{"id":5736,"date":"2025-02-18T19:34:06","date_gmt":"2025-02-18T19:34:06","guid":{"rendered":"https:\/\/journalofmedicaloptometry.com\/vol4issue2\/?p=5736"},"modified":"2025-05-20T13:39:58","modified_gmt":"2025-05-20T13:39:58","slug":"guess-the-disease-when-the-great-masquerader-unveils-its-disguise","status":"publish","type":"post","link":"https:\/\/journalofmedicaloptometry.com\/vol4issue2\/volume-3-issue-1\/guess-the-disease-when-the-great-masquerader-unveils-its-disguise\/","title":{"rendered":"Guess the Disease: When the Great Masquerader Unveils Its Disguise"},"content":{"rendered":"

[et_pb_section fb_built=”1″ _builder_version=”4.16″ global_colors_info=”{}”][et_pb_row _builder_version=”4.16″ background_size=”initial” background_position=”top_left” background_repeat=”repeat” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_text _builder_version=”4.27.4″ background_size=”initial” background_position=”top_left” background_repeat=”repeat” global_colors_info=”{}”]<\/p>\n

doi: 10.62055\/63904278We<\/a><\/p>\n

 <\/p>\n

Case Presentation<\/strong><\/h2>\n

A 49-year-old white man presented to the eye clinic due to sudden-onset scotoma in the right eye. The scotoma was inferior to fixation. He noticed it after exercising and taking a shower the morning prior. He reported having fatigue since last year.<\/p>\n

Patient History<\/strong><\/h3>\n

Ocular History: Unremarkable<\/p>\n

Medical History: Unremarkable<\/p>\n

Social History: IV drug use, sober for 10 years; denies sex with men; isolated instance of unprotected sex with an unfamiliar female one year prior<\/p>\n

Medication: None<\/p>\n

Entrance Testing<\/strong><\/h3>\n

Entering Visual Acuity:<\/p>\n

OD: 20\/25<\/p>\n

OS: 20\/20<\/p>\n

Confrontation Visual Field: Full-to-finger counting, each eye<\/p>\n

Pupils: Direct and consensual responses without afferent pupillary defect<\/p>\n

Extraocular muscles: Smooth and unrestricted in all directions of gaze, each eye<\/p>\n

Anterior Segment Examination<\/strong><\/h3>\n

\"anterior<\/a><\/p>\n

Posterior Segment Examination<\/strong><\/h3>\n

\"findings<\/a><\/p>\n

Diagnostic Images<\/strong><\/h3>\n
\"figure<\/a>

Figure 1. In the right eye, the creamy lesion extended from the optic nerve superior temporally into the macula and along the superior arcades. The inferior and temporal border of the lesion was distinct, with less distinction at the superior and nasal borders.<\/p><\/div>\n

 <\/p>\n

\"figure<\/a>


Figure 2. The lesion was nasal to the optic disc in the left eye. Only the superior border of the lesion in the left eye was distinct.<\/p><\/div>\n

 <\/p>\n

OPTOS Fundus Autofluorescence (FAF)<\/h4>\n
\"imgonline<\/a>

Figures 3+4. The fundus autofluorescence (FAF) showed increased autofluorescence of the lesions in both eyes (OU). The borders of the lesion were better visualized on FAF than color fundus photos.<\/p><\/div>\n

OCT Macula<\/h4>\n
\"figure<\/a>

Figure 5. OCT showed diffuse loss of the outer ellipsoid zone and nodular irregularity of the retinal pigment epithelium and outer retina OD (green arrows).<\/p><\/div>\n

\u00a0<\/h4>\n

Humphrey Visual Field 30-2<\/h4>\n
\"figure<\/a>

Figure 6. There was an absolute defect that extends inferiorly from the horizontal midline OD (Figure 6B) which correlated to the location of the lesion. There was a possible inferior nasal defect OS (Figure 6A)\u00a0 which was not consistent with the location of the lesion.<\/p><\/div>\n

 <\/p>\n

Fluorescein Angiography<\/h4>\n
\"figure<\/a>

Figure 7. Fluorescein angiography showed late-stage vascular leakage corresponding to the area of the lesion OD<\/p><\/div>\n

 <\/p>\n

\"figure<\/a>

Figure 8. Fluorescein angiography showed late-stage vascular leakage in the nasal lesion OS.<\/p><\/div>[\/et_pb_text][et_pb_text _builder_version=”4.24.3″ background_size=”initial” background_position=”top_left” background_repeat=”repeat” custom_margin=”5%||5%||true|false” custom_css_free_form=”selector p{||margin-bottom: 0px!important||||}” global_colors_info=”{}”]<\/p>\n

Knowledge Check<\/strong><\/h3>\n

1. What are appropriate case history questions to ask the patient?<\/strong><\/p>\n

    \n
  1. \n
      \n
    1. Have you ever been diagnosed or treated for an STD?<\/li>\n
    2. Are you a man who has sex with men?<\/li>\n
    3. Are you living with or have been tested for HIV?<\/li>\n
    4. Do you recall a chancre or rash (particularly on the palms of hands or soles of feet?)<\/li>\n
    5. All of the above<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n

