遷延する結膜充血が初期症状であった梅毒性ぶどう膜炎の1例

A case of syphilis uveitis that initially presented as prolonged conjunctivitis

要約　目的：遷延する結膜充血が初期症状であった梅毒性ぶどう膜炎の1例を報告する。

症例：79歳，男性。以前より両開放隅角緑内障と両白内障の経過観察中であった。X年2月に右眼結膜充血を主訴に総合上飯田第一病院眼科を受診した。右眼急性結膜炎と診断し抗菌薬とステロイド点眼で経過観察した。3週間後に右眼に前房蓄膿，毛様充血を認め，血液検査から梅毒によるぶどう膜炎と診断した。

所見：初診時，最高矯正視力は右0.2，左0.3で右眼結膜炎以外に所見を認めなかった。3週間後，右眼前房蓄膿，毛様充血，硝子体混濁を認め，右眼視力は手動弁まで低下した。眼底は透見困難であった。血液検査で梅毒血清反応が陽性のため梅毒性ぶどう膜炎と診断した。精査加療目的で愛知医科大学病院へ紹介した。梅毒同定のための前房水，髄液のポリメラーゼ連鎖反応検査はいずれも陰性であった。皮膚所見や神経学的所見，MRI検査での頭蓋内精査でも梅毒性病変はなかった。脳脊髄液検査の蛋白濃度上昇と梅毒トレポネーマ蛍光抗体吸収検査陽性のため，無症候性神経梅毒としてセフトリアキソン全身投与と，眼症状に対する抗菌薬，ステロイド，散瞳薬，緑内障点眼での治療が行われた。3週間後に前眼部症状の改善を認め，視力は（0.2）に改善した。点眼治療の継続で2か月後にぶどう膜炎は改善した。

結論：梅毒感染は特異的な眼所見を呈さないため，診断には血液検査が有効である。全身的に無症状でも全身合併症の精査が重要である。

Abstract　Purpose：To report a case of syphilis uveitis that initially presented as prolonged conjunctivitis.

Case：The patient was a 79-year-old man who had a history of bilateral primary open angle glaucoma and cataract. He visited the hospital with a chief complaint of conjunctival hyperemia in the right eye. In February of the year X, his right eye showed acute conjunctivitis and he had received topical antibiotics and steroids. Three weeks later, ciliary hyperemia and hypopyon were found in his right eye. He was diagnosed with syphilis uveitis by serological test.

Findings：At his first visit, his best corrected visual acuity was 0.2 in the right eye and 0.3 in the left eye. Other than conjunctivitis of his right eye no other conditions were observed. Three weeks later, his right eye developed ciliary hyperemia, hypopyon and vitreous opacity and the visual acuity decreased. The fundus could not be observed. The syphilis serodiagnosis was positive. We referred the patient to Aichi Medical University for further investigations. Polymerase chain reaction testing of the hydatoid and cerebrospinal fluid（CSF）were negative to identify syphilis. Nothing particular had been found in skin, neurological examination, and brain magnetic resonance imaging test. Since the CSF protein was high and fluorescent treponemal antibody absorption was positive in the CSF test, he was diagnosed with asymptomatic neurosyphilis. He started receiving intravenous ceftriaxone sodium hydrate and topical antibiotics, steroid, mydriatic and glaucomatous. Three weeks later, the ciliary hyperemia and hypopyon disappeared and the visual acuity increased to 0.2. He continued the topical administrations, and the uveitis had improved 2 months later.

Conclusions：Since ocular syphilis has various clinical manifestations, syphilis serodiagnosis is useful for diagnosis. Additionally, it is important to investigate systemic complications even though it is asymptomatic.