Case 20-2016

Abstract

2586T h e ne w e ngl a nd jou r na l o f m e dicine Pr esentation of C a seDr. Eric D. Gaier (Ophthalmology): A 50-year-old man with psoriatic arthritis and human immunodeficiency virus (HIV) infection was seen at the Massachusetts Eye and Ear Infirmary because of cloudy vision.The patient had been in his usual state of health until 3 days before this evaluation, when cloudy vision in both eyes developed gradually over the course of the day. Three days later, he sought medical attention at the emergency department of the Massachusetts Eye and Ear Infirmary. On arrival, he reported fatigue. He also reported that the rash, joint pain, and stiffness associated with his psoriatic arthritis had recently worsened.Sixteen years before this evaluation, the patient had had laser surgery for a retinal tear in the left eye. Ten months before this evaluation, he had had an episode of Pneumocystis jirovecii pneumonia that led to an evaluation for and diagnosis of HIV infection, and he had begun taking antiretroviral medications 2 months before this evaluation. Six weeks before this evaluation, he had been admitted to another hospital because of hypotension, hyponatremia, pancytopenia, and acute kidney injury; the serum alkaline phosphatase level was elevated, the CD4 count and blood cortisol level were low, and blood cultures had no growth. Adrenal insufficiency, disseminated infection with Mycobacterium avium-intracellulare, and the immune reconstitution inflammatory syndrome were suspected. Antiretroviral medications were stopped, and azithromycin, rifabutin, ethambutol, hydrocortisone, and fludrocortisone were administered, as was trimethoprim-sulfamethoxazole three times weekly. Two weeks before this evaluation, emtricitabine, tenofovir, ritonavir, and darunavir were again initiated. The patient had no known allergies. He lived with his husband, did not smoke tobacco or use illicit drugs, and drank alcohol socially.On examination, the patient was alert and oriented to person, place, and time. The pulse was 91 beats per minute, the blood pressure 121/77 mm Hg, the respiratory rate 20 breaths per minute, and the oxygen saturation 100% while he was breathing ambient air. Ophthalmologic examination revealed visual acuity of 20/25 in the right eye and 20/30 in the left eye. The pupils were equally round

All Eyes and Ears: A Case of Neurosyphilis Presenting With Simultaneous Ocular and Otic Involvement

“…However, our patient’s scleral injection and tinnitus also suggest concurrent ocular and otologic syphilis. Instances of concurrent otologic and ocular syphilis, such as in our case, are exceedingly rare, with few case reports in the literature [ 9 - 11 ]. Our patient notably did not report any symptoms of early classical neurosyphilis, such as headache or photophobia, nor did his neurologic exam show any abnormalities.…”

Rescue Intravitreal Methotrexate Treatment Following Early Recognition of Proliferative Vitreoretinopathy

“…More recently, MTX has been proposed as a possible treatment in the management of PVR, an important cause of failure of retinal detachment repair. 6 Subsequent in vitro work showed that methotrexate reduces cellular proliferation, reduces formation of PVR bands (analogous to contractile bands seen in vivo), and induces significant cell death after 4 weeks in cells cultured from human PVR membranes. 8…”

“…A Phase-1 study showed that repeated intravitreal injections of MTX into silicone-filled eyes with recurrent retinal detachment as a result of PVR or retinal detachment resulting from open globe injury may be a safe treatment, and there was a suggestion of efficacy in preventing recurrent PVR. 6 A small case series showed that following repair of rhegmatogenous retinal detachments with PVR with silicone oil tamponade in 11 patients, repeated injection of 250- µ g intravitreal MTX resulted in stable retinal reattachment in all cases for at least 6 months after the surgical procedure. 9 A larger series of 50 patients with rhegmatogenous retinal detachments complicated by Grade C or B PVR applied a treat-and-extend approach to intravitreal methotrexate injections in the management of PVR and yielded a 96% rate of reattachment.…”

“…Recently, a series of intravitreal methotrexate injections has been proposed as a potential medical treatment for PVR. 6 A Phase-3, multicenter, clinical trial to evaluate its efficacy in preventing PVR is currently ongoing. 7 To date, the use of intravitreal methotrexate to arrest the progression of PVR after its apparent development, as opposed to its use to prevent initial formation of PVR, has not been reported.…”