2019 Research Forum

Applicant: Phillip Aguìñiga-Navarette RA Principal Investigator & Faculty Sponsor: Jagdipak Heer MD

Syphilitic Neuroretinitis

Matthew Stapleton MD R4, Jagdipak Heer MD, Rachel O’Donnell MD, Daniel Quesada, MD, Phillip Aguìñiga-Navarrete RA, Luke Kim RA

INTRODUCTION We describe a case of painless vision loss secondary to neurosyphilitic neuroretinits. Consent was obtained, including IRB approval for the case report.

PURPOSE A 37-year-old male presented to the Emergency Department complaining of painless left eye vision changes for the past three days described as “white out” with positional changes. He also noted a four-week-old diffuse, erythematous, nonpruritic truncal rash. Visual exam findings were notable for OS 20/25. Ocular pressures were unremarkable. No ptosis was evident on physical examination. A fundoscopic exam of the left eye revealed unilateral papilledema (UP) and bilateral retinal hemorrhage (Image 1). Bilateral fluorescein stain and slit lamp exam were unremarkable. Elevated lymphocytes and protein from a lumbar puncture raised concern for neurosyphilis. Labs were significant for reactive Hepatitis B, ANA screen, RPR w/ reflex, FTA, S R West Auto, Crp of 3.1. VDRL(CSF) was nonreactive. Lyme AB screen and Bartonella AB panel were both negative. Syphilis AB QL was positive. An MRI of the brain revealed 12 mm of high right frontal lobe CSF density. The patient was given benzylpenicillin with subsequent vision improvement within 18 hours of administration, indicative of painless vision loss secondary to neurosyphilitic neuroretinitis. DISCUSSION Common causes of UP and vision loss include anterior ischemic optic neuropathy (AION) and optic neuritis (ON).1 AION is often seen in patients older than 50 years with associated comorbidities, making it an unlikely cause of the patient’s vision loss.1 ON typically affect females between 20-35 years of age.1 ON in 90% of cases have associated headaches, eye pain or both; whereas 19% of AION have associated pain.1 Neuroretinitis is uncommon, typically characterized by optic disc edema and subsequent formation of a macular star figure. The underlying pathophysiology involves increased permeability of disc vasculature, but the etiology is not fully defined.2 Our patient’s exam and symptoms were most consistent with neuroretinitis.

CONCLUSION Painless UP in younger patients should raise concern for an insidious process and prompt a thorough investigation.

18