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Acute Retinal Necrosis due to Luetic Infection - 2 Case Reports

Hayler J. K. M., Bergua A., Wenkel H.,
Friedrich-Alexander-Universität, Augenklinik (Erlangen)

Background: Acute retinal necrosis is usually caused by viral infections. We report on 2 immunocompetent patients who suffered from a peripheral acute retinal necrosis due to an otherwise asymptomatic luetic infection.
Patients: Patient A: a 44 year old male presented with unilateral diffuse headache and decreased visual acuity (V) on his right eye (OD) (V: OD 20/30; OS 20/20). Patient B: a 52 year old male suffered from decreased visual acuity for 2 weeks on OD (V: OD 20/600; OS 20/20). On examination of the affected eye both presented with inflammation of the anterior chamber and showed a sharply delineated area of necrotic and oedematous peripheral retina without retinal bleeding. The contralateral eye did not show any pathological findings. Serological testing for immunological, viral or bacterial causes was unremarkable except increased TPHA-titer (A: 1:163840; B: 1:81920), a positiv FTA-Abs-test, IGM-FTA-Abs-Test (A: negativ , B: 1:2560) and a cardiolipin CBR (A: 1: 80; B: 1:320). Follow up: Prior to specific therapy visual acuity droped to 20/80 in patient A and light perception in patient B. During therapy with initally i.v.-penicillin followed by i.m.-depot-penicillin for 21 days visual acuity improved markedly in both patients. Shortly after initiation of therapy both patients showed marked inflammation of the vitreous body representing a localized "Herxheimer reaction", which was readily controlled by steroid therapy. 4 weeks after therapy visual acuity of patient A had improved to 20/20.
Conclusions: In patients with unilateral acute retinal necrosis luetic infection should always be excluded. Additive steroid therapy should be considered under tight clinical control to treat vitreous inflammatory reaction caused by lysis of treponema pallidum.