Case Presentation: An uninsured, homeless 26-year-old male with no past medical history presented with two weeks of progressive left eye vision loss described as a central enlarging black spot progressing to complete vison loss. Three months prior, he describes a painless, penile bump and a skin rash which started on his hands and feet. He endorses unprotected sexual intercourse with men and women. Physical exam was notable for left eye conjunctival injection with green discharge, decreased visual acuity and pupillary response. He had a diffuse truncal desquamating rash with macular lesions on his palms and soles. A penile chancre was present. Slit lamp examination showed panuveitis and posterior uveitis.Labs revealed positive HIV-1 antibodies with a CD4 count of 46 cell/µL, reactive rapid plasma reagin with a titer 1:32, positive gonorrhea, chlamydia PCR, and a cytomegalovirus (CMV) PCR with 2,920 copies/mL. Lumbar puncture was negative for Venereal Disease Research Laboratory Test. Tests for viral hepatitis, herpes simplex virus (HSV), tuberculosis, varicella zoster virus (VZV) and toxoplasmosis were negative. Vitreous aspiration was negative for CMV, VZV and HSV.Treatment for ocular syphilis with IV penicillin G infusion was initiated. Antiretroviral therapy was initiated. Empiric IV ganciclovir was initiated with valganciclovir induction then maintenance dosing at discharge. Intravitreal ganciclovir was given at the time of aspiration. At discharge, the patient was enrolled in an HIV program with medication, insurance and housing assistance. Despite multidisciplinary discharge planning and outpatient outreach, the patient was lost to follow up.

Discussion: With the increase in the incidence of syphilis in the United States over the past decade, it is important to recognize that rates of syphilis coinfection in HIV positive patients have been reported to be 86 times higher than syphilis rates in patients without HIV. Coinfection with HIV and syphilis doubles the risk of ocular syphilis compared with patients without HIV. Studies suggest poor visual prognosis is associated with viral loads greater than 200 copies/mL, CD4 counts less than 200 cells/mL, greater than 28 days since onset of ocular symptoms and greater than 12 weeks between uveitis symptoms and treatment. The presence of optic neuritis and optic atrophy are more commonly associated with permanent vision loss. As seen with this patient, HIV with syphilis coinfection may present with concurrent stages of the disease. Patients with ocular syphilis should be screened for HIV, hepatitis, and other sexually transmitted diseases. Fungal, bacterial, and viral etiologies of vision loss such as CMV, VZV, and HSV should also be considered. The impact of age, low CD4 count, lack of social support, transportation, insurance and unstable housing impact outcomes in HIV positive patients. Though resources are available for HIV positive patients, the barriers to optimal care are still high and clinicians should utilize evaluated interventions emphasizing frequent communication to optimize care retention.

Conclusions: HIV with syphilis coinfection should be on the differential for patients presenting with vision changes and rash. Since ocular syphilis occurs at any stage of syphilis, prompt diagnosis and treatment are necessary to prevent permanent vision loss and other sequelae of neurosyphilis.

IMAGE 1: Desquamating rash