Case Presentation: There is a trend for increasing frequency of primary and secondary syphilis in developed countries, especially in men who have sex with men. Ocular manifestations of syphilis are rare, occurring in less than one in 1 million persons. Distinctive patterns of syphilitic uveitis include white, focal preretinal opacities, and acute posterior placoid uveitis. It is both immediately sight threatening and associated with the risk of both systemic and ocular long-term complications that may result in severe loss of function. Ocular syphilis can occur at any stage of the disease and may also be the only presenting sign of syphilis. We report the case of a 59 year old male with a past medical history of diabetes mellitus, hypertension, human immunodeficiency virus (HIV) on highly active antiretroviral therapy (CD4 count 501) who presented to our hospital with a 3 week history of blurry vision, pain and redness in his left eye. Ophthalmoscopy revealed a diminished near visual acuity on the left at 20/400 vs 20/20 on the right eye and the dilated eye exam was consistent with disseminated chorioretinitis and panuveitis. Given his history of HIV and the ophthalmology test finding, we suspected an infectious process. Interestingly the infectious work up revealed a positive rapid plasma reagin (RPR) titer with 1:512 and a reactive fluorescent treponemal antibody absorption test. A lumbar puncture showed a pleocytosis with lymphocytic predominance, (WBC 191 with 97 % lymphocytes). A reactive venereal disease research laboratory (VDRL) test (1:16) in the cerebrospinal fluid (CSF) confirmed the diagnosis of ocular syphilis which is classified as neurosyphilis. Other viral studies including cytomegalovirus-, toxoplasmosis-, herpes simplex virus-, varicella zoster virus-, JC/BK virus- polymerase chain reaction in CSF were negative. The patient was immediately started on IV penicillin G 2.4 million units every 3 hours with improvement of the visual acuity (20/200 oculus sinister) and significant pain relief in the left eye within 72 hours of treatment. On hospital day 8, the patient was discharged to complete his 14 day course of IV penicillin. During his clinic follow up six weeks later, he reported only partial resolution of his blurry vision. Due to a twofold increase in his RPR titer to 1:1024 at that time, he underwent another 2 weeks course of IV Penicillin G after which his vision significantly improved and his chorioretinitis completely resolved.
Discussion: A lumbar puncture should be performed in all patients with syphilis and ocular complaints. A reactive VDRL is very specific for neurosyphilis. Patients with neurosyphilis should be treated with a 2 week course of IV Penicillin G followed by a 3 week course of IM Benzathine Penicillin in certain cases.A repeat CSF examination should be considered at 6 months post treatment to evaluate changes in the CSF-VDRL and cell count normalization which is a sensitive parameter for therapy effectiveness
Conclusions: The diagnosis of ocular syphilis should be suspected in patients with ocular complaints and high-risk sexual behavior and/or another sexually transmitted disease such as HIV. This case illustrates the importance for prompt recognition and treatment of this locally destructive ocular inflammation, but curable.
.png)