 All right, guys, if you could go ahead and get seated, we're gonna get started in a minute here. We're really lucky this morning to have four of our amazing fourth year rotating medical students presenting all very interesting and different cases. They've put a lot of preparation, so we're really excited to see these talks. To start us out this morning, Ian Christensen is one of our Utah medical students who's gonna be talking to us about ocular syphilis. A little bit about Ian, he was born actually down in Provo, but it sounds like after a couple of weeks moved to China, is that right? And then spent some time traveling with his family in the foreign services before ending up back here. So welcome Ian, take it away. Okay, well thanks for that kind introduction, Tina. My name's Ian, I'm a fourth year medical student here at the University of Utah, she said. Today I'm presenting on ocular syphilis. So kind of the point of this presentation is to sort of provide an overview of ocular syphilis and I also have an interesting case that was seen here at the Moran Eye Center that I'm also going to present in conjunction with this. So many of you may recognize this handsome gentleman. This is Christopher Columbus and it was kind of this brief history of syphilis which I didn't realize before I started this presentation or preparing this presentation. There's credible evidence that Christopher Columbus and his crew actually brought syphilis back from the new world to Europe. And the first known epidemic of syphilis was in 1495 among French troops besieging Naples and how they got it is anyone's best guess. Maybe Spanish mercenaries has been sort of suggested as a hypothesis. I thought that was kind of an interesting tidbit of history and of course syphilis continued to ravage the old world for hundreds of years in Europe and until these two gentlemen discovered that it was caused by a trepanema pallidum and they discovered this in their lab that these are two German researchers and then penicillin was discovered in 1940 and since then Syphilis has become a relatively treatable condition. In the United States syphilis was a fairly high prevalence but in the 70s, 80s and 90s the prevalence declined precipitously and due to the success of many sort of public health programs and it kind of reached a nadir in the year 2000 around 2.7 on a national level, 2.7 per 100,000 persons. Unfortunately, since then it's been going back up and as you can see from this graph, Utah is not immune to this trend and it's also uptrending here although we are at a lower rate than the rest of the country in general. So, and as you might expect from a sexually transmitted disease the prevalence is highest in the younger population and increases in men, especially men who have sex with men and it's also associated with IV drug use and female sex workers are at a higher risk for this disease. So, just something to keep an eye out for. So, we're gonna move on to the case. This is not a picture of the man who came in. I'm sure he looks much happier than the gentleman who was the syphilis but he came into the UBI Disclinic and was seen by Dr. Chris Conraddy and Dr. Shakur and he's a 25, we'll call him James. It's not his real name, but he's a 25 year old male with unspecified liver disease, secondary to alcohol use. He was in with two months of blurry vision in his left eye. So, he had sort of this brown spot in his left eye that he'd noticed a few months before he presented to clinic in January and he also had some peripheral flashing lights in his vision. So, Dr. Conraddy being an excellent clinician and we all know him to be gathered a thorough history and it was relatively unremarkable. He has this liver disease, as mentioned, anxiety, PTSD, no surgeries. He was adopted. So, not much of a family history that could be gathered there. He, on review systems, he reported having headaches. He had some hearing loss bilaterally that had sense resolved and some skin sores, alopecia, sort of some non-specific symptoms and his social history is a little bit more interesting. He has four dogs and two cats. One of the cats is not pictured here. These aren't his. And he's a male who has sex with men and he has a fiancee with whom he is currently sexually active. He's a heavy smoker, some marijuana, a prior heavy drinker. He's sent stops, has been diagnosed with liver disease and some jail time in the past. He's on parole currently. No international travel, no IV drug use, and history of herpes zoster. So, just as a sort of a way from the case here, the ocular findings of syphilis, before we move on to the exam, the ocular findings of syphilis are fairly broad. So as you can see from this chart, it can involve pretty much any anatomic location of the eye and it can cause any type of UV-itis, posterior, intermediate, anterior and there's some suggestion that, or some research suggests that posterior UV-itis or pan-UV-itis are the most common presentation. It can involve one eye or both eyes. It can occur in any stage of syphilis, the primary, secondary, tertiary. And so the idea is, or the point is that it's difficult to identify by exam alone. And even if they present with ocular syphilis, it can sort of mimic a lot of other things. It could be autoimmune or any other sort of infectious ideology. So the point is it's important to gather a thorough history and look for risk factors when it comes to diagnosing syphilis. So on exam, he had remarkably reduced visual acuity. He was 20, 20 before this event. He was 22, 50 in his left eye. His right eye seemed to be unaffected. He was vomiting that day. So some of the testing was not done. He did not have a fluorescein angiography done because he was already nauseous and vomiting. Here's his slit lamp exam, which sort of shows this pan-UV-itis type picture. And so moving on to some of the imaging, here's his picture of his fundus, color picture of his fundus. As you can see, I have a note here in case I forget the more accurate descriptions. But he's got some plaque with spots here, as you can see. The next picture here is an auto fluorescence image. He's multiple hyper-autofluorescent foci and plaque with inferior changes. You can kind of see that here. His right eye, however, is unaffected. And on OCT, which is a little bit harder to appreciate, but he has some overlying vitritus, significant ISOS loss, inferiorly, and sub-retinal deposits. So at this point, thinking about a differential, he does have risk factors for syphilis, and he does have pets, maybe thinking about toxoplasmic gondii, and he does have prison time, exposure potentially to TB, all things that should be tested for in addition to kind of some of these autoimmune things that could cause pan-UV-itis. So in terms of syphilis testing, the CDC website has two algorithms for this. This is kind of the reverse screening algorithm, which is gaining popularity. This