Case Presentation: A 51-year-old male presented to the Emergency Department (ED) after referral by ophthalmology for blurry vision. Three months prior to presentation, he was admitted after seeing ophthalmology for bilateral blurry vision and right eye scotoma. During that hospitalization, with a past medical history of atrial fibrillation without anticoagulation, his symptoms were attributed to a central retinal artery occlusion due to transient ischemic attack, and he was initiated on apixaban. A week before his present ED encounter, he noticed worsening blurry vision, despite anticoagulation, which he reported to his ophthalmologist. With suspicion of neurosyphilis, the ophthalmologist obtained syphilis serology – fluorescent treponemal antibody (FTA) antibody reactive, rapid plasma reagin (RPR) titer 1:256 and was referred to the ED with complaints of worsening blurry vision and floaters. He reported one sexual partner with the last sexual encounter 6 months prior. He denied any prior genital lesions, but related that five months prior he had a diffuse erythematous macular rash that began on the trunk and spread to bilateral thighs, neck, and top of the head. Although a trial of steroids did not provide relief, he was reassured, and the rash resolved. Physical examination now showed bilateral visual field defects and normal eye movements. Ophthalmology was consulted, and examination showed cystoid macular edema bilaterally. He received intravenous penicillin G inpatient and completed a 10-day course outpatient.
Discussion: This case highlights the importance of early recognition and treatment of syphilis to prevent rare manifestations and disease progression. Syphilis typically occurs in four sequential stages – primary, secondary, early/late latent, and tertiary. Per history, this patient likely had an unrecognized and untreated secondary stage (diffuse macular rash) two months before his initial ocular symptoms. Although ocular syphilis can occur at any stage, the lack of a primary stage in his disease course is atypical and made recognizing disease progression difficult, delaying diagnosis. This case also shows how a highly treatable ocular syphilis may be overlooked for other common diagnoses such as stroke. There has been an increase in syphilis since the late 1990s after being on the brink of eradication earlier in the decade due to the increased national coverage of the HIV epidemic promoting safe sex practices. A recent retrospective review showed an over 50% increase of inpatient syphilitic uveitis cases from 2010-2019. The study also revealed the average incidence of syphilitic uveitis was 4 times greater in men than women. Although all racial groups increased in incidence during the study period, black men showed the highest incidence rate. Hospitalists should have a high index of suspicion and a low threshold for testing when evaluating patients with new complaints of vision change.
Conclusions: With syphilis on the rise since the start of the century, both outpatient and inpatient clinicians should maintain a high index of suspicion for syphilis and its complications. Early recognition and treatment of syphilis is critical to prevent rare manifestations and disease progression. While outpatient physicians play a crucial role in preventing late syphilis manifestation by recognizing and treating earlier phases of infection, hospitalists should remain vigilant to consider syphilis as a potential cause of unusual, unexplained neurologic or visual complaints expressed by inpatients.