Bilateral Syphilitic Optic Neuropathy with Secondary Autoimmune Optic Neuropathy and Poor Visual Outcome

Abstract

We describe the case of a 65-year-old man who suffered progressive visual loss despite appropriate treatment of ocular syphilis. Our patient initially presented with a unilateral 6th nerve palsy and associated double vision, which self-resolved over 6 months. His ophthalmic examination was otherwise normal. 12 months after the initial complaint, he represented with dyschromatopsia, reduced visual acuity, tonic pupils, and optic nerve atrophy. He tested positive for syphilis and was admitted for treatment of neurosyphilis with high-dose benzylpenicillin. Despite treatment, at a 4-month review his visual acuity remained poor and progression of optic nerve atrophy was noted alongside the development of bilateral central scotomas. Further testing was congruent with a diagnosis of autoimmune optic retinopathy. We propose this to be secondary to his syphilitic infection. Syphilis is known as the “great mimicker,” and despite being quite treatable, this case highlights ongoing complexity in the diagnosis and management of syphilis, unfortunately with a poor visual outcome.

Dyschromatopsia and contrast sensitivity changes in COVID-19 patients

“…[ 24 ] In comparison, our patients had milder disease and normal visual status. The other infectious diseases that lead to dyschromatopsia are syphilis and Bartonella henselae neuro-retinitis[ 25 26 ]; however, these are likely to be a result of neural mechanisms associated with optic neuritis and show profound drop in vision and afferent pupillary defect. Dyschromatopsia is also reported in a case of Progressive multifocal leukoencephalopathy associated with acquired immunodeficiency syndrome.…”

Neurosyphilis presenting as visually asymptomatic bilateral optic perineuritis

“…Syphilis must be considered as a differential diagnosis in all cases of optic nerve swelling,20 especially as early treatment with penicillin remains effective with high cure rates 4 21. However, poor visual outcome in spite of prompt treatment has been reported 22…”