Ocular Syphilis

choi

I need about ten minutes to finish this posting (about penicillin) which I do not have. Will do this next Monday.


Lisa Sanders, Connect the Sparkly Spots. The man began seeing sparkly dots on the edge of his vision. Then an ophthalmologist found a worrying smudge on a photo of his retina. New York Times, Magazine, June 20, 2021, at page 18.
https://www.nytimes.com/2021/06/ ... on-what-was-it.html

My comment:
(a)
(i) This report is sloppily written, in part because ophthalmology is very specialized that a physician really does not know much about. I will explain.
(ii) I find no piracy, so I type the whole thing.

(b) "On the third visit, she saw something and immediately arranged for him to see Dr Marianeli Rodriguez, an ophthalmologist who specializes in diseases of the retina, in Worcester, Mass * * * Rodroguez had trained as an ophthalmologist at Harvard Medical School [a shorthand for MEEI], and her mentor, Dr Dean Elliott, had a particular interest in ocular syphilis."
(i) Meet Our Doctors. Vitreo-Retinal Associates (VRA), undated
https://www.retina-docs.com/doctors
(Associate [ie, not partner]  Marianeli Rodriguez  Dr Rodriguez is a graduate of John Hopkins School of Medicine, where she earned her combined MD/PhD. She completed her ophthalmology residency at Bascom Palmer Eye Institute. She then completed an intensive vitreo-retinal disease fellowship at the Mass Eye and Ear Infirmary in Boston, MA.  As the newest addition to VRA, Dr Rodriguez specializes in the diagnosis and management of vitreo-retinal disease, including, but not limited to, macular degeneration, retinal detachments/tears, and diabetic retinopathy.  Dr Rodriguez is originally from Cuba and is fluent in Spanish")
(A) Neli is the Spanish version of English female given name Nelly. See Nelly (given name)
https://en.wikipedia.org/wiki/Nelly_(given_name)
(B) Bascom Palmer Eye Institute
https://en.wikipedia.org/wiki/Bascom_Palmer_Eye_Institute   
(1962- ; of the University of Miami Leonard M. Miller School of Medicine; was founded by Edward WD Norton, MD [of Univ of Miami]; was named after Dr Bascom H Palmer, a Miami ophthalmologist who settled in Miami in the 1920s
(ii)
(A) Dean Eliott, MD. Massachusetts Eye and Ear Infirmary, undated
https://doctors.masseyeandear.or ... phthalmology-boston
("Massachusetts Eye and Ear[:] Director, Retina Service[,] Director, Vitreoretinal Fellowship [;] Harvard Medical School[:] Stelios Evangelos Gragoudas Professor of Ophthalmology")
(B) Massachusetts Eye and Ear
https://en.wikipedia.org/wiki/Massachusetts_Eye_and_Ear
(table: Opened 1824:  "surrounded by various Massachusetts General Hospital (MGH [opened: 1811]) buildings. MEEI and MGH are both Harvard Medical School teaching hospitals * * * Despite this organizational and physical closeness, MEEI is a separate organization from MGH, with its own Board of Directors and executive team. * * * Consisting of a 12-story tower, the current main building was completed in 1973")

(c) Symptoms and signs of the patient: "stars * * * One afternoon, the sparkles were followed by a burst of bright white light, like a flash from an old-fashioned camera, smack in the middle of his visual field. It took a minute or so for his vision to come back. After that, the world started to seem a bit grayer. That really scared him. * * * On the third visit, she [his eye doctor] saw something and immediately arranged for him to see Dr Marianeli Rodriguez * * * Rodriguez looked over the picture of the inside of his left eye. She identified three problems. First, the optic nerve was swollen. Normally, the spot where the nerve enters the eye from the brain is a crisply defined bright circle in the dark red background. In this man's eye, the edge seemed blurry and the flat screen of the retina seemed to bulge forward around the fuzzy circle. Second, in the macula, where most of the seeing takes place, the normally darker red of the vision center was obscured by a smear of yellow gray material. That was why he wasn't seeing well. Finally, in the normally clear fluid that filled the eye itself, a thick gel called the vitreous, Rogriguez could see tiny white specks. These, she suspected, were white blood cells."
(i) The stars (floaters with "sparkly aspect" described in this article), flash, and "the world started to seem a bit grayer" are all signs of retina tear (medical jargon: retinal detachment) -- stars were caused at the moment of minute tears, a flash at the moment of a big tear, and the vision turns gray OVER the vision field covered by a tear. (The tear and grayness more or less stay there for a while at least.)

