Context: Syphilis is a pleomorphic, insidious disease and an important differential diagnosis of ocular and CNS involvement. Its recognition and treatment are extremely important, given the high morbidity of its natural history. Case report: A 79-years-old woman started bilateral, intermittent and progressive visual turbidity, evolving in 5 months with pain on eye movement and intense throbbing bilateral headache, worse on the right, plus photophobia, and poor painkillers response. After 3 months, she presented fleeting amaurosis and was admitted to our service. On examination: severe low visual acuity, relative afferent pupillary defect, red desaturation and papilla edema. In CSF: hyperproteinorrachia and negative VDRL. Prednisone 60mg/day was started due to papillitis. Blood analysis showed 1/8 reagent VDRL, with other serologies, tumor and rheumatology markers negatives. She received crystalline Penicillin for 14 days, obtaining remission of headache, papilla edema and improved visual acuity. After 12 days, the visual acuity worsened, so Penicillin was extended to 21 days with 7g of methylprednisolone. After 3 days, the patient recovers the visual acuity she had before. Conclusions: The present study describes neuro-ophthalmological manifestation of syphilis in an immunocompetent individual. Although there is still controversy in the literature, in this case, high dose short-term corticoids was chosen, due to the severity of the loss of visual acuity, obtaining a favorable therapeutic response.
Context: PML is a dymyeliniating disease of the brain, caused by JC virus infection reactivation in immunocompromised patients, especially by AIDS, hematological disease and immunosuppressive therapies. Case report: A 67-year-old woman was diagnosed with multiple myeloma (MM) in 2018 and use of bortezomib/cyclophosphamide/dexamethasone and thalidomide was ineffective. She underwent treatment with monthly daratumumab starting in January 2020. After one year, she experienced progressive amnesia, apathy and confusion. At admission, examination revealed apathy, monosyllabic communication and frontal release, progressing to mutism and abulia. T2 FLAIR-weighted MRI of the brain performed in March 2021 showed a hyperintense non-enhancing lesion affecting thalamus, internal capsule, lentiform and deep white matter of left lobes. MRI performed one month before symptoms onset showed a small lesion in subinsular region – indicating incipient involvement. Cerebrospinal fluid PCR was positive for JC viruses, and PML was diagnosed. Conclusions: This report proves that concomitant hematologic and drug- immunocompromised patients presenting with neurological symptoms should be investigated for PML. There are few reports in the literature of PML occurring in MM, especially after use of daratumumab, an anti-CD38 monoclonal antibody. Recently, one small case series demonstrated some improvement in pembrolizumab (a checkpoint inhibitor)-treated PML, but no routinely therapy is recommended. Understanding severity of both disease, patient was discharged receiving conservative treatment.
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