Abstract

P 222

Jarisch-Herxheimer reaction after primary therapy of a Treponema pallidum/ HIV coinfection with bilateral asymptomatic panuveitis and papilledema in a 22-year-old homosexual patient – therapy and prophylaxis

Christina Müller, Bernhard Stoffelns, Norbert Pfeiffer
Universitäts-Augenklinik Mainz

Objective
Infection of Treponema pallidum is reincreasing within the last decades. Particularly homosexual males in urban areas are under high-risk and coinfections with further sexual transmitted diseases are frequent. Jarisch-Herxheimer reaction causing shock can occur during primary therapy due to massive decay of bacteria.
Methods
The patient was referred because of a bilateral panuveitis with papilledema, which was noticed during a rheumatologic clarification. Visual acuity was 1.0 in both eyes without correction. Beside an inflammation of the iris and ciliary body there was a papilledema on both eyes. Ultrasonographic optic disc drusen were excluded. Intraocular pressure, pupillary reaction as well as perimetric examination were without pathological findings. From 10/07 our patient suffered from a progressive alopecia, and from 08/08 he was under medical attendance because of pain in several joints and muscles with elevated inflammatory markers. Urological examination showed condyloma acuminata. Two years ago he was treated due to a gonococcus infection.
Results
Serologically an infection with HIV and Treponema pallidum was detected. A performed spinal puncture verified a neurosyphilis. Despite immunosuppressive therapy with 80 mg Prednisolone, two hours after primary therapy with penicillin 10 Mega I.E. intravenously the patient presented pyrexia, after 5 hours he developed a oliguric shock in terms of a Jarisch-Herxheimer reaction. Due to intensive volume therapy with cristaloid and colloidal solutions the circulation was recovered 12 hours after the inicial primary therapy.
Conclusions
Despite of systemic steroidal therapy that was given because of the uveitis a distinctive Jarisch-Herxheimer reaction took place. Avoiding a life-threatening immunologic reaction by bacterial decay a simultaneous immunsuppressive therapy with glucocorticosteroids (1 mg/kg prednisolone) is recommended. If such a reaction occurs close meshed control of circulatory parameters and intensive volume therapy is indispensable. With regard to the increasing incidence in patients with vague intraocular inflammation a serological examination of Treponema pallidum infection should be performed. Particularly members of a high-risk group are to be screened regarding further sexual transmitted diseases. In a patient with HIV coinfection progression can be accelerated. For that reason even young patients can present advanced course of diseases.

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