Medical Ophthalmology: Case two

This 30 year-old woman was seen in the eye casualty because of a right anterior uveitis. She also had the above skin rash for the past 6 days.

a. What is the most likely diagnosis?

Secondary syphilis.

This usually begins about 6 weeks after the onset of the primary chancres (painless ulcer at the site of inoculation).  The rash is typically maculopapular with symmetrical distribution; less commonly it may present as annular, pustular or psoriariform lesions. It is commonly mis-diagnosed as pityriasis rosea, psoriasis, erythema muliforme or drug reaction.
Ocular involvement may present as anterior uveitis which can be either granulomatous or non-granulamatous. Posterior involvement may include vitritis, chorioretinitis, vasculitis optic papillitis or neuroretinitis.

b. What other physical signs may be present?

Other common signs of secondary syphilis include:
  • lymphadenopathy
  • alopecia (scalp, loss of eyebrow or lashes)
  • mucous patches (painless erosion of mucous membrane sometimes with snail-track appearance)
  • condylomata lata (white flat papules found mainly in genitals or flexures)

c. How would you diagnose this condition?

Blood tests. VDRL (venereal disease research laboratory) and RPR (rapid plasma reagin) tests are usually positive in active infection. For more specific test FTA-ABS (fluorescent treponemal antibody absorption) is performed as VDRL may be false positive in conditions like SLE, rheumatoid arthritis and pregnancy.

d. How do you treat this condition?

The patient can be treated with long-acting procaine penicillin (1.2g daily) by intramuscular injection for 10 days. If the compliance were doubtful, the patient can be given benzathine penicillin (2.4 g) which maintain a high level for 2 weeks.
Patients allergic to penicillin can be given erythromycin 500 mg qds for 2 weeks.
Click here for the answers Click here for the main page Click here for MRCOphth/FRCS tutorials