Case Presentation: 52-year-old female with a past medical history of cervical cancer, hypothyroidism, scleritis, episcleritis, glaucoma and Raynaud’s disease presented to the hospital for progressive onset blurry vision. The patient stated that roughly 2 months ago she had pneumonia and as it was starting to clear up she began to notice a “foggy” visual field. The patient was treated with azithromycin dextromethorphan, and methylprednisolone at that time and finished her course of antibiotics and steroids. However, her vision started becoming worse roughly 3 weeks prior to admission and at the time she also started noticing peripheral sparks in her visual field which acutely increased over the past week. Symptoms improved with her eyes closed. She also felt a pressure sensation behind her eyes bilaterally. The patient was admitted for further workup.In the hospital, the physical exam was relatively benign as there was no optic disc swelling appreciated on fundoscopic exam. Additionally, neurological exam was normal with cranial nerves II-XII intact. Initial lab workup was also benign except for the initial sed rate which was elevated at 46. CT head was performed and negative for any acute intracranial pathology so lumbar puncture was performed and found the patient had an elevated CSF protein of 61. A broad infectious workup was initiated but as the patient was clinically showing signs of improvement she was discharged. However, workup resulted after the discharge which found the patient had a positive RPR in a 1:128 ratio. The patient was informed of results and returned back to the hospital for penicillin treatment.
Discussion: Syphilis is a sexually transmitted disease caused by the gram-negative bacteria Treponema Pallidum. It has three stages of infection, but in all stages the organism can affect the eye, causing symptoms typically of eye pain, redness, floaters, and light sensitivity. Although there are multiple stages and subtypes of infection, all are treated with penicillin which is critical for resolution of infection. This case illustrates a rare presentation of syphilis in a patient that would not be considered high risk for the sexually transmitted disease. The importance of keeping a wide differential and a broad workup in patients with unclear initial presentations is illustrated by this case.
Conclusions: This case of ocular syphilis illustrates a rare subtype of an infectious disease and the critical necessity of a wide differential and broad workup. Without the discovery of her disease, patient was at risk of further vision changes, additional stages of infection, and transmission of disease to other sexual partners.