Retinal Detachment. National Eye Institute, National Institute of Health, undated
https://www.nei.nih.gov/learn-ab ... /retinal-detachment
(" * * * sudden symptoms, including:
• A lot of new floaters (small dark spots or squiggly lines that float across your vision)
• Flashes of light in one eye or both eyes
•  A dark shadow or 'curtain' on the sides or in the middle [location of the curtain depends on where the tear is] of your field of vision
Retinal detachment is a medical emergency * * * ")
(ii) Reena Mukamal, What Are the Moving Dots I See When I Look at a Clear Blue Sky?   American Academy of Ophthalmology, Mar 10, 2021
https://www.aao.org/eye-health/t ... g-spots-in-blue-sky
("Look up at a bright, blue sky and you may notice tiny dots of moving light. * * * This is a very normal occurrence called the blue field entoptic phenomenon. * * * Blood flows to your eyes through blood vessels that pass over the retina — the part of your eye that acts as a receptor for all light. Red blood cells [in the blood vessel, of course], which make up more than 90 percent of your blood, absorb blue light. White blood cells let blue light through to your retina, which then sends a signal of increased brightness to the brain.   When white blood cells stretch to pass through the blood vessels in your eyes, you may see dots that look like little worms moving around in your vision. This is most noticeable when staring at a wide, clear area—like a blue sky.   Speed of the moving dots vary in time with your pulse, accelerating with your heartbeat. You may also see a dark tail with the dot of light, which is a bunch-up of red blood cells behind the slower-moving white blood cell")

entoptic (adj; ento- (same meaning as endo-) + optic)
https://www.merriam-webster.com/medical/entoptic
(iii)
(A) slit lamphttps://en.wikipedia.org/wiki/Slit_lamp  
("to shine a thin sheet of light into the eye * * * provides a stereoscopic magnified [does not say how many times] view of the eye * * * A second, hand-held lens is used to examine the retina * * * may involve placing drops in the eye in order to dilate the pupils")
(B) It is indeed a sheet of light (through a slit) -- not a point of flight.
https://www.ccteyes.com/comprehe ... heyre-so-important/
(C) "A second, hand-held lens is used to examine the retina"

https://srseye.com/project/slit-lamp-examination/
(D) Slit Lamp Eye Exam. Power Eye Center (address: 6160 Tutt Blvd #220 Colorado Springs, CO 80923), July 2, 2017
https://www.powerseyecenter.com/2017/07/02/slit-lamp-eye-exam/
("A slit lamp has an opening that allows it to shine a thin “sheet” of light into the eye. The brightness of the light can be adjusted so that the examining doctor either sees the front part of the eye or all the way to the back, where the retina sits. * * * The entirety of your eyes is examined during this test. Your eyelids, iris, sclera, conjunctiva, and cornea are given special attention as the front parts of your eyes are checked. If your retina and other deep eye structures are to be examined, you’ll be given eye drops to dilate your pupils. Another small lens will be used along with the slit lamp to provide the doctor with the needed magnification")
(E) Slit Lamp CS-1 Microscope ( Circa 1976 ). Nikon's Museum of Microscopy, undated
https://www.microscopyu.com/museum/slit-lamp-cs-1-microscope
("Interchangeable paired 10x and 15x eyepieces fit the binocular tubes of the CS-1 biomicroscope. * * * Objectives for the Nikon slit lamp microscope are relatively low-powered 1.0x and 1.6x lenses, which combine with the eyepieces for total magnifications ranging from 10x to 24x")
(F) I fail to find a photo or a video showing white blood cells in vitreous. However, I do find both a photo and a video showing white cells in anterior chamber of they eye. See
Timothy Root, MD, 'Cell and Flare' in the eye (Video). undated
https://timroot.com/cell-and-flare-in-the-eye-video/
(photo caption: "This photo shows anterior chamber cell and flare. The cells are individual white blood cells floating in the aqueous")

Anterior chamber of a human eye is made up of cornea, iris, lens and aqueous humor bound by these boundaries. Posterior chamber is the rest of the eye.

