Syphilitic scleritis
Introduction
Introduction to syphilitic scleritis Syphilis is a subacute to chronic infectious disease caused by Treponema pallidum. Syphilis is mainly transmitted through sexual contact, blood and placenta, and is extremely harmful in infectious diseases. Syphilis is known for its diverse clinical manifestations. Syphilis is almost exclusively due to intimate contact with primary and secondary syphilis infections, except for congenital syphilis. Sometimes medical staff are infected with patients who do not expect to have an infected lesion. The syphilis epidemic has no significant increase in syphilis cases of class, group and ethnicity, especially among young people with active sexual behavior in large cities. What is worrying is that syphilis is indeed a common cause of serious diseases such as syphilis and HIV infection. basic knowledge The proportion of illness: the proportion of illness is 0.003% - 0.005% Susceptible people: no special people Mode of transmission: through sexual contact, blood and placenta Complications: anterior uveitis optic disc edema macular cystic edema
Cause
Cause of syphilitic scleritis
(1) Causes of the disease
In 1905, Schaudinn and Hoffman first discovered the pathogen of syphilis. The Helicobacter pallidum is a small and slender spiral-shaped microbe with 6 to 14 spiral circles. The ends are tapered and can not be seen under ordinary light microscope. It can be seen in dark field or silver staining. The structure of the spirochete is very similar to that of Gram-negative bacilli. Its appearance is surrounded by a layer of hyaluronic acid mucus, which may be a virulent pathogenic substance. So far known, pale. The natural host of Treponema pallidum is only humans, some monkeys and higher apes.
(two) pathogenesis
Syphilis is not only transmitted by sexual intercourse, but also transmitted to the fetus by the infected mother (congenital syphilis). The syphilis is initially expressed as an ulcer of T. pallidum infection, that is, painless hard chancre, more common in the genital area with local lymphadenitis (primary syphilis) ), after 1 month to 3 years, blood transfusion leads to secondary syphilis, which is characterized by skin and mucous membrane damage and systemic lymphadenitis. In individuals with normal immune function, humoral immunity and cellular immunity can inhibit Treponema pallidum. The latent period is formed, and one-third of infected individuals often form three-stage syphilis after an incubation period of 1 to 30 years, including immunological reaction to Treponema pallidum and its metabolites to form sputum (gumma), which can occur in any part. Often caused by cardiovascular damage and symptoms of the central nervous system (), Treponema pallidum can be found in syphilis, congenital syphilis caused by infected mothers of Treponema pallidum, mainly manifested as early mucosal skin damage, saddle nose ), arched palate and periostitis, etc., late manifested as stromal keratitis, Hutchison teeth, god Deafness (neurodeafness) and skull abnormalities (skull abnormalities) and other congenital syphilis performance Hutchinson teeth, nerve deafness and stromal keratitis collectively known as Hutchinson triad, has important diagnostic value.
Prevention
Syphilitic scleritis 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.
(3) Tracking the patient's sexual partners, including patient self-reports and medical personnel visits, finding all sexual contact persons, conducting preventive examinations, tracking observations and performing necessary treatments. The spouse is absolutely forbidden to have sex before the cure.
Complication
Complications of syphilitic scleritis Complications anterior uveitis optic disc edema macular cystic edema
Scleral staphyloma and anterior uveitis can be formed in anterior scleritis, especially in necrotizing scleritis; subretinal mass, optic disc edema, and cystoid macular edema can occur in posterior scleritis.
Symptom
Symptoms of syphilitic sclera Symptoms Common symptoms Eye pain, lacrimal keratitis, mucosal damage, elevated intraocular pressure, syphilis infection, nodular uveitis, ptosis, retinal detachment
Common major ocular lesions are stromal keratitis, uveitis, chorioretinitis, optic neuritis, optic nerve inflammation, optic retinitis, optic atrophy, ptosis, strabismus, orbital or keratoconus, periostitis , Argyll-Roberston pupil and scleritis or sclera.
It is reported that the incidence of syphilis in patients with scleritis is 2.89%, scleritis can be the first manifestation of syphilis, second or third syphilis or congenital syphilis more scleritis, scleral inflammation can occur in primary syphilis, syphilitic sclera Inflammation or scleral inflammation occurs as a direct violation of Treponema pallidum (Phase I or II) or by an immune response from Treponema pallidum and its metabolites (Phase III or congenital).
Acquired syphilis is divided into three phases:
Primary syphilis: The episcle of the sclera is secondary to the conjunctival sac, the anterior and submandibular lymphadenitis.
Secondary syphilis: scleritis or scleral inflammation and skin, mucosal damage appear at the same time or later, more with conjunctival lesions, scleritis or scleral inflammation and conjunctival lesions have obvious boundaries, edema at the limbus, Wrinkles.
