Syphilitic uveitis
Introduction
Introduction to syphilitic uveitis Syphilitic uveitis is a sexually transmitted or blood-borne disease caused by Treponema pallidum. It can be divided into congenital and acquired types, both of which can cause ocular lesions. Uveitis occurs in 5% to 10% of patients with secondary syphilis. Currently syphilitic uveitis has become a rare or rare type. The syphilis spiral is shaped like a spiral, 6 to 20 m long and 0.25 to 0.3 m wide. It splits and divides under appropriate conditions and divides once every 30 hours. Dry, sun, soapy water and general disinfectants can easily kill them. It only infects humans, and human beings are the only source of infection for syphilis. basic knowledge The proportion of illness: 0.008% Susceptible people: no special people Mode of transmission: sexual and blood-borne transmission Complications: cataract glaucoma cystoid edema retinal detachment retinopathy choroidal neovascularization
Cause
Causes of syphilitic uveitis
(1) Causes of the disease
Treponema pallidum is spiral-like, 6~20m long and 0.25-0.3m wide. It splits and divides under suitable conditions, splits once every 30h, dry, sunlight, soapy water and general disinfectant can easily kill it. It only infects humans, and human beings are the only source of infection for syphilis.
(two) pathogenesis
Treponema pallidum breaks through the damaged skin, mucous membrane invades the human body, reaches the nearby lymph nodes within a few hours, and enters the blood circulation after 2 to 3 days. The pathogen can spread to the whole body. After 2 to 3 weeks, it will cause hard chancre in the pathogen invasion. Self-healing, but Treponema pallidum continues to multiply in the body, until 8 to 10 weeks, a large number of pathogens enter the blood circulation, causing secondary syphilis, skin, mucous membranes, bones, eyes and other organ tissue lesions; when the body's resistance is strong When the lesion subsides, it enters the latent state; when the body's resistance is reduced, the pathogen that lurks in the lesion enters the blood circulation again, causing the second-stage recurrence of syphilis, which occurs within 1 to 2 years after infection; the pathogen is once again eliminated and suppressed. That is to enter the incubation period, sustainable life, a small number of patients can relapse into the fourth stage of syphilis (late syphilis), causing skin, mucous membranes, bones, cardiovascular and nervous system and other diseases.
Prevention
Syphilitic uveitis prevention
(1) All suspected patients should be examined and tested for syphilis serum in order to detect new patients early and treat them promptly.
(2) Patients with syphilis must be forced to undergo isolation treatment. The patient's clothing and supplies, such as towels, clothes, razors, tableware, bedding, etc., should be strictly disinfected under the guidance of medical personnel to eliminate the source of infection.
Complication
Complications of syphilitic uveitis Complications cataract glaucoma macular cystic edema retinal detachment retinopathy choroidal neovascularization
Meitoxin uveitis, like many other types of uveitis, can cause a variety of complications, such as complicated cataracts, secondary glaucoma, cystoid macular edema, retinal anterior membrane, retinal detachment (mostly exudative, It may also be pore-derived), proliferative vitreoretinopathy, choroidal neovascular membrane, and the like.
Symptom
Symptoms of syphilitic uveitis common symptoms nodular uveitis eye pain joint pain ataxia macular cystic edema retinal edema hyperemia wet corneal opacity
Syphilis can be divided into congenital syphilis and acquired syphilis, respectively, to describe their clinical manifestations.
Congenital syphilis
(1) Whole body performance:
1 Early congenital syphilis: occurred 3 weeks to 2 years after birth, mainly caused by nutritional disorders, weight loss, skin atrophy (looks like the elderly), rash, skin blisters, flat wet warts, mouth and perianal radioactive cleft palate or scar, syphilitic dermatitis , periostitis, chondritis, swollen lymph nodes, hepatosplenomegaly and so on.
2 late congenital syphilis: occurred in those over 2 years old, nodular syphilis, gum swelling, nasal septum perforation, saddle-shaped nose, saber sputum, joint cavity water, wedge-shaped teeth, neurological deafness.
(2) eye performance: congenital syphilis can cause various types of uveitis, such as corneal uveitis, acute iridocyclitis, chorioretinitis and so on.
