Case Presentation: A 38-year-old male with past medical history of HIV, congenital blindness of the left eye presented with a chief complaint of blurred vision in the right eye since past 6 months. He reported that blurring of vision fluctuates with dark spots in between. He had full work up done in his past hospitalization. Fundoscopy didn’t show anything significant, fluorescein angiography showed diffuse hyper fluorescence of optic nerve head with no leakage. CT head and MRI of the brain was unremarkable. He was given a diagnosis of vitrtis with vasculitis. He lost to follow up with insurance issues. He symptoms started getting worse. Basic laboratory workup done with his primary care provider(PCP) showed positive RPR titer of 1: 8192. The patient reported that his RPR was positive 3 years back which was done for the genital lesion. He received 3 injections of penicillin at that time. Other laboratories workup were negative for gonorrhea, chlamydia, treponemal antibody, hepatitis A and B. Cerebrospinal fluid analysis showed WBC: 111/ mm3 with lymphocytic predominance, VDRL in CSF fluid was positive with titer at 4. Other CSF pathogen panel was negative. He was treated with 2 weeks course of intravenous penicillin. His symptoms started improving and he was discharged with intravenous antibiotics. Follow up PCP note reported that he had the resolution of his visual symptoms.

Discussion: Ocular syphilis is a form of neurosyphilis which has been detected with increased frequency in the United States in the last 2 years. It presents with visual symptoms in a person with laboratory confirmed syphilis at any stage. It can mimic a variety of ocular conditions mostly uveitis, retinitis, keratitis and retinal vasculitis. It is treated as neurosyphilis and the symptoms begin to resolve in 7-14 days of treatment. Early diagnosis and prompt treatment is essential because a delay in treatment can lead to irreversible visual loss.

Conclusions: The diagnosis of ocular syphilis can be challenging because a patient usually present to the primary care provider where STDs are not highly on the differentials. Ocular symptoms in the setting of elevate RPR should be treated with a low threshold if fundoscopy or CSF examination is not available. Also, we should have increased vigilance for ocular disease in the patients with syphilis.