is sort of the more traditional one, and both are offered by ARUP. I think this one, to me, seems a little bit simpler. And this RPR test is a non-treponemal antibody test, RPR or VDRL, which are useful and very sensitive for this disease. And so it's important to get this, and it's also useful for tracking the disease and tracking for resolution of the disease after treatment. So, and then this treponyl-apolitum antibody test is important for kind of confirming the diagnosis. It's much more specific to syphilis. So this gentleman, he received, he had his RPR titer tested, and it was highly reactive, one to 4,000. He had his FDA antibody tested, it was reactive. Another thing I failed to mention is that, given his risk factors, you should always be tested for HIV. And if he had not been tested in the past, you should definitely test for that. Toxoplasma-Gondii, he was tested for it and was negative. His TB test was negative, and he had a CMP, CBC, and chest x-ray, which were mostly unmarkable, except for his elevated liver enzymes, consistent with his previously diagnosed liver disease. So, treatment and management of syphilis. So it's important to test and treat all of the patient's partners. In terms of tracking the disease, once you find a case of syphilis, you should report it to the health department. And for ocular syphilis, you should treat it like neuro-syphilis, which is 10 to 14 days of IV penicillin, as opposed to your normal garden-variety syphilis, which is only treated with one dose of penicillin. So, you should test for HIV, as I mentioned, and a lumbar puncture is indicated as well to sort of rule out more systemic, or rather, rule out neuro-syphilis in conjunction with ocular syphilis. And you can consider systemic steroids on day two to three, for treatment of gyroshock-cymer reaction, which is, you may recall, is when some of the bacteria begin to die and you have sort of an allergic-type reaction, the toxins released by the bacteria. And this is kind of a soft recommendation. And once the patient has been treated, then you should retest it six to 12 months, and a four-fold decrease in the RPR titer kind of indicates cure. And so you can assess for whether or not they need to be re-treated, or if they failed their initial treatment. And there are some alternative antibiotics that can be used if they're allergic to penicillin, which I don't go into. So, this patient was referred to the EED, told to go straight there, and he didn't. And four months went by, and this is a depiction of Dr. Conraddy, who I'm sure was a very frustrated callings patient, I think over 50 times, hanging with him and his mother, urging him to go and get treated. But he never did, so he came back to the clinic, and he had not yet received treatment. His vision was worsening in his left eye. He didn't have any complaints in his right eye. He had fluctuating eye sensitivity and floaters in his temporal, or fluctuating eye sensitivity to light, and floaters in his temporal vision. And so on exam, his visual cutie actually looked better. I was talking to Dr. Conraddy, and it sounded like the exam was kind of difficult the first time around. He was vomiting actively, he was not feeling well at all. But his visual cutie quantitatively was a little bit better. But he also had an APD, minimally active to light on the left, which can be indicative of syphilis infection. And he had sort of this interesting, superior visual field defect. So, on a split-lamp exam, you can see that the right eye is beginning to show some signs of involvement, whereas in the retinal exam, he has these hypopigmented spots superiorly in a plaqueoid-like distribution. And his left eye is also looking at least the same and probably in a little bit worse. He's has this sort of significant RPE modeling now, white choreorentinal punctate spots throughout the mid-periphery with overlying inflammation and clear signs of inflammation in the anterior eye as well. So, he's not looking too good. This is a black-and-white photo of the fundus. You can see here, it's a little bit harder to appreciate, but maybe some modeling here and discoloration compared to his January fundus photo. Here we have his right eye, which is a little bit harder to appreciate. Maybe some increased peripheral color changes over here, and then this is the most remarkable of his photos. And this is fluorescein angiography, which he did not get on his initial presentation. But you can see here that there's some significant peripheral ferning, some scattered hyperfluorescence with some optic nerve leakage here. So, clearly sort of a worsened clinical picture. Again, he was urged to go to the emergency department and to this day does not seem to have received treatment. So, hopefully he comes back and gets treated. And that's it. Any questions? Yes? Did you have a sense of false negative RPRs? In other words, patients that have syphilis that have a negative of the positive FDA and a negative RPR? So, I was, so a false positive. I'm not sure what the exact rate is. I think that the sense is that it's much more sensitive and that it should be confirmed with the FDA antibody, but I'm not sure that the exact rate is. He's asking about false negative. Oh, false negative, sorry. Eric just asked if it was about the false negative. Some sources that I read said that it can be as high as like 70%, or not, sorry, 30%. It can be as high as 30%. I'm not sure what, if that's changed. And it could have to do with kind of the rising popularity of this reverse screening algorithm, which may lead to less of that. But I was able to find exact numbers. So, I thought that the Department of Health would get after folks like this. I mean, usually if you order an RPR and it comes back positive, the Health Department calls you before you even get the lab result back. So, syphilis is not a disease that they'll come banging on your door to throw penicillin in you? Well, I mean, it doesn't appear to be. I guess not in this case. This is very evasive. He went four months without having, yeah, I mean, he did answer the phone occasionally, but still refused to go. It sounded like he even presented the emergency permit at Intermountain of Health and then left, and he came here and then left without being treated. So, again, yeah, I mean, seems like a fairly evasive character. Hopefully he comes back and then at the very least be interested in case that he in the natural history of ocular syphilis. And then the Health Department, it takes responsibility to track down the contacts, right? Yeah, that's what I understand, yeah. So, I'm not sure what the status is for him on that. And Chris Connerty did have several phone calls with the Health Department, too. I mean, he, I couldn't believe the measures he went to to try and get this guy treated. Well, I can believe it. Yeah. Yeah, exactly. Thank you, Ian. Thanks a lot. Yeah, thank you.