Diameter of a white blood cells and a red blood cell, of humans, is 14016 and 7-8 micrometers, respectively.
(iv)
(A) fundus
https://en.wikipedia.org/wiki/Fundus
(" (Latin for 'bottom') is an anatomical term referring to that part of a concavity in any organ, which is at the far end from its opening. It may refer to: fundus (eye)")
(B) ophthalmoscopy
https://en.wikipedia.org/wiki/Ophthalmoscopy
("also called funduscopy * * * using an ophthalmoscope or funduscope")

Pictures may be taken, resulting in fundus photography.
(C) Optic nerve into an eyeball has no capillaries, so it looks yellow when yellow light is shined on it. The retina looked red (dark or bright red, depending on light intensity).
(D) It is hard to tell what Dr Sanders tried to say when she used "yellow gray material," rather than a medical term.


(d) "The patient contacted his infectious-disease specialist, Dr Raul Davaro, who prompt;y tested him for syphilis. The test was positive."

Of course the patient has an infectious-disease specialist, because he is HIV positive. And the Bueno Aires-born and raised Dr Raul Davaro specializes in HIV.

What I do not like this article is, in particular, it did not say where the syphilis came from. I guess it is almost certain that it was a new infection, rather than inadequate treatment in the prior infection (because in between the tests for syphilis had been negative).

(e) "He had a total of four weeks of intravenous antibiotics and monthly infections of a medicine to kill off the obstructing new blood vessels in his eyes. The patient felt squeamish when Eliott said he would have to get these injections directly into his eye, but Eliott told him that they weren't nearly as bad as they sounded. And that was true."
(i) Bacterium underlying syphilis has for centuries NEVER developed resistance to penicillin.
(ii) penicillin
https://en.wikipedia.org/wiki/Penicillin   
("was discovered in 1928 by Scottish scientist Alexander Fleming * * * The purified compound (penicillin F) was isolated in 1940 by a research team led by Howard Florey and Ernst Boris Chain at the University of Oxford. Fleming first used the purified penicillin to treat streptococcal meningitis in 1942. For the discovery, Fleming shared the 1945 Nobel Prize in Physiology or Medicine with Florey and Chain"/  section 3        Medical usage: penicillin G and V)
(iii) Syphilis Treatment and Care. CDC, undated
https://www.cdc.gov/std/syphilis/treatment.htm
("syphilis is easy to cure in its early stages. A single intramuscular injection of long acting Benzathine penicillin G (2.4 million units administered intramuscularly) will cure a person who has primary, secondary or early latent syphilis. Three doses of long acting Benzathine penicillin G (2.4 million units administered intramuscularly) at weekly intervals is recommended for individuals with late latent syphilis or latent syphilis of unknown duration. Treatment will kill the syphilis bacterium and prevent further damage, but it will not repair damage already done")

choi

-----------------------------full text
The golden retriever bounded down the stairs with his 66-year-old owner right behind him. This afternoon romp in the backyard was a high point of the Covid-19 homebound days for both of them. This time, though, the man abruptly stopped halfway down. He hadn’t hit his head, but he was seeing stars in the upper right corner of his vision. When he closed his right eye, the stars remained. He closed his left eye; they disappeared. He wondered what that was. But not for long. His dog, 5 years old but still acting like a puppy, demanded his attention. And when he looked for the stars a few minutes later, they were gone.

They didn't stay gone, though. At first, it seemed as if the stars appeared only when he was running up or down stairs. But soon they appeared randomly at just about any time of the day or night. Nothing hurt; he would just suddenly see this cluster of sparkly dots. After two weeks or so, when it seemed clear this wasn't going to go away on its own, he called his eye doctor.

The doctor did all her usual tests. The sparkly aspect of the image was suggestive of a retinal problem, she told him, but his retina, and indeed the rest of his eye, looked completely normal. Let's wait and see what happens, she suggested. Either it was nothing and it would just go away, or it would progress and there would be something for her to see.

The man found it a reassuring if not completely satisfying answer. He tried to ignore the little dazzles while he waited for them to either go away or get worse. Days passed, and they didn't go away. if anything, the episodes became more frequent. And then they got worse. One afternoon, the sparkles were followed by a burst of bright white light, like a flash from an old-fashioned camera, smack in the middle of his visual field. It took a minute or so for his vision to come back. After that, the world started to seem a bit grayer. That really scared him.  

A Yellow-Gray Smear

He went back to his ophthalmologist with each change. On the third visit, she saw something and immediately arranged for him to see Dr Marianeli Rodriguez, an ophthalmologist who specializes in diseases of the retina, in Worcester, Mass, 20 minutes away.