Stage III syphilis: Scleritis or scleral inflammation is similar to other diseases. This stage of scleritis can be diffuse, nodular and necrotizing anterior scleritis and posterior scleritis, immune mechanisms leading to scleral granuloma and infectivity Microvascular disease, scleritis may be associated with stromal keratitis, syphilitic stromal keratitis, unilateral, early onset of eye pain, tearing, photophobia and decreased vision, lesions confined to the upper part of the cornea, mild endothelium Edema, small matrix turbidity, 5 months to 10 years after infection, the lesion spreads from the periphery to the center, deep opacity of the corneal stroma occurs, and fuses with each other, affecting the local or the entire cornea, the lesion corneal thickening, the posterior elastic layer folds The broken lens-like phenomenon occurs, and finally the blood vessel invades into the deep matrix to form a dark red brush-like deep corneal neovascularization. After several weeks and months of inflammation, the corneal infiltration and edema gradually absorb, the inflammation subsides, and the blood vessels invade the cornea. The blood flow disappears, and the atrophic deep corneal neovascularization leaves a phantom microvascular network in the corneal basement, which is characterized by a grayish white filamentous structure. Anterior uveitis, episcleritis the same time period as simple or nodular, ocular manifestations associated with the occurrence of damage to other systems such as neurosyphilis or cardiovascular disease.
In children with congenital syphilis, scleritis occurs after many years of characteristic symptoms, not too serious, long course, poor treatment, scleritis type diffuse anterior scleritis or posterior scleritis, 5% to 20% Patients with scleritis have stromal keratitis at the same time, both eyes, easy to relapse, more serious than the third stage syphilis stromal keratitis, can be spread, and more with anterior uveitis. The clinical manifestations of various types of scleritis are as follows:
1. The onset of scleral outer inflammation is sudden, red eyes, eye pain, pain at night, and generally does not affect vision, the superficial sclera of the sclera and the conjunctival diffuse congestive edema above the sclera, the tone is red, 2/3 cases Limitations, 1/3 of the case range, the scleral surface vasodilation is distorted, radial, visible reflex edema in the orbit, nodular sclera, sclera, sclera infiltration, edema, formation of fire red limitation on the surface of the sclera Sexual nodules, single or multiple, ranging from a few millimeters in diameter, with obvious tenderness, syphilitic scleritis can affect the anterior and posterior part of the scleral wall, forming diffuse, nodular and necrotizing anterior scleritis and posterior scleritis, Conscious symptoms include red eyes, eye pain, photophobia, tearing, conjunctival sac secretions and decreased vision. Eye pain is caused by nighttime radiation along the branches of the trigeminal nerve. The most serious is necrotizing anterior scleritis, the severity of eye pain and The degree of inflammation is directly proportional. When the posterior scleritis is limited, there may be no manifestation of anterior hyperemia. When posterior scleritis occurs alone, the decrease in visual acuity is sometimes the only manifestation, vision loss. Depending on the degree of ocular complications may be.
2. Diffuse anterior scleritis accounts for about 40% of syphilitic scleritis. It is the most benign of various scleritis. The conjunctiva and anterior sclera are congested and swollen. In severe cases, the conjunctiva is highly edematous. 1000 adrenaline in order to determine that the sclera has no edema or nodules, the extent of the lesion is limited or occupies the entire anterior sclera.
3. Nodular anterior scleritis accounts for about 44% of syphilitic scleritis. The nodules are single or multiple, deep red. They are located in the deep sclera and are completely inactive. Most patients have nodular pain and the surface vessels are The nodule is topped up.
4. Necrotic anterior scleritis accounts for about 9.6% of syphilitic scleritis. This type is the most destructive. More than 60% of patients have this complication. Most of them occur in the second and third phases of syphilis. Scleritis, and acute hyperemia, if a flaky avascular area is found on the surface of the sclera, there may be necrotizing anterior scleritis. If not treated in time, the scleral tissue in this area may be completely necrotic, and scleral inflammation is around the original lesion. Development to both sides, and finally damage the entire front of the sclera, due to scleral necrosis, thinning of the sclera, uveal exposure, formation of grape swollen, necrotizing anterior scleritis can occur independently in the second or third stage syphilis, but also due to diffuse or Nodular anterior scleritis was developed without timely treatment.
