Framboesiform Facial Lesions and Chorioretinopathy as Presenting Signs of Syphilis in an Immunocompetent Patient.

ABSTRACT: Syphilis has long been considered the "great masquerader," notorious for its varying presentations and ability to affect most organ systems in the body. We report the case of a 41-year-old immunocompetent man who presented to ophthalmology with rapidly progressive visual complaints from bilateral panuveitis and concomitant verrucous facial lesions initially disregarded by the patient as acne. Serum testing for syphilis was positive, and he was admitted for 14 days of intravenous (IV) penicillin with multiservice care from dermatology, ophthalmology, and infectious disease. We present photographic documentation showing his stepwise resolution of his facial and retinal involvement with penicillin treatment course. This case is unusual in the concomitant presentation of ocular and facial syphilitic findings in an immunocompetent patient and highlights the need to include syphilis in the differential for unusual appearances.

SMOKING, RURAL RESIDENCE AND DIABETES AS RISK FACTORS FOR PRESUMED OCULAR HISTOPLASMOSIS SYNDROME.

PURPOSE: To investigate the relationship of smoking, urbanicity, and diabetes to presumed ocular histoplasmosis syndrome (POHS) and associated choroidal neovascularization (CNV). METHODS: Medical records of 751 adult patients with POHS were reviewed, including 603 patients without CNV and 148 patients with CNV. Age-matched and gender-matched controls were randomly selected from the same practice for comparison. Statistical comparisons of smoking history, urbanicity, and diabetic history were performed using chi-square and conditional logistic regression analyses. RESULTS: Increased rates of current or former smoking, rural residence, and diabetes were found in patients with POHS compared with controls. POHS patients with CNV had increased rates of current or former smoking and rural residence as compared with controls. CONCLUSION: A history of current or past smoking is associated with an increased risk of developing both POHS alone and POHS with CNV. We did not find a significant additional risk of smoking on the development of CNV in patients with POHS. Patients living in rural locations are more likely than those in urban locations to develop both POHS and POHS with CNV. Diabetics may be more likely to develop POHS than nondiabetics.

Mycobacterium Tuberculosis Modulates Fibroblast Growth Factor and Vascular Endothelial Growth Factor in Ocular Tuberculosis.

Purpose: To evaluate the role of angiogenic growth factors in the pathogenesis of intraocular tuberculosis.Methods: Retinal Pigment Epithelium (RPE) cells were infected with varying dilution of Mycobacterium tuberculosis (MTB), ranging from several thousand to a few MTB bacilli to replicate paucibacillary conditions. Angiogenesis growth factors were evaluated using multiplex fluorescent bead based flow cytometry in the culture supernatant of RPE cells infected with MTB, vitreous fluids and tear samples of uveitis patients visiting retina clinic.Results: Vascular endothelial growth factor (VEGF) levels were elevated and fibroblast growth factors (FGFs) were down regulated in RPE-infected MTB cells. Similar pattern of VEGF and FGF was observed in the vitreous of IOTB patients. However, no changes were observed in tear samples.Conclusions: MTB exploits the angiogenesis growth factors for pathogenesis by decreasing FGF with concomitant surge of VEGF in MTB infected RPE as well in the vitreous of IOTB patients.

Subretinal abscess as an initial presentation of systemic nocardiosis.

We report a case of subretinal abscess as the initial presentation of systemic nocardiosis. The patient was a known case of chronic inflammatory demyelinating polyneuropathy and on long-term immunosuppressants. He presented with a rapidly progressive, unilateral decline in visual acuity in the right eye. Dilated fundus examination showed a large whitish subretinal lesion. A working diagnosis of subretinal abscess was made. The appearance was highly suspicious for Nocardia abscess. On further direct questioning, it was noted that the patient had been experiencing low-grade fever and non-productive cough for 1 month. The patient was referred to infectious diseases for systemic work-up and a vitreous tap was done, along with intravitreal antibiotics. Blood culture and bronchoalveolar lavage both reported Nocardia species. Sensitivity-guided antibiotic therapy resulted in improved systemic condition and a quiet and comfortable right eye, but vision could not be saved due to late presentation.

Retinal dysfunction of syphilitic outer retinopathy.

