Clinical & Laboratory Characteristics of Ocular Syphilis, Co-Infection & Therapy Response

Purpose

To describe the clinical presentation of patients diagnosed with presumed latent ocular syphilis and congenital ocular syphilis at tertiary referral center in Turkey, and to compare the clinical findings with patients described in other studies, specifically focusing on demographics and co-infections.

Methods

This is a retrospective study reviewing the medical records of patients diagnosed with ocular inflammation between January 2012 and June 2014 at a tertiary referral center in Turkey. Ocular syphilis was diagnosed on the basis of non-treponemal and treponemal antibody tests, and cerebrospinal fluid analysis. All the patients diagnosed with ocular syphilis were tested for human immunodeficiency virus (HIV), Toxoplasma gondii, rubella, cytomegalovirus, and herpes.

Results

A total of 1,115 patients were evaluated between January 2012 and June 2014, and 12 patients (1.07%) were diagnosed with ocular syphilis based on the inclusion criteria. None of the patients were seropositive for HIV. Two patients were seropositive for T. gondii-specific IgG. Clinical presentations include non-necrotizing anterior scleritis, non-necrotizing sclerokeratitis, anterior uveitis, intermediate uveitis, posterior uveitis, panuveitis, and optic neuritis. All of the patients showed clinical improvement in the level of ocular inflammation with intravenous penicillin 24 million U/day for 10 days. Three patients received additional oral methotrexate as an adjunctive therapy. Two cases received low-dose trimethoprim–sulfamethoxazole.

Conclusion

Ocular syphilis is an uncommon cause of ocular inflammation in HIV-negative patients. Central retinochoroiditis is the most common ocular manifestation, and it is the most common cause of visual impairment. Ocular syphilis might present associated with co-infections such as T. gondii in developing countries. Oral methotrexate might be beneficial as an adjunctive therapy for ocular syphilis in resolving the residual intraocular inflammation and cystoid macular edema after specific therapy with intravenous penicillin.

Below:  Represents the color photo of the left eye at pre-treatment and post-treatment phases.

Notes: (A) Color photo of left eye with sclerokeratitis discloses 2+ scleral injection at the nasal quadrant associated with limbal corneal thinning at 9 o’clock position. (B) Color photo of left eye with sclerokeratitis discloses resolution of scleral injection and limbal corneal thinning with frequent instillation of topical prednisolone acetate at the 10th day of penicillin therapy.

Full article at:   http://goo.gl/NUljae

By:  Ozlem Sahin1 and Alireza Ziaei1,2,3

¹Department of Ophthalmology/Uveitis, Dunya Goz Hospital, Ankara, Turkey

²Department of Ophthalmology, Boston University School of Medicine, Boston, MA, USA

³Department of Ophthalmology, Dunya Eye Hospital Ltd, Ankara, Turkey

Correspondence: Ozlem Sahin, Department of Ophthalmology/Uveitis, Dunya Goz Hospital, Tunus Caddesi No 28 Kavaklıdere, Cankaya, Ankara 06690, Turkey, Tel +90 312 416 7000, Email moc.oohay@8511melzo

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Evaluating Quality of Care for Sexually Transmitted Infections in Different Clinical Settings

We examined quality of care across different clinical settings within a large safety-net hospital in Massachusetts for patients presenting with penile discharge/dysuria or vaginal discharge.

Using a modified Delphi approach, a list of sex-specific sexually transmitted infection (STI) quality measures, covering 7 domains of clinical care (history, examination, laboratory testing, assessment, treatment, additional screening, counseling), was selected as standard of care by a panel of 5 STI experts representing emergency department (ED), obstetrics/gynecology (Ob/Gyn), family medicine (FM), primary care (PC), and infectious disease. Final measures were piloted with 50 charts per sex from the STI Clinic and age, sex, and visit date-matched charts from PC, FM, ED, and Ob/Gyn. Performance was scored as compliance among individual measures within 7 domains, standardized to add up to one to adjust for variable number of measures per domain, with an overall score of 7 indicating complete adherence to standards.

Expert review process took 2 weeks and resulted in 24 and 34 final measures for male and female patients, respectively. Performance on 7 clinical domains ranged from 3.16 to 4.36 for male patients and 3.17 to 4.33 for female patients. Sexually transmitted infection clinic seemed to score higher on laboratory testing, additional screening, and counseling, but lower on examination and assessment, and ED seemed to score higher on examination and treatment, PC and FM on laboratory testing for male patients and on examination and treatment for female patients, and Ob/Gyn on treatment.

An instrument to discern standard of care and identify strengths and weaknesses in specific domains of clinical documentation for patients presenting with STI complaints can be developed and implemented for quality evaluation across care settings. Further research is needed on whether these findings can be integrated into site-specific quality improvement processes and linked to cost analyses.

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By:  Sequeira S1, Morgan JR, Fagan M, Hsu KK, Drainoni ML.

• 1From the *Boston University School of Medicine, Boston, MA; †Massachusetts Department of Public Health, Boston, MA; and ‡Boston University School of Public Health, Boston, MA. 

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