5. Posterior scleritis accounts for 6.4% of syphilitic scleritis. It occurs in the third stage of syphilis or congenital syphilis. The anterior and posterior scleritis are more than 1/2, and both eyes are more common. The first diagnosis is the posterior sclera. Inflammation accounts for 33%. The signs of scleritis after syphilis include: due to the spread of inflammation to the extraocular muscles and orbital tissues, limited eye movement, diplopia, ptosis and orbital edema, and various manifestations of the choroid of the retina. Non-specific changes:
1 subretinal mass: the incidence of scleritis after syphilis is 14%, with a dome-shaped mass and normal retinal pigment epithelium are also orange-red; the choroid at the mass has a checkerboard appearance; there are choroidal folds and retina around the mass Stripes wrap around 3 important features,
2 choroidal folds, retinal streaks: the incidence of syphilitic scleritis is 14%, 16.3%, respectively, both of which can exist alone or simultaneously, manifested as a line-like change between the dark and dark phases of the posterior pole, the temporal side More common, often wrapped around the subretinal mass,
3 optic disc edema, cystoid macular edema: the incidence of scleritis after syphilis is 2.3%, caused by the spread of posterior sclera and choroidal inflammation to the optic nerve and retina,
4 annular choroidal detachment and exudative retinal detachment: the incidence of post-syphilitic scleritis is 17.5%, 34.8%, posterior scleritis invades the choroid, ring choroidal detachment, can also cause posterior pole blood-retina Barrier destruction, exudative retinal detachment, and other peripheral retinal detachment, Wilhelmus et al found that about half of the patients with anterior and posterior uveitis, some authors reported that different proportions of patients with posterior scleritis found vitreous Internal cells or elevated intraocular pressure, etc.
Examine
Examination of syphilitic scleritis
It is difficult to determine the Treponema pallidum by silver staining (Levaditi staining or Warthin-Starry staining), direct or indirect immunofluogical, immunooperoxidase testing, etc. From the conjunctival or scleral granuloma, Treponema pallidum can be detected by fluorescent treponemal antibody absorption (FTA-ABS) or microhemagglutination assay for T pallidum (MHA-TP). A presumptive diagnosis of scleritis, central nervous system signs or cardiovascular disease is also helpful in diagnosis.
The serological test for the diagnosis of syphilis also has a slide test for the slide, namely the venereal disease research laboratory (VDRL), the T. pallidum immobilization (TPT), and the rapid plasma reaction. The rapid plasma-reagin card test (RPR), automated reagin test (ART), etc., the positive rate of serological tests for each stage of syphilis is shown in Table 1.
FTA-ABS and MHA-TP test spirochete antibody fluorescence adsorption test and Treponema pallidum microcoagulation test are most sensitive to syphilis in the first phase, early phase II and early congenital, and MHA-TP is only for leprosy, recurrence fever. Systemic lupus erythematosus, rheumatoid arthritis and yaws have a false positive of 17% or less, and the STD laboratory test (VDRL) is unreliable for tertiary syphilis and has a high false positive, FTA-ABS or MHA -TP is sensitive to scleritis or scleral inflammation caused by syphilis, but it does not indicate activity. FTA-ABS and MHA-TP positive suggest a history of syphilis, idiopathic sclera infection or superficial sclera that has been treated or latent syphilis Infection, clinically effective treatment of syphilis is effective in indicating that patients with FAA-ABS and MHA-TP are positively caused by syphilis.
In the case of ocular damage caused by stage III syphilis, including scleritis or scleral inflammation, the presence or absence of cells and proteins in the cerebrospinal fluid should be carefully examined in parallel with the VDRL test to rule out neurosyphilis.
Because syphilis patients can be associated with HIV infection, all patients with syphilitic scleritis or scleral inflammation should be examined for HIV to diagnose AIDS, and vice versa.
B-ultrasound, CT, MRI, etc. can show the shape of the posterior eye wall. Local thickening is an important manifestation of posterior scleritis.
Diagnosis
Diagnosis and diagnosis of syphilitic scleritis
diagnosis
The diagnosis of syphilis is mainly based on medical history, clinical manifestations, laboratory tests, etc.
The syphilitic scleritis is mainly based on the history of syphilis infection and the clinical manifestations of the eye. It can be diagnosed with reference. The systemic examination and the auxiliary examination can be used to further determine the cause of the diagnosis, but the diagnosis of syphilitic scleritis is due to posterior scleritis. Symptoms and signs are diverse, the severity of the disease is complex and variable, and spirochetes are rarely found in the sclera, especially in the third stage and congenital syphilis. The diagnosis is difficult. According to the history and signs, especially when the fundus changes, it is supplemented with B-ultrasound. And CT, MRI scan can make a correct diagnosis.
Congenital syphilitic scleritis can be based on the history of ocular inflammation in children, the history of previous syphilis treatment, the positive history of serological syphilis in the mother, other fundus changes such as the fundus of capsicum choroidal retinitis, or eyeball atrophy, or late onset of syphilis Clinical manifestations, such as deafness, abnormal teeth, arched or saddle-like nose, and FTA-ABS or MHA-TP test positive diagnosis.
Differential diagnosis
Identification of inflammation caused by other infections.