      2. What is the most appropriate diagnosis?<\/strong><\/p>\n

        \n
      1. \n
          \n
        1. Acute posterior multifocal placoid pigment epitheliopathy (APMPPE)<\/li>\n
        2. Acute Syphilitic Posterior Placoid Chorioretinopathy<\/li>\n
        3. Age-related macular degeneration (AMD)<\/li>\n
        4. Choroidal osteoma<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n

          3. What is the most appropriate treatment?<\/strong><\/p>\n

            \n
          1. \n
              \n
            1. Doxycycline 100 mg taken twice daily by mouth for 14 days<\/li>\n
            2. Prednisone 60 mg taken daily by mouth for 10 days<\/li>\n
            3. Aqueous crystalline penicillin G 18-24 million units per day, administered as 3-4 million units IV every 4 hours, or continuous infusion, for 10-14 days<\/li>\n
            4. Keflex 500 mg taken twice daily by mouth for 14 days<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n

              4. True or False:<\/strong>\u00a0Syphilis is known as the \u201cgreat masquerader\u201d for its ability to mimic several conditions due to its extensive range of clinical manifestations.
              \n 
              \n5. Which of the following labs CANNOT be used to monitor disease activity?<\/strong><\/p>\n

                \n
              1. \n
                  \n
                1. Fluorescent treponemal antibody absorption (FTA-ABS)<\/li>\n
                2. Venereal Disease Research Laboratory (VDRL)<\/li>\n
                3. Rapid plasma reagin (RPR)<\/li>\n
                4. Treponema pallidum particle agglutination (TP-PA)<\/li>\n
                5. A and D<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n

                  6. True or False:<\/strong>\u00a0Ocular syphilis is neurosyphilis.
                  \n 
                  \n7. True or False:\u00a0<\/strong>Patients diagnosed with ocular syphilis should be tested for HIV. HIV Pre-exposure prophylaxis (HIV PrEP) should be offered if the HIV test is negative.[\/et_pb_text][et_pb_text _builder_version=”4.24.3″ background_size=”initial” background_position=”top_left” background_repeat=”repeat” global_colors_info=”{}”]<\/p>\n

                  Diagnosis and Treatment<\/strong><\/h3>\n

                  Based on the placoid lesions and sexual history, the diagnosis was presumed to be Acute Posterior Placoid Syphilitic Chorioretinitis. Laboratory tests were ordered to confirm the diagnosis. The following is a summary of the test results.<\/p>\n

                  \"table<\/a><\/p>\n

                  The patient was admitted to the hospital for IV penicillin. He received 4 million units of aqueous penicillin G infusion every four hours for 3 days. He was discharged on the fourth day with continuous home infusion therapy. He completed 14 days of treatment.<\/p>\n

                  Follow-Up<\/strong><\/p>\n

                  The patient has yet to follow up in the eye clinic due to conflicts with his work schedule. Although a formal visual field has not been repeated, the patient noted that the scotoma had resolved via telephone follow-up two weeks after treatment completion.<\/p>\n

                  Discussion<\/strong><\/p>\n

                  Syphilis is a sexually transmitted disease caused by the Gram-negative spirochete Treponema pallidum<\/em>.1,2<\/sup> It is known as the \u201cgreat masquerader\u201d for its ability to mimic several conditions due to its extensive range of clinical manifestations.1,2<\/sup> In contrast to most manifestations of ocular syphilis, Acute Syphilitic Posterior Placoid Chorioretinitis (ASPPC) is easily identifiable due to its characteristic pattern of placoid chorioretinitis. It may be the first presenting sign of syphilis, as it was in this case.3<\/sup><\/p>\n

                  General Characteristics<\/strong><\/p>\n

                  ASPPC is characterized by the presence of one or more yellowish, ill-defined, placoid lesions that are typically in the posterior pole or mid-periphery of the fundus.4,5<\/sup> These lesions usually have a faded center and ground-glass pattern of RPE hyperpigmentation.5,6<\/sup> They can coalesce to become large confluent lesions.6,7<\/sup> The chorioretinal lesions can be localized, diffuse, or peripheral.3<\/sup> Chorioretinitis is accompanied by variable amount of vitreous inflammation and can be associated with superficial retinal hemorrhages, retinal vasculitis, optic disc edema, and serous detachment of the RPE.3,6<\/sup><\/p>\n

                  The most common presenting symptom of ASPPC is the presence of a scotoma, as it was with the chief complaint of the patient presented in this case.8<\/sup> Symptomatic eyes are significantly more likely to have a scotoma at presentation, disruption of the ellipsoid zone (EZ), and hyper-reflective elevated lesions of the RPE.8<\/sup> This EZ disruption produces a scotoma in the involved area.6<\/sup> Elevated hyperreflective lesions of the outer retina and RPE along with disruption of the EZ and RPE-photoreceptor complex as seen by OCT imaging seem to be associated with worse entering visual acuity (VA). After antibiotic treatment, most patients will have complete or near complete recovery of the scotoma and visual acuity. 6<\/sup><\/p>\n

                  Diagnostic Imaging Techniques<\/strong><\/h3>\n