Ocular syphilis: opportunities to address important unanswered questions.
Ocular syphilis: opportunities to address important unanswered questions.
复制标题
眼梅毒：解决重要未解答问题的机会。
DOI：
10.1136/sextrans-2016-052570
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发表时间：
2016
影响因子：
3.6
通讯作者：
Ghanem,KhalilG
中科院分区：
文献类型：
--
作者：
Tuddenham,Susan;Ghanem,KhalilG
美国疾病控制和预防中心(CDC)去年年底发布了一份关于眼部梅毒的临床建议。2014年12月至2015年3月，旧金山和西雅图这两个美国城市报告了12例眼部梅毒病例。1随后的病例发现在过去两年中发现了来自20个州的200多例病例。目前尚不清楚这是一种或多种嗜眼性菌株(已经描述了神经侵袭性菌株)2的结果，还是由于梅毒筛查越来越多地使用反向序列算法而导致的增强病例检测的结果。在马里兰州，到目前为止，在发布咨询意见后，通过仔细的记录审查确定了13例病例，其中9例(70%)表现为晚期眼部梅毒(马里兰州卫生和精神卫生部个人沟通部门伊丽莎白·利博和亚历山德拉·古德)。如果这一不断增加的病例检测是由一种循环菌株造成的，那么该菌株已经传播了一段时间。不管观察到的眼部梅毒病例数量增加的原因是什么，仍有几个重要但尚未回答的临床问题：眼部梅毒和神经梅毒之间的关系是什么？艾滋病毒对眼部梅毒和这种关系有何影响？对于怀疑患有眼部梅毒的患者，是否有必要进行腰椎穿刺术？眼部梅毒最好的治疗方法是什么？其他需要澄清的问题包括眼部梅毒的出现与梅毒感染阶段的关系，血清组患者患眼部梅毒的风险，以及既往有治疗记录的患者的眼部梅毒是否代表复发或再感染。有几项研究试图解决其中的一个或多个问题。所有这些研究都受到样本量小的限制，无法得出有意义的结论。在本期中，Tsuboi等人发表了一系列病例，摘自对前往艾滋病毒临床中心就诊的患者的回顾图表。他们检查了20名感染艾滋病毒的日本男子的眼部梅毒的临床过程和预后。患者在确诊后平均随访21个月。这篇论文强调了及时识别和治疗该综合征的必要性，因为在治疗前28天出现眼部症状与预后不良有关。在17名接受LP的患者中，53%的患者根据血清血清学阳性和脑脊液(CSF)的一项或多项异常诊断为神经梅毒。然而，考虑到疾控中心最近的临床咨询，这是一篇及时的论文，它仍然是一篇回溯性综述，样本量相对较小，只包括HIV阳性患者。因此，重要的问题仍然存在(本期中的Tsuboi等人)。眼部梅毒可发生在感染的任何阶段，可累及眼睛的几乎任何部位。除了视网膜前混浊和急性后绒毛膜视网膜炎外，3已有报道的两种眼部表现为梅毒，但大多数眼部梅毒的临床表现都是非特异性的。因此，大多数眼部梅毒的诊断往往是基于眼部症状和梅毒血清阳性的推定。大多数眼部结构的受累可发生在梅毒的不同阶段，尽管斯普里克等人区分了急性眼部炎症(表现为前葡萄膜炎和后葡萄膜炎、视神经炎或神经周围炎)更常与早期梅毒有关，而视神经萎缩和瞳孔异常以及脉络膜视网膜炎与晚期梅毒有关。4 5然而，对…的系统描述
The US Centers for Disease Control and Prevention (CDC) issued a clinical advisory late last year on ocular syphilis. Between December 2014 and March 2015, 12 cases of ocular syphilis were reported from two US cities, San Francisco and Seattle. 1 Subsequent case finding identified more than 200 cases reported over the last 2 years from 20 states. Whether this is the result of one or more oculotropic strains (neuroinvasive strains have been described) 2 or enhanced case detection due to, for example, the increasing use of the reverse sequence algorithm for syphilis screening, is unclear. In Maryland, to date, following the release of the advisory, 13 cases have been identified through careful record reviews with 9 (70%) of the 13 presenting as late ocular syphilis (personal communication Elisabeth Liebow and Alexandra Goode, Maryland Department of Health and Mental Hygiene). If this increasing case detection is the result of a circulating strain, the strain has been circulating for a while. Irrespective of the cause of this observed increase in the number of cases of ocular syphilis, there are several important yet unanswered clinical questions: what is the relationship between ocular and neurosyphilis? How does HIV impact ocular syphilis and this relationship? Is a lumbar puncture (LP) necessary for the evaluation of patients suspected of having ocular syphilis? What is the best treatment of ocular syphilis? Other issues to clarify include the relationship of ocular syphilis presentation to stage of syphilis infection, the risk of ocular syphilis in serofast patients, and whether ocular syphilis in patients with a previous record of treatment represents recrudescence or reinfection. Several studies have tried to address one or more of these questions. All of these studies suffered from a small sample size that limited their power to draw meaningful conclusions. In this issue, Tsuboi et al have published a case series drawn from a retrospective chart review of patients attending an HIV clinical centre. They examine the clinical course and prognosis of ocular syphilis in 20 HIV-infected Japanese men. The patients were followed for an average of 21 months after their diagnosis. The paper highlights the need for prompt recognition and treatment of the syndrome, as having ocular symptoms for> 28 days before treatment was associated with poor prognosis. Of the 17 patients who had an LP performed, 53% were diagnosed with neurosyphilis based on a positive serum serology and one or more abnormalities on cerebrospinal fluid (CSF) examination. This is a timely paper, given the recent CDC clinical advisory, however, it is still a retrospective review with a relatively small sample size, and includes only HIV-positive patients. As such, important questions still remain (Tsuboi et al, in this issue). Ocular syphilis may occur during any stage of infection and may involve almost any portion of the eye. Save for preretinal opacities and acute posterior placoid chorioretinitis, 3 two ocular manifestations that have been reported to be specific for syphilis, most clinical manifestations of ocular syphilis are non-specific. Thus, most diagnoses of ocular syphilis tend to be presumptive based on ocular signs and symptoms and positive syphilis serologies. Involvement of most of the eye structures can occur at different stages of syphilis, though Spoor et al make a distinction between acute ocular inflammation (presenting as anterior and posterior uveitis, optic neuritis or perineuritis) being more commonly associated with early syphilis, and optic atrophy and pupillary abnormalities as well as chorioretinitis being associated with late syphilis. 4 5 However, a systematic characterisation of …