Physical and Laboratory Findings
Background
A 40-year-old male visited the clinic complaining of acute and progressive vision loss in the past few weeks. These symptoms started to emerge after his return from holiday in Las Vegas, where he had gone on a trip with some of his friends. He suggested that he was only able to make out blurry figures in the right eye and shadows in the left eye. The man also implied that he experienced rashes around the eye. However, he denied focal neurological deficits, vomiting, nausea, stiffness of the neck, headache, and painful vision. Past medical history of the patient only indicated hemolytic uremic syndrome, which was resolved through medication and treatment. He denied the use of illicit drugs such as tobacco and alcohol in the past five years but admitted having unprotected sex with numerous men in the recent past.
Physical and Laboratory Findings
On physical examination, he had a 20/40 visual acuity of the left eye while the right eye was only able to identify a hand waving. He also had an erythematous rash with clear sclera and bilateral periocular. The edema of the left optic nerve was identified through a fundoscopic examination. In contrast, fluorescein angiography and slit-lamp examination revealed inflammatory lesions in the retina, extensive cellular debris, serious bilateral vitreous, and bilateral optic nerve head edema. We were also able to note the bilateral posterior synechiae, which had resulted in the irregular shape of the pupil. Various injection spots were evident in his forearm, which suggested the recent use of methamphetamine.
Laboratory tests were important for a complete blood count. To begin with, the analysis of the cerebrospinal fluid indicated 26 mg/dL protein, 40 mg/dL glucose, nine white blood cells, and 0 red blood cells/μL. The lumbar puncture demonstrated a 9 cm H2O pressure, while the Gram stain did not show any microorganisms. Subsequent results of microbiology and laboratory test included a positive serum syphilis EIA with a 1: 245 serum RPR tier. The results also demonstrated a 377 cells/mL CD4+ cell count with a 124,450 copies/mL HIV RNA level. The CSF Cryptococci antigen, Serum toxoplasma IgG, and serum tests were all negative. Lastly, the tests confirmed a positive Confirmatory western blot and positive HIV/AIDS. The man was informed of his positive neurosyphilis and HIV status. He admitted that even though he has never had an HIV test, his current partner was positive. However, he recalls that he has previously been diagnosed with syphilis even though it’s unknown to his partner. There is usually no screening tests for patients who have been previously diagnosed with the disease, but cerebrospinal fluid (CSF) test are recommended if ocular manifestations are present.
Diagnosis, Disease, and Organism Discussion
Most researches posit that syphilis is a sexually transmitted disease even though other studies suggest that it can be transmitted through contact with infectious lesions, breaks on the skin, through blood transfusion, and from mother to fetus. The disease is transmitted through the Treponema pallidum bacteria. The term syphilis thought to have originated from an Italian poem about a young shepherded who contracted a French illness that was spreading through Europe in the early 1500s. Even though other researches suggest that syphilis was already present in Africa, history indicates that Columbus contacted the disorder from an island where the Dominican Republic and Haiti are located. Consequentially, World pandemics and wars generally aided the rapid spread of the disease. Since its advent, the management of the disease has been a huge challenge for public health practitioners and medical care providers. Some of the common symptoms include a painless sore on the sexual organs, inside the mouth or rectum. The sore is commonly referred to as a chancre and is not easily noticeable during the early stages. After a few weeks of the healing of the original sore, the patient may experience a rash that starts on the trunk. The rashes may be accompanied by warlike sores on the victim’s foot or mouth, while others may experience swollen lymph, sore throat, fever, muscle aches, or hair loss.
The condition develops in stages, with each stage having different symptoms. These stages include primary, secondary, latent, and tertiary in order of how it worsens. According to SAMUEL (2012), patients that have been diagnosed with primary and secondary syphilis ought to go through clinical and serologic examination at 6 and 12 months in the bid to establish treatment reinfection or failure. On the other hand, patients with latent syphilis require such follow-ups within 24 months. Furthermore, Cerebrospinal fluid (CSF) analysis should be conducted if the high baseline titers do not decline within two years of treatment or if symptoms are still evident. Similarly, most patients that have reactive tests might be obliged to have such tests in all their lives regardless of disease activity and treatment. A good percentage of patients that are treated during the early stages revert to being serologically nonreactive after a few years.
Treatment
Treatment began with intravenous penicillin G in the bid to improve his bilateral vision and rash. He was discharged and put on a two-week complete intravenous penicillin G. it was also recommended that his partner should undergo examination for potential sexually transmitted diseases. Regarding his HIV condition, he was initiated to antiretroviral therapy and substance abuse treatment, which he voluntarily complied with. When the patient visited the clinic after two weeks, his papilledema and uveitis had resolved while his vision was now at 20/60 bilaterally. His serum RPR tier also improved to 1:125. Due to the slow improvement of the RPR, the lumbar puncture was conducted a few months after treatment, which revealed VDRL was nonreactive while the white blood cells also improved. Treatment of primary and secondary syphilis generally entails a single dose of benzathine penicillin G. however, there is no much information on the treatment of tertiary and late latent syphilis.
Outcome
With significant improvements six months after treatment, the patient was considered successfully treated.
However, his serum RPR and clinical treatment were to be observed regularly. Fortunately, the disease is curable; thus, along with treatment, the victims should be offered emotional support and educated about it. In pursuit of curbing its spread, patients that have been diagnosed with syphilis should be advised to refrain from sexual activities until the sores and lesions have healed. Victims must also understand that successful treatment does not mean immunity from the infection. Thus they should be serious about abstinence or safe sex to prevent syphilis reinfection.