PURPOSE: We present our findings in two cases of retinal dysfunction caused by syphilitic outer retinopathy. CASE 1: A 59-year-old man visited our clinic complaining of blurred vision in his left eye. Optical coherence tomography (OCT) demonstrated an absence of the ellipsoid zone (EZ) in the left eye. A round yellowish-white lesion was observed in the posterior pole of the left fundus. Fundus autofluorescence (FAF) showed hyperfluorescent areas in the posterior pole of both fundi although no specific ophthalmoscopic findings were seen in the right eye. The amplitudes of the LA 3.0 1 Hz and LA 3.0 30 Hz ERG responses were reduced with better preservation of the rod responses. Based on a strong positivity to the rapid plasma reagin (RPR) assay and the Treponema pallidum hemagglutination (TPHA) test, he was diagnosed with syphilitic outer retinopathy and treated with systemic antibiotics. The treatment resulted in a restoration of the retinal structures and cone function. CASE 2: A 47-year-old man was referred to our clinic complaining of reduced vision in both eyes. Although the ocular fundus appeared normal, FAF showed a diffuse hyperfluorescent area in the posterior pole and multiple hyperfluorescent spots. Indocyanine green angiography showed multiple confluent areas of hypofluorescence. OCT demonstrated irregular EZs in both eyes. The amplitudes of the LA 3.0 1 Hz and LA 3.0 30 Hz ERG responses were slightly reduced with prolonged implicit times. These findings are comparable to the findings in patients with multiple evanescent white dot syndrome. However, the strong positivity to the RPR and TPHA tests led us to diagnose the patient with outer retinopathy caused by syphilis. Systemic administration of antibiotics resulted in the restoration of the retinal structures and retinal function. CONCLUSIONS: Syphilitic outer retinopathy affected the retinal structures and function that can be restored by antibiotic treatments.

MRSA Septicemia With Septic Arthritis and Prostatic, Intraretinal, Periapical, and Lung Abscesses.

INTRODUCTION: Methicillin-resistant staphylococcus aureus (MRSA) bacteremia is a life-threatening illness and a major global health care problem. It can cause metastatic and complicated infections. CASE PRESENTATION: A 58-year-old man with uncontrolled type 2 diabetes mellitus presented with altered mental status after a fall. He was found to have a hip fracture, diabetic ketoacidosis, and MRSA bacteremia. This was complicated by septic knee arthritis, prostatic abscess, intraretinal abscess, periapical abscesses, and pulmonary abscesses. He was treated with intravenous vancomycin and oral linezolid and eventually recovered. DISCUSSION: Severe metastatic MRSA infection was likely due, in part, to the patient's uncontrolled diabetes, as he has no underlying immunodeficiency and was HIV negative. Prostatic abscesses are a relatively rare occurrence that typically develop in immunocompromised patients. CONCLUSION: This case is an interesting confluence of sequelae of MRSA bacteremia and reinforces the necessity for clinicians to be diligent when evaluating a patient with a suspected prostatic abscess.

Optical coherence tomography features of retinal lesions in Chinese patients with endogenous Candida endophthalmitis.

BACKGROUND: To evaluate the optical coherence tomography (OCT) features of retinal lesions in Chinese patients with endogenous Candida endophthalmitis (ECE). METHODS: We performed a retrospective review of patients diagnosed with ECE at one medical center. The medical records of the patients including predisposing risk factors, treatment and visual acuity were reviewed. And we focused on the analysis of OCT images of retinal lesions before and after treatment. RESULTS: A total of 16 Chinese patients (22 eyes) were included in this study. The most frequent predisposing risk factors were intravenous use of corticosteroids or antibiotics, lithotripsy for urinary calculi, and diabetes. After treatment, visual acuity was improved in 13 (59.1%) of the 22 eyes, and remained the same in the other 9 (40.9%) eyes. Pre-treatment OCT images obtained at presentation were available for 17 of the 22 eyes. Four types of the OCT manifestations of retinal lesions were identified: type 1 (subretinal macular lesions), type 2 (lesions are located in the inner retinal layer), type 3 (lesions involve the full-thickness retina and accompanied with macular edema), type 4 (sub-inner limiting membrane lesions). Pre-treatment OCT imaging of the 17 eyes revealed five as type 1, four as type 2, six as type 3, and two as type 4. After treatment, OCT images revealed epiretinal membrane and subretinal fibrosis as the most common post-treatment complications of ECE. Epiretinal membrane was detected in 2/4 type 2 lesions, in 4/6 type 3 lesions, and in 1/2 type 4 lesions, while subretinal fibrosis was mainly seen in type 1 lesions (4/5). Among the types, visual prognosis was best in eyes with type 2 lesions. CONCLUSIONS: In this case series, the OCT manifestations of retinal lesions in ECE could be classified into four types. The post-treatment OCT manifestations were different in four types of lesions. We preliminarily found that the OCT morphology of retinal lesions was associated with the visual prognosis of ECE.