1 corneal uveitis: This inflammation can occur in children with congenital syphilis from birth to 25 years old, caused by an immune response to Treponema pallidum, patients with obvious eye pain, photophobia, diffuse cornea Turbidity, severe vision loss, often accompanied by corneal neovascularization, due to corneal opacity, signs of anterior uveitis are sometimes difficult to observe.
2 acute iridocyclitis: can occur within 6 months after birth.
3 Chorioretinitis: occurs 6 months after birth, a typical "salt and salt"-like fundus, lesions may involve the peripheral or posterior pole retina, showing multifocal old chorioretinitis with retinal pigment epithelial proliferation And atrophy, or involving a single quadrant, the lesion is generally non-progressive, and the patient's vision can be unaffected.
4 retinitis pigmentosa-like changes: a small number of patients with secondary retinitis pigmentosa with retinal, choroidal and vascular thinning and pale disc, similar to retinitis pigmentosa.
5 stromal keratitis: often occurs in 8 to 15 years old, manifested as corneal stroma infiltration, visual acuity can be seriously reduced.
2. Acquired syphilis Acquired syphilis can be divided into four phases, namely, primary syphilis, secondary syphilis, third (latent) syphilis, and fourth-stage syphilis, each with different clinical manifestations.
(1) Whole body performance:
1 stage syphilis: it is characterized by a hard chancre in the invasion of treponema pallidum, which occurs in the genitals, can also occur in the mouth, skin, conjunctiva and eyelids, usually occurs 2 to 6 weeks after infection, showing no Painful papules, which contain a large number of spirochetes, can gradually progress to ulcers. 4 weeks after the onset, they can resolve spontaneously even if they are not treated.
2 secondary syphilis: characterized by the spread of Treponema pallidum in the blood, which occurs 4 to 10 weeks after the onset of the disease, typically manifests as diffuse rash and lymphadenopathy, and the rash is a maculopapular rash, most prominent in the palm and foot. Other manifestations include fever, discomfort, headache, nausea, anorexia, hair loss, mouth ulcers and joint pain. This period can cause liver, kidney, gastrointestinal tract, eye and other organ damage, causing uveitis in the eye. The incidence rate is about 10%.
Stage 3 (latency) syphilis: This stage of patients has no systemic symptoms and signs, no infection, but can cause uveitis, this period lasts for a lifetime, about one-third of patients progress to four-stage syphilis.
4 four-stage syphilis: multiple system damage can occur in this period, it can be divided into three types, namely benign four-stage syphilis, cardiovascular syphilis and neurosyphilis, benign four-stage syphilis is characterized by dermal syphilis of the skin mucosa, also Iris and choroid syphilis can occur; cardiovascular syphilis manifests as aortic inflammation, aortic aneurysm, aortic valve insufficiency, coronary stenosis and other lesions; neurosyphilis has two types, one is meningeal vascular syphilis, performance For aseptic meningitis, headache, neck stiffness, spinal cord involvement, tonic paraplegia, bladder incontinence, motor ataxia, decreased tendon reflexes, paresthesia, severe lower limb tingling; another type is brain parenchyma Syphilis, mainly manifested as meningoencephalitis, decreased progressive cortical function, memory loss, confusion, delusions and so on.
(2) Eye performance: syphilitic uveitis can be manifested as anterior uveitis, intermediate uveitis, posterior uveitis (focal chorioretinitis, macular choroidal retinitis, choroiditis, retinitis, Neuroretinitis, posterior squamous chorioretinitis, retinal vasculitis, uvitis, conjunctivitis, lacrimal gland inflammation, stromal keratitis and other inflammatory diseases.
1 anterior uveitis: anterior uveitis is a common ocular manifestation of syphilis. It is reported that in syphilitic uveitis, anterior uveitis accounts for 78%, which is easy to occur in patients with secondary syphilis. Patients with latent syphilis, that is, patients may not have any systemic manifestations, glomerulone alone, inflammation may involve both sides (44% to 71%), may also involve unilateral; more manifested as granulomatous inflammation, according to According to Barile and Foster, in 17 patients with syphilitic anterior uveitis, granulomatous inflammation accounted for 65%, and a small number of patients showed non-granulomatous inflammation; inflammation may be acute or chronic.
