|Year : 2022 | Volume
| Issue : 2 | Page : 427-429
Use of intravitreal dexamethasone implant to control paradoxical worsening in a case of syphilitic acute placoid posterior chorioretinitis
Manpreet Brar1, Dilraj Singh Grewal2, Satinder Pal Singh Grewal1, Mansi Sharma1, Rahatdeep Singh Brar3, Mangat Dogra1
1 Grewal Eye Institute, Chandigarh, India
2 Duke Eye Center, Department of Retina, Durham, NC, USA
3 Homi Bhabha Cancer Hospital & Research Center - Tata Memorial Center, Department of Radiology, Mullanpur, Punjab, India
|Date of Submission||28-Feb-2021|
|Date of Acceptance||13-Sep-2021|
|Date of Web Publication||13-Apr-2022|
Department of Retina, Grewal Eye Institute, SCO 168-169, Sector 9-C,Madhya Marg, Chandigarh
Source of Support: None, Conflict of Interest: None
Paradoxical worsening of ocular syphilis after initiation of antimicrobial therapy is rare, however it is important for the clinicians to be aware of this occurrence, as prompt recognition and timely intervention with corticosteroids can lead to restoration of vision. Alteration/discontinuation of antimicrobial therapy may not be indicated. Our case highlighted the role of dexamethasone implant to control such paradoxical worsening in a young patient with ocular syphilis.
Keywords: Dexamethasone implant, OCT angiography, syphilitic chorioretinitis
|How to cite this article:|
Brar M, Grewal DS, Grewal SP, Sharma M, Brar RS, Dogra M. Use of intravitreal dexamethasone implant to control paradoxical worsening in a case of syphilitic acute placoid posterior chorioretinitis. Indian J Ophthalmol Case Rep 2022;2:427-9
|How to cite this URL:|
Brar M, Grewal DS, Grewal SP, Sharma M, Brar RS, Dogra M. Use of intravitreal dexamethasone implant to control paradoxical worsening in a case of syphilitic acute placoid posterior chorioretinitis. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 May 26];2:427-9. Available from: https://www.ijoreports.in/text.asp?2022/2/2/427/342997
A transient immunological reaction called Jarisch Herxhemir reaction (JHR) has been described to occur in approximately 95% of patients with secondary syphilis where patients develop exacerbation of lesions despite treatment. However, not much is known about such episodes in ocular syphilis except a few case reports. A similar phenomenon of paradoxical worsening has been commonly reported in ocular tuberculosis and few cases with ocular bartonellosis.,,
| Case Report|| |
A 28-year-old male came to our clinic with two weeks history of blurred vision in his right eye. On examination, his Snellen visual acuity was 5/200 in the right eye (RE) and 20/20 in the left eye (LE). Slit-lamp examination was unremarkable for both eyes, except 1+ vitreous cells in the RE. Intraocular pressure recorded by noncontact tonometry was 16 mm Hg and 14 mm Hg in the RE and LE, respectively. Color fundus photograph (CPH) of the RE showed a large yellowish placoid lesion at the posterior pole with multiple patches of active choroidal lesions, Few pigmented chorioretinal lesions were present in the superior retina, and few scattered splinter hemorrhages were visible in the retina [Figure 1]a and [Figure 2]a. Fundus fluorescein angiogram showed early hypofluorescence at the edges of active lesions, associated with late staining hyper fluorescence [Figure 1]b and [Figure 1]c. OCT angiography revealed well-defined hypo flow void lesions at the level of the choriocapillaris, more pronounced at the edges of the lesions, with the central part of the lesion showing mixed pattern of hyper and hypo flow regions [Figure 1]d. Spectral-domain OCT image demonstrated irregular RPE/choriocapillaris band thickening and nodularity [Figure 1]e. The patient underwent a complete uveitis workup including chest X-ray, Mantoux skin test, and blood test (including QuantiFERON gold, serum ACE, Syphilis serology, hemogram, and ESR). All other investigations were negative except positive titer of syphilis antibody on FTA-ABS. A diagnosis of syphilitic placoid chorioretinitis was made, and the patient was started on intravenous ceftriaxone for 14 days and oral corticosteroids under physician guidance. His partner was advised syphilis serological testing and she too tested positive and was subsequently treated as instructed by the treating physician.
|Figure 1: (a) Fundus image showing a large yellowish placoid lesion at the posterior pole with multiple patches of active (arrow 1) and healed (arrow 2) choroidal lesions. (b) Early FFA showing early hypofluorescence in the area of active choroiditis patch (c) Late FFA showing hyperfluoresent staining. (d) OCT angiography, CC slab revealed well-defined hypo flow void lesions at the level of the choriocapillaris, more pronounced at the edges of the lesions. (e) OCT image demonstrated irregular RPE/choriocapillaris band thickening and nodularity|
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|Figure 2: (a) CPH at baseline in case of ASPPC. (b) CPH 5 days after initiating treatment did not show any development of new lesions. (c) CPH 10 days later showed signs of healing in the older lesions, but development of few new active patches of chorioretinitis was noticed (arrow). (d) CPH 17 days from baseline demonstrated further progression and enlargement of active chorioretinal lesions (arrow). (e) CPH 2 weeks after dexamethasone implant showed no new patches with signs of healing of the chorioretinal lesions. (f) CPH 3 months from baseline showed healed chorioretinitis|
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CPH 5 days after starting treatment did not show any new lesions [Figure 2]b. However, CPH 10 days later showed signs of healing in the older lesions, but development of few new active patches of chorioretinitis was noticed [Figure 2]c. At this stage, the patient was advised an intravitreal dexamethasone implant (IVT-DEX) to control increased disease activity. The patient refused this treatment and follow-up 17 days later revealed further progression and enlargement of active chorioretinal lesions [Figure 2]d. IVT-DEX was implanted under topical anesthesia. Follow-up images done 2 weeks after revealed signs of healing [Figure 2]e. His VA improved to 20/50 and oral corticosteroids were successfully tapered, and at the last follow-up that was 3 months from baseline, he showed healed chorioretinitis [Figure 2]f
| Discussion|| |
Gass et al. introduced the term “syphilitic acute placoid posterior chorioretinitis” to describe the ocular manifestation of syphilis that is characterized by the presence of one or more placoid yellowish outer retinal lesions, typically in the macula. Usual treatment consisting of use of antibiotics and/or oral corticosteroids are added to control the inflammatory load. Dexamethasone implants have been shown to be very effective in managing intraocular inflammation in both noninfective and infectious uveitis, and the local approach has the advantage of providing a more localized anti-inflammatory response; thus, we considered this treatment as a suitable option for our patient. An extensive literature search did not reveal any case report highlighting the use of dexamethasone implant for paradoxical worsening of ocular syphilis. The release of endotoxin-like material from the spirochetes and elevation of cytokines following the antibiotic treatment has received much consideration.
| Conclusion|| |
We report multimodal imaging findings in a patient with acute syphilitic acute placoid posterior chorioretinitis that developed paradoxical worsening and responded well to local intravitreal dexamethasone implant.
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
Conflicts of interest
There are no conflicts of interest.
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