Dados do Trabalho

Título

The refractory treatment in a patient with syphilitic uveitis: A case report

RESUMO

Case Report: A 23 year old man was admitted in emergency with progressive bilateral vision impairment, which started one month ago with ocular hyperemia and dark spots. Also reported history of adynamia, hyporexia and fever. Upon neurological exam: pupils with light-near dissociation, fundoscopy: bilateral posterior synechiae and right eye with optic nerve with infiltrative-appearing papilledema. The laboratory tests revealed a venereal disease research laboratory test (VDRL) 1:1024 and HIV reagent, confirmed by two positive samples. Cerebrospinal fluid (CSF) analysis showed non-reactive VDRL and increased protein. A diagnosis of neurosyphilis was made. Treatment with crystalline penicillin and eye drops (corticoid and tropicamide) was instituted. After 21 days of crystalline penicillin with persistent lesions in the eye, and evidence of capture contrast in basal ganglia in cranial magnetic resonance (MRI), empirical treatment for toxoplasmosis neuroretinitis was discussed and sulfadiazine was prescribed to treat neurotoxoplasmosis. The patient was later reassessed by the ophthalmologist, showing improvement in the retinal edema. Discussion: Syphilitic uveitis comprises less than 1-2% of all uveitis cases, however an increase in the number of cases over the past decade was observed. The manifestations are diminished visual acuity, blindness, optic neuropathy, interstitial keratitis and it can occur at any state of natural history of untreated syphilis. In the present case, even with CSF non-reactive, the signs of active uveitis and the VDRL titulation suggested neurosyphilis. Neuroretinitis is a phenotype of syphilis uveitis and is described as a clinical triad of unilateral vision loss accompanied by optic disc edema and the formation of a characteristic macular star. Pacientes should test for HIV infection either, because the co-infection are frequent. A few cases of neuroretinitis by Toxoplasma gondii have been reported, however the presence of hiperdense lesions in basal ganglia in MRI associated with lack of improvement of ocular lesions support the treatment choice for neurotoxoplasmosis. Conclusion: Immunosuppression by HIV may contribute to the appearance of opportunistic infections with atypical involvement, such as neuroretinitis in toxoplasmosis and syphilitic uveitis. For the adequate management of these patients a thorough etiological investigation should be performed, as well as the observation of improvement after treatment.

Palavras Chave

UVEITIS; SIFILIS; HIV; TOXOPLASMOSE; IMUNOSUPRESSION.