Severe acute iridocyclitis can cause redness, eye pain, photophobia, and tearing. A large number of inflammatory cells in the anterior chamber and significant aqueous humor flash, granulomatous inflammation occurs in sheep fat KP, iris nodules and syphilis Such changes may occur in a small number of patients with iris rash, which is caused by superficial vascular congestion of the iris, usually occurring 6 weeks after infection, without the signs of other ocular inflammation, or as the initial eye lesion, other Table shows iris vascularized papules, interstitial keratitis, lens dislocation, posterior iris adhesion, iris atrophy, etc. Some patients may be accompanied by vitreitis.
2 posterior uveitis: multiple types of posterior uveitis can occur:
A. multifocal choroidal (retinitis), in syphilitic uveitis, posterior uveitis is also quite common, it is reported that after eye involvement, uveitis accounts for 36% to 65%, the most common performance Chronic retinitis, typically a gray-yellow lesion, can occur anywhere in the fundus, but is more common in the posterior pole and near the equator. The diameter of the lesion is 1/2 to 1 optic disc diameter, from several to several tens Can vary with serous retinal detachment, optic disc edema and retinal vasculitis;
B. Multifocal chorioretinitis, some patients may have focal choroiditis, and those in the macular area are similar to central chorioretinitis. Patients have blurred vision, dark spots in the center, and can detect neurosensory layers. Retinal detachment, deep chorioretinopathy can be seen in the detachment area, may be associated with small retinal hemorrhage and exudation lesions, and a small number of patients have macular pseudohypopyon, which appears yellow-white effusion below serous retinal detachment flat;
C. Retinitis, some patients may have focal retinitis, without choroidal involvement, focal retinal edema, mostly in the posterior pole, often accompanied by optic discitis and optic disc edema, vitreitis and retinal vessels Inflammation, some patients may develop necrotizing retinitis, lesions appear in the middle and peripheral retina, white plaque, can occur with fusion, accompanied by retinal vasculitis and vascular occlusion, with herpes zoster virus, herpes simplex virus Retinal necrosis caused by cytomegalovirus, etc. is similar, but the lesions quickly resolve after the use of antibiotics such as penicillin;
D. Retinal vasculitis, some patients may have retinal vasculitis, which may be characterized by retinal arteritis, retinal phlebitis or perivascular inflammation, yellow-white exudation around the artery, retinal vascular sheath or hemorrhage; E. posterior pole squamous In choroidal retinitis, one or more squamous lesions appear in the macular area or near the optic disc, at the level of the retinal pigment epithelium.
3 intermediate uveitis: some patients may have significant vitreous inflammatory response, accompanied by cystoid macular edema, peripheral retinal vasculitis, optic disc swelling and optic disc edema, which are typical manifestations of intermediate uveitis, but patients usually The snow-like embankment of the ciliary body flat portion and the vitreous base portion is changed.
4 total uveitis: in syphilitic uveitis, 1/4 to 1/2 of patients in front of the eye, the latter segment is affected, typically manifested as total uveitis.
5 other eye lesions: in addition to causing uveitis, syphilis can cause eyelid sputum, nodular conjunctivitis and other ocular lesions.
Examine
Examination of syphilitic uveitis
Serological examination
Serological tests for diagnosis fall into two broad categories, one for non-specific tests (also known as non-treplidometry) and the other for specific tests (tibicular test).
(1) Non-specific test: A non-specific test is a test for measuring antibodies against certain autoantigens of the host in serum, which binds to the infected Treponema pallidum and stimulates the body to produce antibodies against these autoantigens. The determination of these antibodies can indirectly determine the infection of spirochetes. The main antigen associated with spirochete infection is cardiolipid, a phospholipid produced by the liver.
There are two types of non-specific tests most commonly used: one for venereal disease research laboratory (VDRL) and the other for rapid plasma responsiveness test (rapid).
Plasma reagin (RPR), both tests were quantitative determination of anti-cardiolipin antibodies in serum, and the results were judged as "reaction", "weak reaction", "critical" and "no reaction".
(2) Specificity test: The specificity test is a method for quantitative determination of anti- Treponema antigen. The most commonly used test methods are two: one is fluorescent treponemal antigen absorption (FTA-ABS), The other is a microhemagglutination assay for treponema pallidum (MHA-TP). The FTA-ABS method is: mixing the heated test serum with a sorbent to remove non-specific antibodies, and then serum. Incubate with a slide containing Treponema pallidum antigen and add fluorescein-labeled anti-human globulin, and judge the result as "reaction" or "no reaction" under a fluorescence microscope; MHA-TP method is: Dissolving Treponema pallidum The sensitized sheep red blood cells are added to the serum to be tested. If there is antibody in the serum, an agglutination reaction occurs. The test results are judged as "reaction" and "no reaction". High specificity and sensitivity, occasionally false positive results in connective tissue disease.
