Case Presentation: Case Presentations: Five new cases of ocular syphilis were diagnosed and treated at Naval Medical Center Portsmouth between December 2020 and August 2021. Although this manifestation is rare, there has been an increase in rate of occurrence of newly diagnosed syphilis cases every year since 2000, to include preliminary data from the CDC estimating over 46,000 new cases in 2021. All five of the cases in this series occurred in men, with a median age of 47 (range = 27-73). The time to diagnosis from onset of symptoms ranged from 8 days to 7 months, averaging approximately 3 months. Ocular manifestations for these patients included panuveitis, uveitis, neuroretinitis, bilateral chorioretinitis, choroiditis, iridocyclitis, and unilateral central vision loss; two of the patients had more than one ophthalmologic diagnosis. Among these patients, 3 were men who have sex with men and 2 were heterosexual. Two of the patients were HIV positive, one of which was diagnosed from additional screening completed at the time of diagnosis of ocular syphilis. All five of the patients had a lumbar puncture at time of diagnosis of syphilis, resulting in two positive CSF venereal disease research laboratory (VDRL) testing and were additionally treated for Neurosyphilis. Four of the patients had near total to total resolution of ocular symptoms with completion of 12-14 day course of Penicillin G. One patient received prolonged systemic and topical steroids in addition to a single dose of intraocular steroid injection prior to syphilis diagnosis. This patient ultimately had very limited improvement of ocular symptoms despite eventual syphilis diagnosis and completion of appropriate antibiotic therapy.
Discussion: Syphilis is caused by the spirochete, Treponema pallidum. In 2020, over 138,000 cases were reported in the US equating to a case report of 40.8 per 100,000 people. Ocular syphilis is a rare manifestation with estimated incidence of 0.6-2% of all cases. Ocular syphilis is defined as clinical presentation of ocular disease in a person with laboratory-confirmed syphilis infection of any stage. Ocular syphilis is known as ‘The Great Imitator,’ as it can present as nearly any form of ocular disease, though the most common ocular manifestations are posterior uveitis and panuveitis. We presented a case series of five patients diagnosed with ocular syphilis at an MTF. Each patient had different presenting symptoms as well as different ocular manifestations.
Conclusions: The majority of newly reported syphilis cases are in men who have sex with men and also frequently in patients co-infected with HIV. Untreated syphilis infections can spread anywhere in the body, to include any ocular structure. Highly variable clinical presentation often leads to delayed diagnosis allowing the potential for poor, often preventable outcomes due to inappropriate treatment. This highlights the need for providers to have a high level of clinical suspicion and awareness of ocular manifestations of syphilis, especially in high risk populations.