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Inicio Enfermedades Infecciosas y Microbiología Clínica (English Edition) Tonic pupil and dermal injuries, is it just what it seems?
Journal Information
Vol. 37. Issue 4.
Pages 274-275 (April 2019)
Vol. 37. Issue 4.
Pages 274-275 (April 2019)
Diagnosis at first sight
DOI: 10.1016/j.eimce.2019.02.005
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Tonic pupil and dermal injuries, is it just what it seems?
Pupila tónica y lesiones dérmicas, ¿únicamente es lo que parece?
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María del Carmen Pecero-Hormigoa,
Corresponding author
mamen_ph@hotmail.com

Corresponding author.
, Cristina González-Tenaa, Elsa Gaspar-Garcíab, Leticia Nair López-Laraa
a Servicio de Medicina Interna, Complejo Hospitalario Universitario de Cáceres, Cáceres, Spain
b Servicio de Medicina Interna, Hospital de Zafra, Zafra, Badajoz, Spain
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This case discusses a 33-year-old male who reported unprotected sex with men (MSM), consulting with a two-month history of night fever and non-painful, non-pruritic skin lesions and, in recent days, blurred vision in his right eye and intermittent headache. Physical examination revealed a widespread maculopapular rash, including on the palms of his hands and soles of his feet (Fig. 1), and marked anisocoria with right pupil mydriatic and hyporeactive to light and accommodation (Fig. 2), with no meningism or other focal neurological signs.

Fig. 1.

Maculopapular and erythematous exanthema on the trunk.

(0.08MB).
Fig. 2.

Anisocoria due to right pupil mydriatic and hyporeactive to light.

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Tests showed the patient to be positive for anti-T. pallidum antibodies with an RPR titre of 1/128 and positive for anti-HIV antibodies (CD4 T-cell count 184 per mm3 and plasma viral load 110,012copies/ml). Analysis of cerebrospinal fluid (CSF) showed 29 leucocytes/μl with predominance of lymphocytes (75%), glucose 51mg/dl, proteins 0.84g/dl and positive VDRL (venereal disease research laboratory test).

With the diagnoses of HIV and neurosyphilis, the patient was given penicillin G sodium in continuous infusion for 14 days, antiretroviral treatment and primary prophylaxis for P. jirovecii. The patient made good progress, with the skin lesions disappearing and pupil contraction returning (Fig. 3).

Fig. 3.

Recovery of right pupillary contraction after 10 days of treatment with penicillin G sodium.

(0.03MB).

Nowadays, the tertiary forms of neurosyphilis (tabes dorsalis and progressive general paralysis) are rare, but early neurosyphilis is on the increase, especially in MSM with HIV infection.1,2 Although the most common form of ocular neurosyphilis is uveitis, T. pallidum can affect almost any structure of the eye. The classic Argyll-Robertson pupil tends to accompany tertiary forms, while in our patient (with early syphilis) the mydriatic and non-reactive pupil (mimicking an Adie pupil) was the only manifestation of neurosyphilis; similar cases have even been described with no other signs of early syphilis.3 It is therefore necessary to maintain a high degree of suspicion in the case of any eye disease in MSM, especially if they have HIV, and perform serology for syphilis and, if positive, a lumbar puncture to rule out neurosyphilis.

References
[1]
C.M. González-Doménech, I. Antequera, E. Clavijo-Frutos, M. Márquez-Solero, J. Santos-González, R. Palacios-Muñoz.
Sífilis e infección por el virus de la inmunodeficiencia humana: una endemia en hombres que tienen sexo con hombres.
Enferm Infecc Microbiol Clin, 33 (2015), pp. 32-36
[2]
Grupo de Expertos del Grupo de Estudio de SIDA de la SEIMC (GESIDA), Secretaria del Plan Nacional sobre el SIDA (SPNS), Grupo de Estudio de ITS de la SEIMC (GEITS), Grupo Español para la Investigación de las Enfermedades de Transmisión Sexual de la Academia Española de Dermatología y Venerología y de la Sociedad Española de Infectología Pediátrica (SEIP).
Documento de consenso sobre diagnóstico y tratamiento de las infecciones de transmisión sexual en adultos, niños y adolescentes.
[3]
M. Tsuboi, T. Mishijima, S. Yashiro, K. Teruya, Y. Kikuchi, N. Katai, et al.
Time to development of ocular syphilis after syphilis infection.
J Infect Chemother, 24 (2018), pp. 75-77

Please cite this article as: Pecero-Hormigo MC, González-Tena C, Gaspar-García E, López-Lara LN. Pupila tónica y lesiones dérmicas, ¿únicamente es lo que parece? Enferm Infecc Microbiol Clin. 2019;37:274–275.

Copyright © 2018. Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica
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