Patient Overview Presentation regarding neurosyphilis

Patient Overview Presentation regarding neurosyphilis

1. SATURDAY FORUM Dr. H.Y.C. SENANAYAKE MEDICAL REGISTRAR WD 28/29

2. HISTORY Mr. B 33Y old male patient From Katugasthota Employed as a salesmen Unmarried Living with his parents

3. Presenting complain Progressive visual loss since December 2023

4. History of presenting complain Initially the patient developed pain in his right eye with red eye followed by gradual visual loss which started 8 months back. 3 months later he developed painful red eye with gradual visual loss of the left eye.

5. Associated with this the patient had significant loss of appetite and loss of weight for 4 months duration. Patient did not have small or large joint pains, back pain, skin rashes, oral ulcers, hair loss. No history of episodic blood and mucous diarrhea, watery diarrhea with abdominal pain. No chronic cough, haemoptysis , evening pyrexia and neck and axillary lumps. No past history of TB or contact history of TB

6. No history of limb weakness, slurred speech, seizures or other neurological manifestations. No frothy urine, haematuria , dysuria or lower limb oedema. Normal Urine output. No dry mouth or dry eyes. Not on long term drugs. No cats, dogs or other pets at home. Since the age of 22 years the patient has been having high risk sexual behaviour with female sex workers without protection.

7. He denies sexual acts with other males. No history of IV drug use. History of a tattoing of the right arm from a road side tattoo shop 7 years back. Had a painless genital ulcer 8 years back following a high risk sexual encounter which healed spontaneously and the patient didn’t seek any medical treatment for this. No history of yellowish discolouration of eyes with fever.

8. Past medical history No history of diabetes mellitus, dyslipidaemia , hypertension, joint or connective tissue diseases and malignancy

9. Past surgical history No surgeries in the past

10. Drug history He was given a 6 month trial of Anti TB treatment to which he responded poorly.

11. Allergy history No drug, food or plaster allergies.

12. Family history No history of connective tissue disorders, malignancies or other illnesses.

13. Social history He worked as a technician in a biyagama garment factory. Stopped working due to his illness. Home town is in kothmale . Lives with his father and mother. Father is a manual labourer . Consumes alcohol and smokes occasionally about once a month only.

14. Summary My patient is Mr. B a 33 year old patient who presented with gradually worsening visual loss with redness and pain initially involving the right eye followed by involvement in the left eye. It was associated with significant loss of appetite and loss of weight over 4 months without cough, evening pyrexia, inflammatory type joint pain, diarrhoea or skin rashes.

15. He had a history of very high risk sexual behaviour with female sex workers. There was a history of a painless genital ulcer 8 years back which spontaneously healed. He was given a trial of Anti TB drugs for 6 months to which he responded poorly despite good compliance.

16. Physical Examination No pallor, icterus, cervical, or axillary lymph nodes No oral ulcers No alopecia No rashes anywhere No nail changes No small or large joint swelling or deformities No lower limb oedema No genital ulcers

17. Ophthalm oscopic Findings ( Done by ophthalmologist) - Right Eye: Panuveitis - Left Eye: Vitritis

18. CVS Examination BP- 120/90 Pulse rate- 84, regular, normal volume Other peripheral pulses were normal. JVP not elevated

19. Inspection- No chest wall deformities, No surgical scars Palpation- Apex beat was located in the 5 th intercostal space mid clavicular line. Normal in nature. No thrills or parasternal heaves. Auscultation S1 and S2 normal. No added sounds. No murmurs.

20. Respiratory examination Inspection- Patient was not in respiratory distress. No chest wall deformities Respiratory rate- 18 per minute. Palpation Trachea- Central Bilateral chest expansion normal Bilateral vocal fremitus normal

21. Percussion- Bilateral resonant percussion note. Auscultation- Bilateral vesicular breathing. Vocal resonance normal. No added sounds.

22. Abdominal examination Inspection- No surgical scars. No distension. Palpation- Soft non tender abdomen. No hepatosplenomegaly or ballotable masses Percussion- No flank dullness or shifting dullness. Auscultation- No bruits or rubs. Normal bowel sounds heard.

23. Neurological examination GCS-15/15 Fundus- No papilledema Bilateral pupils 4mm. Equally reactive to light No neck stiffness

24. Lower limbs Tone- Normal Power- 5/5 Reflexes- Normal knee and ankle jerks Bilateral plantar down going Sensory- No sensory impairment

25. Upper limbs Tone- Normal Power- 5/5 Reflexes- Normal Cranial nerves CN 2- Visual acuity normal. CN 3,4,6- Normal. No ophthalmoplegia. CN 5- Sensory and motor components intact.

26. CN 7- No facial weakness CN 8- No hearing impairment or nystagmus. CN 9, 10- No bulbar weakness CN 11- Normal power of trapezius muscle. CN 12- Normal tongue muscle power. No tongue deviation .

27. SUMMARY My patient is Mr. B a 33 year old patient who presented with gradually worsening visual loss with redness and pain initially involving the right eye followed by involvement in the left eye. It was associated with significant loss of appetite and loss of weight over 4 months without cough, evening pyrexia, inflammatory type joint pain, diarrhoea or skin rashes.

28. He had a history of very high risk sexual behaviour with female sex workers. There was a history of a painless genital ulcer 8 years back which spontaneously healed. He was given a trial of Anti TB drugs for 6 months to which he responded poorly despite good compliance. His ophthalmoscopic examination revealed a Panuveitis in the R/ eye with a Vitritis in the L/ eye.

29. Investigations

30. FBC WBC: 6.7 x 10³/ μ L (4-10) - Hb: 14.9 g/dL (11-16) - Platelets: 231 x 10³/ μ L ( 150-450)

31. Inflammatory markers ESR- 88mm/ hr ( 0-10) CRP: 17.6 ( < 6mg/ dL)

32. Liver functions ALT- 37.8 ( < 45U/L) AST- 31.6 ( < 35U/L) ALP- 105 ( 30- 120) GGT- 31 ( 11-61) T. Bilirubin- 13.7 (5-19 microgram/L) D. Bilirubin- 3.7 (1.7-6.8 microgram/L) I. Bilirubin-10 T. Protein- 9.4 ( 6.6- 8.3g/dL) Albumin- 4.8 ( 3.5- 5.3g/ dL) Globulin- 4.6( 2.9- 3.2 mg/L)

33. Renal functions S. Creatinine- 67.6 micromole/ L ( 65- 120) S. Electrolytes S. Sodium- 143 S. Pottasium - 4.3

34. Mantoux test Negative

35. CHEST-X RAY

36. USS Abdomen No Hepatosplenomegaly R/L Kidneys normal in size and echogenicity. No para aortic lymphadenopathy. No pelvic free fluid.

37. ANA Negative

38. Rheumatoid factor Negative- 13.3 ( 0-16)

39. Toxoplasma IgM and Ig G Negative

40. HIV Antibodies ( ELISA Method) Positive

41. CD4 count 374

42. Serum VDRL Positive ( 1024)

43. TPPA ( Treponema pallidum particle agglutination) Positive

44. CMV IgM and IgG Negative

45. Hep B s Ag Negative

46. Hep C IgM and Ig G Negative

47. FBS 5.4 mmol/L

48. CSF Analysis - CSF VDRL: Positive - WBC: 14 cells/μL - Polymorphonuclear cells (PMN): 0% - Protein: 37.9 mg/dL - Glucose: 3.52 mmol/L

49. THANK YOU