prednisone orally. His right eye now has fallen to no light perception. The left eye has some hazy vision. You were concerned about several things; one is mainly what possibilities there might be for diagnosis and therapy, especially to protect the left eye.
VISUAL ACUITY: OD: NLP, OS 20/50. IOP: 13 OU. The right eye has some crystal cellular growth within the LASIK flap and the ReSTOR intraocular lens is in good position. The left eye has a ReSTOR intraocular lens in good position.
EXTENDED OPHTHALMOSCOPY:
OD: Vertical C/D ratio is 0.1. There is neovascularization on the nerve. There are retinal hemorrhages in all four quadrants and the retinal arteries are narrow.
OS: Vertical C/D ratio is 0.2. There is pigment mottling in the macula with sort of a leopard spot pattern of brown hyperpigmentation and superotemporal to the macula there is a whitish looking area of retinitis with an overlying retinal vessel, which looks to be involved with some either intra-arterial plaque or at least irritation of the vessel wall in a way that looks like it may be occlusive.
COLOR PHOTOS: The color photos of the right eye do show retinal hemorrhage with some optic atrophy and a tuft of neovascularization around the nerve. The left eye the retinal vessels visible are clearly aggravated by the inflammation in the retina just superior temporal to the macula.
FUNDUS PHOTOGRAPHY - AUTO FLUORESCENCE: The images show in both eyes a leopard spot pattern of hyperfluorescence scattered in the posterior pole. The right eye has a ring of hypofluorescence around the optic nerve with hyperfluorescence outside of that.
FLUORESCEIN ANGIOGRAPHY: Fluorescein angiography in the right eye shows florid neovascularization of the optic nerve with poor perfusion of the retinal arteries throughout the study. The pigment epithelium appears to be irregularly affected by the disease. There are some areas of hyperfluorescence and some areas of hypofluorescence scattered throughout the posterior pole. There are linear areas of hypofluorescence. I think all of that is left over from the time when he had the exudative detachment, which cleared with therapy. The left eye shows the leopard spot area of hyperfluorescence under the macula and superotemporally the area of whitening does have significant leakage. In the late frames the retinal vessels in that area do appear to still be perfused. That area superotemporally shows capillary dropout.
INDOCYANINE GREEN ANGIOGRAPHY: In the right eye the linear areas of hypofluorescence are present, again looking like they are left over from the old retinal detachment and the neovascularization on the nerve is visible. The angiogram of the left eye, the areas of damage to the retinal vessel walls are more visible than they are on the fluorescein angiogram, but the underlying choroid looks reasonably healthy other than the areas of hypofluorescence corresponding to the leopard spots.
SPECTRALIS-SD-OCT SCAN: The OCT scan of the left eye shows the leopard spot pigmentation. It looks like it is all in front of the retinal pigment epithelium. The OCT scan through the area of retinitis superotemporally shows full thickness retinal disorganization and swelling from the retinitis.
IMPRESSION:
1. BILATERAL PAN UVEITIS
2. FOCAL POSTERIOR RETINITIS – LEFT EYE WITH AN AREA OF RETINAL VASCULITIS OVERLYING IT
3. LEOPARD SPOTS
4. RETINAL ARTERY AND VEIN OCCLUSION – RIGHT EYE RESULTING IN NO LIGHT PERCEPTION VISION
DISCUSSION: I explained to the patient and his wife, at some length mostly that there is still unfortunately a diagnostic dilemma. It is unclear exactly what he has. The treatments of antibiotics combined with the steroids have made the eyes feel a lot better, which does suggest that there might have been an infectious ideology. My only concern is there is still an area of retinitis in the left eye despite what would seem to be adequate treatment for both syphilitic retinitis and for possible fungal issues. I told him at the moment the differential diagnoses include, infectious disease, auto immune disease and unfortunately neoplasm disease, because of the possible ocular lymphoma.
Since it is still unclear exactly what he has, I think that the best thing to do at the moment is for him to see Janet Davis down in Miami for another opinion. This will be a third option and we talked to Janet Davis’s assistant and set that appointment up today for within the next two weeks. In the meantime, I am going to try make sure Dr. Davis has access to all the images that I have taken in the office. I appreciate you getting all the laboratory tests together and hopefully with that we will be able to come up with some sort of definitive plan as to any further diagnosis tests need to be done and any further treatment.
I told him one extreme possibility would be to remove the right eye, since the right eye is no light perception vision and it is possible a pathologist would be able to examine it and help us decide whether this is infectious, auto inflammatory, neoplastic and to further narrow down the diagnosis to something which might allow us to treat and save the left eye.
