Don’t Forget What You Can’t See: A Case of Ocular Syphilis

Abstract

This case describes an emergency department (ED) presentation of ocular syphilis in a human immunodeficiency virus (HIV) infected patient. This is an unusual presentation of syphilis and one that emergency physicians should be aware of. The prevalence of syphilis has reached epidemic proportions since 2001 with occurrences primarily among men who have sex with men (MSM). This is a case of a 24-year-old male who presented to our ED with bilateral painless vision loss. The patient’s history and ED workup were notable for MSM, positive rapid plasmin reagin (RPR) and HIV tests and fundus exam consistent with ocular syphilis, specifically uveitis. Ocular manifestations of syphilis can present at any stage of syphilis. The 2010 Centers for Disease Control and Prevention guidelines now recommend that ocular syphilis be treated as neurosyphilis regardless of the lumbar puncture results. There is a paucity of emergency medicine literature on ocular syphilis. For emergency physicians it is important to be aware of iritis, uveitis, or chorioretinitis as ocular manifestations of neurosyphilis especially in this high-risk population and to obtain RPR and HIV tests in the ED to facilitate early diagnosis, and treatment and to prevent irreversible vision loss.

Clinical Characteristics of a Case Series of Ocular Syphilis With 3 Cases Requiring Multiple Vitrectomies After Late Diagnosis

“…10 Ocular syphilis cases have presented with nonspecific initial symptoms such as tongue chancre, painless vision loss, jaundice, and ocular involvement as varied as anterior uveitis to acute retinal necrosis. [11][12][13][14] Ocular syphilis is highly associated with neurosyphilis and HIV-positive status, although it can occur with isolated syphilis infection as well. 15,16 A presumptive diagnosis is often achieved with nontreponemal tests such as the Venereal Disease Research Laboratory test (VDRL) or rapid plasma reagin (RPR) or treponemal tests such as the Fluorescent Treponemal Antibody Absorption or T pallidum immunoglobulin G. 17 Confirmation of ocular syphilis can be achieved with aqueous fluid polymerase chain reaction testing for T pallidum DNA or dark-field microscopic visualization of the spirochetes.…”