Diagnostic Challenge with Nocardia Subretinal Abscess: A Case Report from Tuberculosis-Endemic Region.

Purpose: To describe a case of Nocardia subretinal abscess, which posed a diagnostic challenge due to the presence of mycobacterial genome in sample obtained from fine needle aspiration biopsy (FNAB). Methods: A retrospective chart review. Results: A 25-year-old male presented with sudden, painless onset diminution of vision of left eye and found to have placoid patch of choroiditis just temporal to the macula in right eye and showed vitritis, subretinal abscess with exudative retinal detachment and vitreous hemorrhage in left eye. Both aqueous and vitreous samples were negative microbiologically and polymerase chain reaction for various genomes. Sample obtained from FNAB was positive for mycobacterial genome and yielded Nocardia arthritidis on culture. She was treated with antitubercular therapy and intravenous and intravitreal antimicrobials. Conclusions: Nocardia subretinal abscess can be a diagnostic challenge in tuberculosis-endemic region, especially in conditions when there is co-infection with Mycobacterium tuberculosis.

Acute subretinal abscess in Staphylococcus aureus septicaemia with endophthalmitis showcased by multimodal retinal imaging and with 2-year follow-up.

A middle-aged man presented to emergency services with central vision loss in the setting of flu-like illness with fever. A striking subfoveal abscess was observed in the right fundus. Focal acute chorioretinal inflammation was noted in the asymptomatic fellow eye. Staphylococcus aureus septicaemia was subsequently diagnosed. He presented with undiagnosed HIV infection and latent syphilis. Serial high-definition multimodal retinal imaging showcased resolution of the dome-shaped subretinal abscess following treatment with intravenous flucloxacillin. A chorioretinal scar swiftly replaced the subfoveal abscess. Peripheral right vision and full left vision was retained. Vision loss due to endogenous endophthalmitis in systemic sepsis is an emergency requiring prompt multidisciplinary care. Sight and life are at risk-thus this is not a diagnosis to miss! Early recognition is paramount to health and in retaining vision. We briefly review relevant literature and portray how multimodal imaging guided response to treatment of acute subretinal abscess.

Disseminated Nocardiosis with subretinal abscess in a patient with nephrotic syndrome-a case report.

BACKGROUND: Nocardia infection is uncommon in clinical practice, with most cases occuring as the result of opportunistic infection in immunocompromsed patients. Here, we report a case of disseminated nocardiosis with subretinal abscess in a patient with nephrotic syndrome, and whom is receiving immunosuppressive therapy. CASE PRESENTATION: A 58-year-old male presented with decreased vision in his left eye, without redness or floaters, which had persisted for three days. The patient had previously been diagnosed with membranous nephropathy, and as such, had received systemic corticosteroid therapy for four months. Further, the patient had developed pneumonia three weeks prior to this presentation. The ocular lesion appeared as a creamy-white subretinal abscess, with overlying retinal hemorrhages. Subsequent administration of three intravitreal injections of vancomycin and ceftazidime ultimately led to eradication of the intraocular infection, however, two months later, the patient developed a brain abcess. Pathogens isolated from the blood were subsequently identified as Nocardia. The patient was successfully treated via systemic administration of imipenem and trimethoprim-sulfamethoxazole. CONCLUSIONS: Clinicians should be aware of the possibility of Nocardia infections within all immunocompromised patients, as well as the tendency of this infection to disseminate--particularly in the brain. The early detection of Nocardia infections and prolonged treatment of the proper antibiotics may significantly improve the prognosis of this life-threatening infection.

Successful treatment of endogenous endophthalmitis with extensive subretinal abscess: a case report.

