Bilateral ocular involvement in a patient with tertiary syphilis

Abstract

Purpose To report a case of a 46‐year‐old man with bilateral neuroretinitis due to tertiary syphilis. Methods The patient presented at the clinic with a history of blurred vision. He was agitated and was looking unwell. Snellen Visual acuity (VA) was 0.2 in the right eye and 0.1 in the left eye. Pupillary reflexes to light were sluggish but normally reactive to accommodation. Fundoscopy showed bilateral optic disc oedema and fluorescein angiography revealed active neuroretinitis. Visual fields (VF) were abnormal in both eyes. Laboratory blood tests, cardiological investigations and a brain MRI were performed. Mantoux test was negative and IV treatment with corticosteroids was initiated. Results Treatment with steroids was discontinued due to the appearance of a maculopapular rash on the head and neck. Laboratory results showed: RPR (Rapid Plasma Reagin)/FTA: positive, TPPA of serum and CSF (IgG, IgM): positive. Virological tests were negative. Based on these findings the diagnosis of neurosyphilis was made. Cardiological investigation was normal and brain MRI did not show any major abnormalities. Patient was started on IV crystalline penicillin, 3‐4 million units q 4h for two weeks. Three months after treatment VA was 0.6 in the right eye and 0.4 in the left. There was an improvement on the VF mainly in the right eye. Electro‐encephalogram showed no significant pathology. ISCEV standard full field and pattern electroretinography were affected bilaterally. Conclusion Bilateral neuroretinitis due to tertiary syphilis affects vision and complete visual recovery may not occur despite adequate treatment.