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye440 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye399 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye374 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye407 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye419 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye334 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye370 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye333 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye361 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye357 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye329 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye342 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye347 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye349 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye368 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye345 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye332 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye366 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye351 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye382 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye372 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye391 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye358 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye373 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye358 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye339 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye - VIDEO TAKES TIME TO LOAD367 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye358 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye323 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye392 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye354 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye342 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye343 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye421 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye370 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye399 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye412 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye362 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye360 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye328 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye392 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye400 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye353 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye391 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye459 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye349 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye374 viewsFeb 07, 2013
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Vasculitis - Retinitis - Uveitis - Vision NLP right eye , 20/50 left eye407 viewsFeb 07, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis405 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis405 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis322 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis388 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis353 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis370 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis344 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis338 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis323 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis356 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis444 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis360 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis333 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis439 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis416 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis355 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis347 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis337 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis353 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis358 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis402 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis458 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis410 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis442 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis406 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis391 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis399 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis401 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis424 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Uveitis - Retinitis - Vasculitis - possibly Syphilitis516 viewsVisit 1: 12-06-12
74-year-old man 12-3-12 visit. 2 months ago noticed vision loss, first in the right eye than the left. He is getting tired easily. He can’t walk for a long distance. He has lost five pounds within the last month. He also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. FTA-ABS is positive but a spinal tap, which was negative. OD 1/200, OS 20/63. Feb 06, 2013
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Visit 1: 12-06-12
74-year-old man was seen in the office on December 3, 2012. He was doing fine until just a few months ago when he started noticing vision loss, first in the right eye than the left. Then the left eye had cataract surgery done back in July. He has noticed recently he is getting tired easily. He gets weak. He can’t walk for a long distance. He has lost five pounds within the last month and he also had a severe itchy episode, but not quite a rash a few days ago, which went away after he took a shower. He does have a positive FTA-ABS, suggesting he might have syphilis, however, he had a spinal tap, which was negative. MRI initially revealed a mass lesion of the occipital lobe however repeat
scanning with contrast showed the suspect area simply to be artifact. Further testing was ordered
including lumbar puncture and blood testing which revealed a negative RPR, VDRL,
Toxo titre, Cryptococcus and lyme titre. A vitreous sample (PPV) had negative PCR for lyme, toxo, HSV, HS and DNA for TP all of which were
negative.
VISUAL ACUITY: OD 1/200, OS 20/63. IOP: OD 14, OS 12. The right eye has 1+ cell and flare of the anterior chamber and a ReSTOR intraocular lens in good position. He also has corneal incisions. The left eye has a trace cell and flare of the anterior chamber and a ReSTOR intraocular lens in good position.
EXTENDED OPHTHALMOSCOPY:
OD: Vertical C/D ratio is 0.2. There is a white intraretinal mass surrounding the optic nerve.
OS: Vertical C/D ratio is 0.4. There are leopard spots temporal to the fovea.
PHOTOS: The color photo in the right eye shows the white retinal mass and the left eye shows the leopard spots temporal to the fovea.
SPECTRALIS-SD-OCT SCAN: The OCT scan through the macula in the right eye shows the mass to be intraretinal and in the left eye there are irregularities at the level of the pigment epithelium.
FUNDUS PHOTOGRAPHY - AUTO FLUORESCENCE: The image in the right eye shows white hyper auto fluorescence centrally where the white reflective lesion is. In the left eye those little leopard spots are hyper auto fluorescencent.
FLUORESCEIN ANGIOGRAPHY: Fluorescein angiography in the right eye shows leakage from the area of retinal infiltrate. In the left eye there is hypo and hyper auto fluorescence corresponding to the leopard spots.
INDOCYANINE GREEN ANGIOGRAPHY: The indocyanine green angiogram similarly shows the leopard spots in the left eye and leakage from the lesion in the right eye.
IMPRESSION:
1. DIFFUSE CHORIORETINITIS – BOTH EYES
2. PROBABLE SYPHILITIC RETINITIS – RIGHT EYE AND CHOROIDITIS IN THE LEFT EYE
3. POSSIBLE OCULAR LYMPHOMA, TUBERCULOSIS, LYME DISEASE, AND GRANULOMATOUS CHOROIDITIS
DISCUSSION: As I discussed on the phone with you, given the positioning FDABS and the classic signs in the retina for syphilis, I think even with the presence of a negative spinal tap, this is in all likelihood syphilitic choroiditis and retinitis and at the moment I don’t see the reason not to try an antibiotic treatment trial prior to other invasive testing.
If he is on the appropriate treatment for neurosyphilis and he doesn’t show improvement within a week or two, then I don’t think there is any harm in doing vitreous biopsy in the right eye looking for PCR and for cytology and even for possible flow cytometry and then ultimately if that is negative, a retinal biopsy could be considered in the right eye, which may not have much visual potential depending on what happens to the optic nerve lesion.
Visit 2: 02-06-13
74-year-old man was seen in the office on February 6, 2013. He has had decreasing vision in both eyes starting prior to his cataract surgery, which is in July of 2012. Since then he has had a sort of steady gradual downhill course, especially in the right eye, which unfortunately completely lost vision to no light perception not too long ago from possibly optic nerve related swelling, retinal vascular occlusion. His left eye unfortunately has continued inflammation. He has had vitrectomies as well as taps sent for his multiple tests. He has had PCR tests sent for toxoplasmosis and he has also had vitreous samples sent for possible lymphoma.
