Anterior nodular scleritis secondary to syphilis

Anterior Non-Necrotizing Scleritis with Active Uveitis in Cases of Ocular Syphilis

PURPOSE

To study clinical characteristics and management outcomes of cases of ocular syphilis co-presenting with scleritis and active uveitis.

METHODS

A retrospective analysis of cases diagnosed with ocular syphilis between January 2020 and December 2023 was conducted at a tertiary eye care centre. Clinical records, investigations, and outcomes were reviewed to identify cases with scleritis with active uveitis. Demographic data, clinical features, treatment modalities, and resolution patterns were analyzed.

RESULTS

Among the 135 eyes of 95 cases of ocular syphilis studied, scleritis with uveitis was observed in 3.70% of eyes (five eyes). All cases with scleritis and uveitis were unilateral and male, with ages ranging from 32 to 61 years. Concurrent features included placoid chorioretinitis, retinal vasculitis, and anterior uveitis. Misdiagnosis with subsequent oral steroid therapy precipitated scleritis as an exacerbation in two cases. Three cases, which were previously undiagnosed, were found to be HIV-positive. Scleritis manifested as anterior, non-necrotizing inflammation, often accompanied by chemosis, and responded rapidly to antibiotic and non-steroidal anti-inflammatory therapy. Scleritis resolution preceded that of chorioretinitis and retinal vasculitis.

CONCLUSIONS

Non-necrotizing anterior scleritis with chemosis can be a rare presentation of active syphilitic uveitis. Large placoid chorioretinitis lesions, preceding inadvertent oral steroid and/or undiagnosed HIV status were the possible risk factors for the development of concurrent scleritis.

Syphilitic scleritis and episcleritis: A review

Scleritis and episcleritis are rare, but potentially sight-threatening forms of syphilis. To provide a full description of this neglected subset of ocular syphilis, we evaluated the English literature for reports of syphilitic scleritis and episcleritis, recording the demographics, clinical characteristics, serological data, management practices, treatment responses, and visual outcomes. Previously published descriptions of 44 patients with syphilitic scleritis (50 eyes) and 9 patients with syphilitic episcleritis (14 eyes) were identified. The predominant type of scleritis was anterior scleritis, accounting for 92.9% of cases, with nodular anterior scleritis being the most frequent subtype at 58.1%. Almost one-quarter of patients were co-infected with human immunodeficiency virus (HIV). Initial misdiagnosis was common and led to delays in initiating treatment with appropriate antibiotics. Visual outcomes were often good in both scleritis and episcleritis, irrespective of HIV infection status, although complications including scleral thinning, keratitis, and uveitis, along with permanent visual loss and an association with neurosyphilis, were reported. Response to antibiotic treatment was typically rapid, often within 1 week. With the rising global incidence of syphilis, testing patients with scleritis or episcleritis for this infectious disease is important to ensure prompt diagnosis and treatment for best ocular and systemic outcomes.

Sclerokeratouveitis and lens dislocation in a patient with genital ulcer: was the great imitator imitated?

Uveitis is the most common ocular manifestation of syphilis, while scleritis is rare. A case of nodular scleritis, peripheral keratitis and uveitis in a patient with genital ulcer is presented in this report. This patient had a clinical profile suggestive of syphilis, though the serology was negative for treponemal antibodies. Other possible differential diagnosis imitating syphilis are discussed.

Ocular Pharmacology for Scleritis: Review of Treatment and a Practical Perspective

Scleritis is defined as an infectious or noninfectious inflammation of the sclera that can be broadly categorized according to anatomic location (ie, anterior or posterior) and whether the process is necrotizing or non-necrotizing. Treatment for scleritis is dictated by the etiology of the inflammation, with infectious forms requiring treatment of the inciting agent and noninfectious forms requiring treatment of the underlying inflammation with immunosuppression. Pharmacotherapy for noninfectious scleritis can be classified according to delivery route (eg, local or systemic) and mechanism of action (eg, biologic or nonbiologic). This review will briefly summarize the classification scheme for scleritis before reviewing in depth both systemic and local pharmacotherapies that can be used to effectively treat an eye afflicted by either infectious or noninfectious scleritis. Traditional anti-inflammatory agents such as nonsteroidal anti-inflammatory drugs, steroids, and immunomodulatory therapy will be discussed, as well as newer biologic therapies such as antitumor necrosis factor alpha and anti-CD20 agents.

