Case Presentation: A 40-year-old man presents with painful, progressive bilateral vision loss which began two months prior, and was described as the patient feeling as if he were “looking through a straw”. He noted excruciating eye pain, redness, and tearing. Despite work as a tree trimmer, patient denied known trauma. He endorsed a twenty-pound unintentional weight loss and an itchy rash on his palms and soles. He denied risky sexual contact or IV drug use.
He was afebrile with normal pulse and blood pressure. He had bilateral conjunctival injection and chemosis with a nonreactive right pupil. Ophthalmology exam revealed progressive outer retinal necrosis. He had two painless ulcerations on his penile shaft and a dry, macular rash on his palms and soles.

Labs revealed positive HIV-1 antibodies and CD 4 count of 205. An anterior chamber fluid tap of the right eye was negative for herpes simplex virus (HSV), varicella zoster virus (VZV), cytomegalovirus (CMV), and toxoplasmosis. Rapid plasma reagin (RPR) was positive. Cerebrospinal fluid analysis revealed 10 white cells, glucose of 39, protein of 75, and a positive VRDL antigen.

A diagnosis of ocular syphilis was confirmed with reactive VRDL antigen in CSF, detectable RPR antibodies at 1:256, and syphilis IgG >8.0 in the context of active retinitis and vitritis in a HIV patient. Penicillin G 4 million units q4h for syphilis was initiated.

Discussion: Hospitalists often admit and care for HIV positive patients with ophthalmologic issues and should be familiar with workup and management of infectious etiologies for painful vision loss. Bacteria, viruses, parasites, and fungi are capable of infiltrating ocular structures and causing acute vision loss. Ocular involvement manifests as uveitis, or inflammation of the iris, ciliary body, and choroid. Opportunistic viruses like VZV, HSV, and CMV are common causes of uveitis in the immunocompromised.

HIV and syphilis coinfection is common; statistical analysis in one retrospective study showed the risk of syphilis infection in HIV patients to be 86 times higher than patients without HIV. Hospitalists should be aware that patients with coinfection frequently present in non-classical ways. Primary syphilis in HIV positive patients is more likely to be asymptomatic, thus patients present with secondary or latent infection. Ocular syphilis, classified as early neurosyphilis, most commonly presents as panuveitis in HIV positive patients and is often painful. With prompt recognition and antibiotic treatment in the absence of marked chorioretinal atrophy, recovery of vision is often possible.

Conclusions: The differential diagnosis of painful, progressive vision loss should include infectious etiologies. HIV positive patients coinfected with syphilis may present with features of primary, secondary, tertiary, and neurosyphilis occurring simultaneously. Panuveitis with positive treponemal testing should prompt the hospitalist to initiate IV Penicillin G.