BACKGROUND: Endogenous endophthalmitis could lead to a devastating outcome without a prompt and appropriate management. We report a case of advanced endogenous Klebsiella pneumoniae endophthalmitis with extensive subretinal abscess that was successfully treated with a vitrectomy. CASE PRESENTATION: A systemically well 61-year-old man complained of ocular pain and visual decrease in his right eye for eighteen days. Ophthalmic examination showed dense inflammation in the anterior chamber and vitreous body. Systemic investigations discovered diabetes and no specific site of systemic infection was found after hospitalization. The inflammation continued to worsen after the intravitreal antibiotic injection. Therefore, a pars plana vitrectomy combined with phacoemulsification was performed. Intraoperatively, a white elevated, fluffy mass with the overlying retinal whitening and necrosis was revealed in superior periphery. In addition to this, extensive retinal hemorrhages and five adjacent subretinal whitish masses with exudative retinal detachment were observed in the posterior pole and inferior quadrants, which were suggestive of extensive subretinal abscess with intense overlying retinal inflammation. The excision of white fluffy mass superiorly was performed without retinotomy and aspiration of extensive subretinal abscess. The polymerase chain reaction of vitreous samples was positive for Klebsiella pneumonia. Intravitreal 2 mg/0.1 ml ceftazidime were repeated. Nine days after the surgery, the inflammation significantly subsided and the retina reattached. The patient was in a stable condition at subsequent visit eight months later. CONCLUSION: The delay in an accurate diagnosis and treatment caused extensive subretinal abscess combined with endogenous endophthalmitis. The treatment modality of subretinal abscess is typically individualized to the patient's presentation. If the retina overlying the abscess is not necrotic, the extensive subretinal abscess can quickly absorbed after vitrectomy, retinotomy with aspiration of the abscess should be avoided to decrease the risk of retinal detachment.

Endogenous Cryptococcus neoformans endophthalmitis with subretinal abscess in a HIV-infected man.

To report a rare case of Cryptococcus neoformans endogenous endophthalmitis with subretinal abscess in a 36-year-old HIV-positive man, referred with progressive blurred vision in his right eye for the last 6 months. Vitreous biopsy followed by intravitreal ganciclovir did not result in significant improvement. Microbiology revealed the presence of C. neoformans, and intravitreal amphotericin B was then administered. The patient was treated aggressively with systemic and intravitreal antifungals but had a poor visual and anatomical outcome. A high degree of clinical suspicion combined with microbiological evaluation helped to arrive at an appropriate diagnosis.

The Role of Microbiota in Retinal Disease.

The ten years since the first publications on the human microbiome project have brought enormous attention and insight into the role of the human microbiome in health and disease. Connections between populations of microbiota and ocular disease are now being established, and increased accessibility to microbiome research and insights into other diseases is expected to yield enormous information in the coming years. With the characterization of the ocular microbiome, important insights have already been made regarding corneal and conjunctival tissues. Roles for non-ocular microbiomes in complex retinal diseases are now being evaluated. For example, the gut microbiome has been implicated in the pathogenesis of uveitis. This short review will summarize the few studies linking gut or oral microbiota to diabetic retinopathy (DR), glaucoma, and age-related macular degeneration (AMD). We will also conjecture where the most significant findings still remain to be elucidated. Finally, we will propose the gut-retina axis, related but distinct from the gut-brain axis.

Disseminated cryptococcosis in HIV negative patient.

A 52-year-old white diabetic male with 4-weeks history of persistent cough followed by headache, drenching night sweats, low-grade fever, worsening photophobia, nausea and vomiting was presented. Examination was significant for photophobia and diminution of vision. His spinal fluid and blood cultures were positive for Cryptococcus neoformans Intravenous fluconazole were given for 2 weeks followed by oral fluconazole. There was significant improvement in systemic and ocular symptoms. HIV serology was negative, but his CD4 counts were low with inverted CD4:CD8 ratio.

[Infection-associated Acute Posterior Multifocal Placoid Pigment Epitheliopathy]. / Infektassoziierte akute posteriore multifokale plakoide Pigmentepitheliopathie.

Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a rare inflammatory chorioretinopathy, which mainly affects young light-skinned, myopic adults between 20 and 30 years of age. The exact aetiology of APMPPE is unknown. Some patients report a viral or flu-like illness preceding the onset of APMPPE symptoms. This condition is usually bilateral and self-limiting with a good overall prognosis. Visual loss is sudden, but usually temporary. Relapses are very rare. Foveal involvement may lead to a worse visual prognosis. There is no current consensus on treatment. A wait-and-see approach with monitoring at short intervals is often sufficient. Based on a case example from our clinic we will demonstrate symptoms, diagnostic work-up and treatment options.