(3) Clinical significance and judgment of serological tests:
1VDRL or RPR presents "response" results, often suggesting that the disease is active, more common in secondary syphilis; with effective treatment, the disease recovers or enters the incubation period, the syphilis test results turn "no response"; some patients without treatment, with With the extension of time, it can also be changed to "no response".
2FTA-ABS or MHA-TP test showed a "reaction" result, which was found in patients with primary syphilis. After the patient was infected, this positive result often lasted for a lifetime.
3 Some diseases may have false positive results of RPR and VDRL, atypical pneumonia, malaria, vaccination can cause short-term (not more than 6 months) false positive results, systemic lupus erythematosus, leprosy and elderly can have persistent false negatives result.
4 some diseases can cause false positive results of FTA-ABS, such as systemic lupus erythematosus, rheumatoid arthritis, biliary cirrhosis, etc. can cause long-lasting or even lifetime false positive results, so this test is performed on patients Attention should be paid to the patient's systemic disease or medical history.
(4) syphilis serological test of cerebrospinal fluid: syphilis serological test on cerebrospinal fluid helps to determine neurosyphilis, and has certain value for guiding treatment. With effective treatment, the level of cerebrospinal fluid protein gradually decreases, and the cell count is 6~ After 12 weeks, it returned to normal. If there is no change in these parameters, it is often suggested that the treatment should be re-administered.
2. Direct observation of Treponema pallidum
The body fluid containing the pathogen is incubated with the fluorescein-labeled antibody and observed under a fluorescence microscope. This observation has been carried out on the aqueous humor of patients with syphilitic uveitis, and this pathogen can be observed during active inflammation. It can not be observed after effective treatment, but this kind of examination is limited by two factors. One is that only one stage of syphilis has sputum or the second stage syphilis has abscesses to obtain positive specimens. Another limitation is this kind of examination. False positive results can occur, antibodies can react with non-pathogenic symbioclastic spirochetes, and are easily mistaken for Treponema pallidum.
3. PCR detection
PCR testing has been used for the diagnosis of syphilis, but such tests can have false positive results and should be avoided during operation.
Including fluorescein fundus angiography and indocyanine green angiography, fluorescein fundus angiography is not specific for syphilitic uveitis, but can detect intraretinal lesions, help determine the extent of lesions, retinal vessels Inflammation, retinal perivascular inflammation, neovascular membrane, cystoid macular edema, etc.; indocyanine green angiography can evaluate choroidal lesions, and Baglivo et al have performed fluorescein fundus angiography in patients with acute syphilitic macular choroidal choroidal retinitis. Indocyanine green angiography, the former showed early weak fluorescence of active lesions, and late fluorescein staining; the latter showed diffuse weak fluorescence in active chorioretinitis in the early stage, and strong fluorescence in the later stage, although these contrast changes were not syphilitic uveal Unique to inflammation, but these changes combined with clinical and serological tests will help diagnose and differentially diagnose.
Diagnosis
Diagnosis and diagnosis of syphilitic uveitis
diagnosis
There is currently no standard treponema pallid culture method, so the diagnosis is mainly based on clinical manifestations, medical history, serological examination, direct observation of Treponema pallidum in body fluids, PCR detection and clinical auxiliary examination.
Differential diagnosis
Syphilitic uveitis can be manifested as granulomatous inflammation, but also as non-granulomatous inflammation; can occur in the anterior segment of the eye, or in the posterior segment of the eye, according to the anatomical location, can be expressed as front, back, middle And total uveitis, there are few characteristic changes in clinical manifestations, so it should be differentiated from uveitis caused by various reasons and a variety of specific types of uveitis, Table 2 lists the disease should be associated with Several major uveitis were identified.
The anterior uveitis identification associated with HLA-B27 antigen is that the latter can be recurrent, HLA-B27 antigen positive, ankle and spine film showing ankylosing spondylitis, or psoriasis, inflammatory bowel disease, patients The prognosis is good.