[Bilateral panuveitis with papillary swelling]

Lues (syphilis) is a chronic cyclic infectious disease which can continue for decades if untreated. A simultaneous HIV infection can result in false negative results in serological tests for lues. The occurrence of neurolues has frequently been described in HIV positive patients. In the differential diagnosis an early ocular manifestion of lues should be considered. A 40-year-old homosexual patient presented in our hospital with bilateral pain-free increasing loss of vision. The ophthalmological examination revealed an intermediately expressed panuveitis with streaky opacity of the vitreous body and pronounced bilateral papillary swelling. Following systemic anti-inflammatory therapy with cortisone the situation worsened after initial improvement. The serological investigations revealed both HIV and lues infections. Intravenous therapy with mega units of penicillin led to a slow improvement of clinical symptoms and also vision. In cases of uveitis of unclear origin together with a HIV infection and suspected lues, regular serological testing should be carried out because the occurrence of late complications of lues can be avoided by the diagnosis of lues and adequate treatment.

Syphilis: the international challenge of the great imitator

Syphilis is a systemic disease caused by the spirochete Treponema pallidum. The name of this ancient but pervasive infection is proverbial to health care providers. The worldwide recognition of this term, however, argues with the intricacy of the disease in addition to the diagnostic and therapeutic challenges that persistently affect the global control of syphilis up to the present. This article focuses on the varied presentations of the infection, earning the title the "great imitator." The article also tackles other significant concerns regarding this malady.

Scleritis

Scleritis is typically a severe painful inflammatory process centered in the sclera that may involve the cornea, adjacent episclera, and underlying uvea; it poses a significant threat to vision. Careful clinical history taking, detailed ocular examination, appropriate investigation for ocular disease with or without underlying systemic disease, and timely intervention with the use of immunosuppressant drugs when necessary, has improved the long-term outcome for patients with this disease.

Anterior scleritis: three case reports and a review of the literature

BACKGROUND

Scleritis is a rare ocular condition involving vasculitis. It can result in severe ocular morbidity and has a high association with underlying systemic disease and mortality. Management can be challenging and under-diagnosis is a concern. Treatment usually requires systemic medications and co-management with a medical specialist in the appropriate field to manage any underlying systemic etiology.

METHODS

Three cases are presented: idiopathic nodular scleritis with complete recovery; bilateral, diffuse anterior scleritis with rheumatoid arthritis; and scleromalacia perforans treated with chemotherapeutic agents and co-managed with a rheumatologist. A search of the English language literature is reported, also.

RESULTS

The reported cases exemplify much of our knowledge regarding scleritis. The literature review focuses on the challenges of an accurate diagnosis and management. Management is challenging and, although standards exist, controversy remains. The literature discusses the relationship of scleritis to underlying systemic disease and the significant implication of this association.

CONCLUSION

Knowledge of scleritis may aid in determining a timely and accurate diagnosis and treatment of both the ocular and any underlying systemic conditions, thus decreasing morbidity and mortality.

Systemic disorders associated with episcleritis and scleritis

Inflammation of the episclera and sclera still represents a diagnostic challenge. Many of these presentations are idiopathic and are managed empirically with the use of anti-inflammatory therapy, usually with a satisfactory response. However, some cases will have a more aggressive nature or will show resistance to conventional therapy, and those potentially are connected to an infectious or underlying disease. In such cases, there is an increased risk of visual loss and severe systemic complications requiring intensive investigations and aggressive therapy. The diseases more commonly associated with these conditions, especially with scleritis, are the connective tissue disorders and systemic vasculitis, but systemic infections and malignancies also must be excluded. Management depends on the specific diagnosis, and every year a new list of potential associations or atypical presentations is reported. For a successful outcome, it is important that these presentations are recognized.