Recently there is a suspicion he may have lymphoma. He was initially treated with a twenty one day course of penicillin, because of his positive FDABS and the possibility of syphilis. He was subsequently put on fluconazole forty one days of infusion and now he is getting IGG infusions. The right eye which was previously quite painful does feel a lot better now with the treatments.
He has been on 20 mg of prednisone orally. His right eye now has fallen to no light perception. The left eye has some hazy vision. You were concerned about several things; one is mainly what possibilities there might be for diagnosis and therapy, especially to protect the left eye.
VISUAL ACUITY: OD: NLP, OS 20/50. IOP: 13 OU. The right eye has some crystal cellular growth within the LASIK flap and the ReSTOR intraocular lens is in good position. The left eye has a ReSTOR intraocular lens in good position.
EXTENDED OPHTHALMOSCOPY:
OD: Vertical C/D ratio is 0.1. There is neovascularization on the nerve. There are retinal hemorrhages in all four quadrants and the retinal arteries are narrow.
OS: Vertical C/D ratio is 0.2. There is pigment mottling in the macula with sort of a leopard spot pattern of brown hyperpigmentation and superotemporal to the macula there is a whitish looking area of retinitis with an overlying retinal vessel, which looks to be involved with some either intra-arterial plaque or at least irritation of the vessel wall in a way that looks like it may be occlusive.
COLOR PHOTOS: The color photos of the right eye do show retinal hemorrhage with some optic atrophy and a tuft of neovascularization around the nerve. The left eye the retinal vessels visible are clearly aggravated by the inflammation in the retina just superior temporal to the macula.
FUNDUS PHOTOGRAPHY - AUTO FLUORESCENCE: The images show in both eyes a leopard spot pattern of hyperfluorescence scattered in the posterior pole. The right eye has a ring of hypofluorescence around the optic nerve with hyperfluorescence outside of that.
FLUORESCEIN ANGIOGRAPHY: Fluorescein angiography in the right eye shows florid neovascularization of the optic nerve with poor perfusion of the retinal arteries throughout the study. The pigment epithelium appears to be irregularly affected by the disease. There are some areas of hyperfluorescence and some areas of hypofluorescence scattered throughout the posterior pole. There are linear areas of hypofluorescence. I think all of that is left over from the time when he had the exudative detachment, which cleared with therapy. The left eye shows the leopard spot area of hyperfluorescence under the macula and superotemporally the area of whitening does have significant leakage. In the late frames the retinal vessels in that area do appear to still be perfused. That area superotemporally shows capillary dropout.
INDOCYANINE GREEN ANGIOGRAPHY: In the right eye the linear areas of hypofluorescence are present, again looking like they are left over from the old retinal detachment and the neovascularization on the nerve is visible. The angiogram of the left eye, the areas of damage to the retinal vessel walls are more visible than they are on the fluorescein angiogram, but the underlying choroid looks reasonably healthy other than the areas of hypofluorescence corresponding to the leopard spots.
SPECTRALIS-SD-OCT SCAN: The OCT scan of the left eye shows the leopard spot pigmentation. It looks like it is all in front of the retinal pigment epithelium. The OCT scan through the area of retinitis superotemporally shows full thickness retinal disorganization and swelling from the retinitis.
IMPRESSION:
1. BILATERAL PAN UVEITIS
2. FOCAL POSTERIOR RETINITIS – LEFT EYE WITH AN AREA OF RETINAL VASCULITIS OVERLYING IT
3. LEOPARD SPOTS
4. RETINAL ARTERY AND VEIN OCCLUSION – RIGHT EYE RESULTING IN NO LIGHT PERCEPTION VISION
DISCUSSION: I explained to the patient and his wife, at some length mostly that there is still unfortunately a diagnostic dilemma. It is unclear exactly what he has. The treatments of antibiotics combined with the steroids have made the eyes feel a lot better, which does suggest that there might have been an infectious ideology. My only concern is there is still an area of retinitis in the left eye despite what would seem to be adequate treatment for both syphilitic retinitis and for possible fungal issues. I told him at the moment the differential diagnoses include, infectious disease, auto immune disease and unfortunately neoplasm disease, because of the possible ocular lymphoma.
Since it is still unclear exactly what he has, I think that the best thing to do at the moment is for him to see Janet Davis down in Miami for another opinion. This will be a third option and we talked to Janet Davis’s assistant and set that appointment up today for within the next two weeks. In the meantime, I am going to try make sure Dr. Davis has access to all the images that I have taken in the office. I appreciate you getting all the laboratory tests together and hopefully with that we will be able to come up with some sort of definitive plan as to any further diagnosis tests need to be done and any further treatment.
I told him one extreme possibility would be to remove the right eye, since the right eye is no light perception vision and it is possible a pathologist would be able to examine it and help us decide whether this is infectious, auto inflammatory, neoplastic and to further narrow down the diagnosis to something which might allow us to treat and save the left eye.