The next day, at this new office, the patient went through the now familiar texts, plus a couple of new ones. Afterwards, as the patient sat waiting in the tiny exam room, Rodriguez looked over the picture of the inside of his left eye. She identified three problems. First, the optic nerve was swollen. Normally, the spot where the nerve enters the eye from the brain is a crisply defined bright circle in the dark red background. In this man's eye, the edge seemed blurry and the flat screen of the retina seemed to bulge forward around the fuzzy circle. Second, in the macula, where most of the seeing takes place, the normally darker red of the vision center was obscured by a smear of yellow gray material. That was why he wasn't seeing well. Finally, in the normally clear fluid that filled the eye itself, a thick gel called the vitreous, Rogriguez could see tiny white specks. These, she suspected, were white blood cells.

The presence of those cells suggested two possible disease processes. This could be a type of cancer known as lymphoma. That was rare but had to be considered. The other possibility was that this was some type of infection and those white cells were there to fight off the bugs. The inside of the eye is an extremely well protected part of the body. Still, some infections that travel through the bloodstream could get there. Only a few of these agents would cause the kind of problems she saw. Tuberculosis could certainly do this. And syphilis could do just about anything. A third possibility was a bacteria called Bartonella henselae, which usually causes a systemic infection called cat-scratch fever.

Asking an Awkward Question

Now that she knew what was going on in the eye, it was time to talk to the patient. He was a cheerful man with a ruddy round face and an easy smile. Other than this eye problem, he told her, he felt great. He wasn't tired; hadn't lost any weight; had no cough; didn't know anyone with TB; had a dog but no cats. The doctor paused. Had he ever had any sexually transmitted diseases?

It was an awkward question, and sometimes people were offended when she asked it. Not this man. Absolutely, he told her without hesitation. Thirteen years earlier he was diagnosed with syphilis and HIV. He'd been treated for two weeks for the syphilis and was still being treated for HIV. The virus was undetectable in his blood, he told her, and had been since the year after his diagnosis. He hadn't always practiced safe sex before his diagnosis, but he had been very careful since then. And he'd been tested for syphilis and other STDs regularly since getting this diagnosis. His last test was a couple of years ago and was negative.

Rodroguez had trained as an ophthalmologist at Harvard Medical School, and her mentor, Dr Dean Elliott, had a particular interest in ocular syphilis. She called him while the patient was still in her office. Eliott arranged to see him later that day. The semar across his macula was th einjury and inflammation caused by the infection. But beneath that, Eliott could see another worrisome finding -- under the very center of the macula was a small cluster of abnormal blood vessels. If that process wasn't reversed, that part of his vision would b e permanently lost. So, in addition to being treated for his infection, the patient would also need treatment to get rid of these destructive vessels.

The patient contacted his infectious-disease specialist, Dr Raul Davaro, who prompt;y tested him for syphilis. The test was positive.

The resurgence of an Age-Old Enemy

The patient was stunned. Because the lesions caused by syphilis are usually painless, patients who are infected are often unaware that they have the disease. He worried about how his partner would feel, hearing this. They;d been together almost two years and were always very careful. Days later his partner reported the news from his own tests: negative. The patient was so relieved he almost cried. Now he just had to take care of himself.

Although syphilis has been recognized since the 15th century, when it was first imported to Europe from the New World, and has had an effective treatment since World War II, a new epidemic of cases has erupted in the 21st century. In one study, the number of reported cases nearly doubled in men and more than double in women from 2014 to 2018. It is increasingly common in those with HIV. The disease is, and always has been, protean in its manisfections. It is contracted through direct contact with a syphilitic lesion and then spreads through the body wherever it can take root. The causative agent, Treponema pallidum, can invade the nervous system, including the brain, the eyes or the ears at any point since it hits the bloodstream. The many manifestations pf the disease as well as the usually painless lesions of the infection make this a difficult diagnosis. Indeed, Sir William Osler, the so-called father of modern medicine, said at the beginning of the last century that the doctor who knew syphilis truly understood all of medicine.

For the patient, this past fall and winter were consumed not by Covid-19 but by the treatment of his illness and the damage it had done. He had a total of four weeks of intravenous antibiotics and monthly infections of a medicine to kill off the obstructing new blood vessels in his eyes. The patient felt squeamish when Eliott said he would have to get these injections directly into his eye, but Eliott told him that they weren't nearly as bad as they sounded. And that was true. Besides, he would do anything to get his vision back. By the time he started treatment, his vision was 20/800 in his left eye. He is almost done with the eye injections, and his vision has improved to 20/40. He hopes it will continue to get better, though he suspects his vision will never be quite as sharp as it once was.

And he has been reminded -- not that he ever thought he would need to -- how much care is required to truly stay safe.