OCR Text |
Show © 1989 Raven Press, Ltd., New York Editorial A Lyme/ Syphilis Serology Scenario Sizzler!! In the last issue of the journal, a paper entitled " Panuveitis with Positive Serological Tests for Syphilis and Lyme Disease" was published by Drs. Zierhut, Kreissig, and Pickert from the University of Tubingen in West Germany. In essence, a 64year- old woman presented with decreased acuity in April 1986, and had a low- grade vitritis, atrophic scars in the retina, and later some keratitic precipitates. She improved for a time after topical steroids, but 6- 8 months later returned with vision much worse. Iritis, posterior synechiae, heavy vitritis, and retinitis pigmentosa- like pigment clumping in the fundus were noted. There were no other systemic findings and her history was negative for prior known venereal infection. The spinal fluid was not remarkable. The problem arose when she had strongly positive blood tests for syphilis, associated with variably positive blood tests for Lyme borreliosis. The authors concluded that the patient probably had ocular Lyme disease and elected not to treat her with systemic penicillin therapy because the intraocular inflammation cleared after photocoagulation therapy. That case prompted an editorial in the same issue of this journal by Dr. Alan MacDonald, a Lyme disease " heavy hitter," entitled " Diagnostic Dente and Spirochetal Serology." The punch line of his editorial stated " I believe that the patient's clinical and laboratory profile support the diagnosis of syphilis. " What you do not know, gentle reader, however, is that even more trans- Atlantic correspondence has related to this case and with findings of such importance to the clinician that they warrant a new first in the jounzal of Clinical Nel/ ro- ophthall11ologyi. e., another editorial in a consecutive issue to bring out even more of the issues at stake' After reading Dr. Zierhut's manuscript, I wrote and asked him to please send another serum sample on his interesting patient to the Institut Alfred F" lI'"'"," r III ['. His Thi" j" the French national center .,', dll',('.,,- and is, in my J. l6 opinion, the most prestigious laboratory for spirochetal serologies in the world. I visited Dr. Pierre Collart there in 1969, and he has been, in my opinion, one of the most outstanding investigators in experimental syphilis in the world. Professor Collart has since retired, but we have enjoyed a close cooperation with the Fournier Institute ever since. The directors of the Institute, which would be the French national equivalent to the Communicable Disease Centers in the United States, are A. Vaisman and A. Paris- Hamelin, and with Dr. Poitevin, they have helped us repeatedly with difficult, ambiguous, or controversial serologic tests. Dr. Zierhut promptly and graciously sent sera from his patient to the Institut Alfred Fournier, and these were reported in a letter of December 2, 1988, by Mme. A. Paris- Hamelin as follows on the patient in question: Serodiagnosis for treponematoses Lyme immunofluorescence IgG 1: 200, IgM = negative VORL = reactive 3 + ( 4 units) TPHA = reactive 4+ ( 2560 units) FTA- ABS = reactive 4 + ( 3200 units) TPI ( Nelson test) = reactive ( 100% immobilization) ( 400 units) IgM ( immunofluorescence) = negative A letter from Mme. A. Paris- Hamelin with this data stated " We have obtained a definitely positive serodiagnosis of syphilis as you can see from the attached results, without the IgM. The Lyme reaction is feebly positive at 1: 200 but this is not specific for there is an evident syphilis with a Nelson test of 100%. The Nelson test ( TPJ) is tile only test risorol/ sly specific for syphilis and absolutely does 110t cross with Lyme disease" ( my italics). " In addition, we enclose a Western blot on a serum of your patient ( i. e., Dr. Zierhut's case) which you will see does not correspond with the findings in a positive case of Lyme disease. In order to compare, we are sending you a positive se- EDITORIAL 147 rum for Lyme disease, with evident disease, which reacts with the same Lyme antigen and you can see the number of findings which exist in the differen t protein fractions." " We can therefore, in a secure way, eliminate Lyme infection and only retain the diagnosis of syphilis. " Dr. Zierhut wrote me a letter dated December 15, 1988, and the