Case Presentation: 56-year-old male with no significant medical history presented to our hospital with progressive monocular vision loss, initially referred by ophthalmology for new diagnosis of uveitis. He initially noticed blurring of vision in his right eye about one month prior to presentation. His ophthalmologist started him on a combination of atropine and Difluprednate eye drops. However, his vision progressively deteriorated until he was only able to see shadows. He was then started on Bactrim and valacyclovir four days before presentation, noting “some improvement in his vision.” On presentation, patient saw ophthalmologist again who then diagnosed him with uveitis and recommend further evaluation at the hospital. Initial vitals 37°C, 154/87, HR 71, RR 18 saturating 98% on room air. Labs were significant for WBC 11.6 and unremarkable CMP. Notable exam findings included extraocular muscles intact, visual fields full to confrontation, 20/250 OD, 20/30 OS. He denied headache, photophobia, ocular pain, nuchal rigidity. Denied fever, chills, nausea, recent sick contacts or travel. Review of all other systems was unremarkable. Of note, he reported current sexual activity with 2 different female partners in the past year with inconsistent safe sex practices. He was unaware of STD/STI history for either partner. Patient denied ever having been treated for STD/STI himself. Patient denied any illicit drug use or IVDU ever. Initial workup included serum testing negative for toxoplasmosis, HIV, HBV and HCV. LP was unimpressive with 2 WBCs, normal glucose and protein. HSV and VZV PCR negative. Aerobic culture negative. However, initial screening with positive RPR and titer of 1,024, with subsequent positive confirmatory Fluorescent treponemal test. Uveitis and positive treponemal testing led to a diagnosis of ocular syphillis involving the right eye. Infectious disease were also consulted while inpatient. The patient was started on intravenous penicillin for 10 days. Upon discharge, ophthalmology recommended atropine and prednisolone eye drops to right eye with follow up in 1 week.
Discussion: Despite syphilis being a nationally notifiable disease that’s been on the rise since 2000, ocular manifestations are not reportable to the CDC. In 2015, the Eighth Jurisdiction surveillance report identified 388 suspected ocular syphilis cases over the preceding year. The predominance of cases were male (93%), proportions of which 51% were homosexual men and/or were HIV-positive, which was consistent with the epidemiology of syphilis in United States. This prompted the CDC to issue a clinical advisory for increased vigilance and early recognition of ocular syphilis in order to prevent significant visual symptoms and sequelae.
Conclusions: Ocular syphilis is a rare subtype of neurosyphilis that can be associated with uveitis, optic neuropathy and other vision-threatening conditions. A high degree of clinical suspicion, diagnosis and early treatment can prevent permanent complications from this disease.