Detection of Treponema pallidum in tears during early neurosyphilis

Abstract

EditorWe report an exceptional case of Treponema Pallidum (TP) highlighted in tears during a secondary syphilis with syphilitic uveitis. A 45-year-old man, with no history of sexually transmitted infection came to our clinic for a screening. He reported orogenital unprotected sex with unknown men during travels in Africa 2 months prior. During the examination, we noticed a red, painful right eye with significant tearing and blurred vision lasting 10 days. Diagnosis of secondary syphilis was suspected on the association with an evocative papulosquamous eruption of the extremities. No chancre was found.Venereal Disease Research Laboratory test (VDRL), TP haemagglutination test (TPHA) and TP Chemiluminescence Immunoassay were positive in the blood, confirming the diagnosis. An HIV antibody test showed a false positive result (with repeated negative Western Blot tests and undetectable viral load), hepatitis B serology showed immunization due to vaccination, and hepatitis C serology was negative. Chlamydia Trachomatis and Neisseria Gonorrhoea nucleic acid amplification tests were negative in pharyngeal, anal and first void urine samples. A direct TP immunochemistry test was strongly positive in a sample of tears collected on the cheek. Ophthalmological examination confirmed a syphilitic panuveitis. Lumbar puncture was not performed. The patient was treated with a 6 day Penicillin G 20 MUI regimen followed by Ceftriaxone 2 g daily for 10 days and oral prednisolone. One month later, we noticed ocular improvement and disappearance of skin lesions. Six months later, ocular healing was complete and there was a fourfold VDRL decrease. Two years later, VDRL and TPHA remained stable in the lowest titre range.Uveitis can occur during secondary syphilis and should be individualized as early neurosyphilis. It reflects the TP multisystem involvement due to bacteraemia.Polymerase chain reaction can be performed to demonstrate TP by aqueous humor aspiration or paracentesis. 1 We did not find other cases in the literature of TP direct demonstration in tears outside invasive methods. TP is a fragile organism and its survival in an external environment depends on its concentration. 2 However, before the era of penicillin, the TP indirect nonvenereal transmission was considered to be frequent, especially in childhood. 3,4 Cases of face, neck, sternum or thigh chancres have been described. Indirect transmission by glasses, spoons, toys or nipples have been highlighted. Few cases of professional contaminations via scalpels, needle injuries, Nichols stain concentrate aerosol or by medical care without gloves have also been documented. 5Our patient's case, with a large amount of TP demonstrated on his cheeks, raises the question of a possible non-venereal transmission from tears. This hypothesis is unlikely but not impossible and should be considered in syphilitic uveitis cases.

Beyond the headlines – JEADV editor's pick of the year 2017

“…Surprisingly, a histamine‐poor diet was effective in patients with chronic spontaneous urticaria in reducing both wheals and itch . In the field of venereology, an interesting observation described the presence of Treponema pallidum in tears from patients with early neurosyphilis …”