following is quoted from his letter: " As you told me I have sent serum of our patient to Mme. A. Paris- Hamelin, Paris.... These investigators seem to leave no doubt about the existence of a syphilis panuveitis in our patient. But I want to point out the following to you: in November ( 1988) I have seen our patient again. She told me that she received treatment with penicillin outside of our clinic four months ago. At the moment we have the following results of our serology tests: TPHA titer 1: 5120, VORL 1: 40, FTAABS weakly positive, Lyme- IgG 150, IgM negative ( immunofluorescence). " " Madame Paris- Hamelin has sent a Western blot of a Lyme positive patient but not of a syphilis positive patient. Only by comparing these two Western blots should allow one to decide if she has syphilis or Lyme disease. The main problem at this moment for me seems to be the very low Lyme antibodies. I think at the moment it is impossible to say if there has been a cross reaction or not. I am very sorry to say that we don't have any blood from the time of the acute ocular problem." " We saw our patient for the first time nearly one year after the beginning of the panuveitis. Before we received the serologic results of syphilis and Lyme disease, we treated her with corticosteroids. Under this treatment the vitritis definitely stopped. From this moment on we have not seen any new acute phase. If a new uveitis surge had appeared we would have begun treatment immediately with penicillin." Dr. Zierhut also pointed out that his patient was HIV negative. He stated that blood tests and clinical investigation of the husband of his patient gave no clue for an old or a new syphilis. Recent investigations in the Bascom Palmer Eye Institute that are to be reported have given us additional insight into the serologic cross- reactivity between syphilis and Lyme borreliosis. The important point to you, dear reader, is this- whenever you see a patient with iritis, vitritis, optic neuritis, Bell's palsy, aseptic meninglhs, or other clinical picture consistent with Lyme borreliosis, you should obtain four serologic tests: ( a) VORL with titer, ( b) FTA- ABS, ( c) Lyme IFA IgG and IgM, and ( d) Lyme ELISA. You can obtain all four of these tests for a total cost of $ 50 on one tube of serum by submitting the specimen to the Microbiology Reference Laboratory, 10703 Progress Way, Cypress, CA 90630- 4714; telephone, 1- 800- 445- 0185. We have recently begun to compare simultaneous aqueous and serum titers for Lyme antibodies while working with Dr. Porschen of this laboratory. There is going to be a 2- day seminar cosponsored by the Lyme Borreliosis Foundation and the Texas State Department of Health Laboratory, Julie Rawlings as director, which will be held in Austin, Texas, on May 4-- 5, 1989. We hope to have many more new gems for you from that meeting! In the meantime, in my personal opinion, Dr. Zierhut's case of panuveitis was definitely due to syphilis, and the importance of a 100% TPI immobilization is absolute confirmation of that and shows us that a negative history cannot always be relied upon. I personally would advise treatment of Dr. Zierhut's patient with intravenous aqueous penicillin 3 million units every 4 h for 10 days and would follow her titers. The reason for giving such a large course of intravenous penicillin would be to do our very best to try to prevent her from developing further late complications from ocular or neurosyphilis. We thought that you would be most interested in these communications, and want to thank particularly our correspondents in the Federal Republic of Germany as well as in France, who have been so very, very cooperative. According to the New York Times, February 19, 1989, Lyme disease is rapidly spreading westward in New York State and the New York State Legislature has appropriated $ 600,000 for fiscal 1989 to study ticks and Lyme disease, $ 250,000 of which has been earmarked for the newly established Tickborn Disease Institute. We are seeing more and more cases of late ocular Lyme borreliosis at the Bascom Palmer Institute now. The disease can be very, very difficult to eradicate in chronic cases. Syphilis, AIDS, and Lyme borreliosis are certainly out on the " cutting edge" of neuro- ophthalmology today! J. L. Smith, M. D. I Cli" Neuro- ophthalmol, Vol. 9, No. 3, 1989 |