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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 427-429

Use of intravitreal dexamethasone implant to control paradoxical worsening in a case of syphilitic acute placoid posterior chorioretinitis


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 Submission28-Feb-2021
Date of Acceptance13-Sep-2021
Date of Web Publication13-Apr-2022

Correspondence Address:
Manpreet Brar
Department of Retina, Grewal Eye Institute, SCO 168-169, Sector 9-C,Madhya Marg, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_417_21

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  Abstract 


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.[1] However, not much is known about such episodes in ocular syphilis except a few case reports.[2] A similar phenomenon of paradoxical worsening has been commonly reported in ocular tuberculosis and few cases with ocular bartonellosis.[3],[4],[5]


  Case Report Top


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 Top


Gass et al.[6] 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.[7] Dexamethasone implants have been shown to be very effective in managing intraocular inflammation in both noninfective and infectious uveitis,[8] 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.[9]


  Conclusion Top


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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Li J, Wang LN, Zheng HY. Jarisch-Herxheimer reaction among syphilis patients in China. J Eur Acad Dermatol Venereol 2013;27:1304-7.  Back to cited text no. 1
    
2.
Saleh MG, Campbell JP, Yang P, Lin P. Ultra-wide-field fundus autofluorescence and spectral-domain optical coherence tomography findings in syphilitic outer retinitis. Ophthalmic Surg Lasers Imaging Retina 2017;48:208-15.  Back to cited text no. 2
    
3.
Ganesh SK, Abraham S, Sudharshan S. Paradoxical reactions in ocular tuberculosis. J Ophthal Inflamm Infect 2019;9:19.  Back to cited text no. 3
    
4.
Cheung C, Chee S. Jarisch–Herxheimer reaction: Paradoxical worsening of tuberculosis chorioretinitis following initiation of antituberculous therapy. Eye 2009;23:1472-3.  Back to cited text no. 4
    
5.
Zimran E, Shilo S, Florescu T, Dotan S, Balag S, Mevorach D, et al. Paradoxical response in ocular bartonellosis. J Ophthal Inflamm Infect 2012;2:53-6.  Back to cited text no. 5
    
6.
Gass JD, Braunstein RA, Chenoweth RG. Acute syphilitic posterior placoid chorioretinitis. Ophthalmology 1990;97:1288-97.  Back to cited text no. 6
    
7.
Eandi CM, Neri P, Adelman RA, Yannuzzi LA, Cunningham ET Jr, International Syphilis Study Group. Acute syphilitic posterior placoid chorioretinitis: Report of a case series and comprehensive review of the literature. Retina 2012;32:1915-41.  Back to cited text no. 7
    
8.
Zarranz-Ventura J, Carreño E, Johnston RL, Mohammed Q, Ross AH, Barker C, et al. Multicenter study of intravitreal dexamethasone implant in noninfectious uveitis: Indications, outcomes, and reinjection frequency. Am J Ophthalmol 2014;158:1136-45.  Back to cited text no. 8
    
9.
Belum GR, Belum VR, Chaitanya Arudra SK, Reddy BS. The Jarisch-Herxheimer reaction: Revisited. Travel Med Infect Dis 2013;11:231-7.  Back to cited text no. 9
    


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