The great imitator on the rise: ocular and optic nerve manifestations in patients with newly diagnosed syphilis

Abstract

Purpose Ocular manifestations of syphilis have been reported in 2–10% of systemic infection. The purpose of this study was to report the incidence of ocular syphilis and various ocular manifestations, particularly optic nerve involvement, in newly diagnosed cases. Methods This was a retrospective study. Medical records of newly diagnosed syphilis patients between January 2009 and January 2017 in a tertiary medical centre were reviewed. Results There were 123 new systemic syphilis cases out of 569,222 (0.02%) admissions to the Tel Aviv Medical Center during the study period. Ninety‐three of the 123 patients (76%) underwent ophthalmological examination. Twenty‐three of the 93 patients (25%, mean age 48.6 ± 12.9 years, 20 males) had ocular syphilis, and in 12/23 (52%) patients, the ocular symptoms and findings prompted syphilis investigation. Eighteen of the 23 (78%) had optic nerve involvement, and the most common was inflammatory disc oedema. Older age (p = 0.0005) and tertiary stage disease (p = 0.0441) were associated with ocular manifestations and the presence of optic nerve findings. Human immunodeficiency virus (HIV) was associated with ocular but not optic nerve findings. Treatment included intravenous penicillin G, and four patients with severe optic neuropathy were also treated with systemic corticosteroids. Visual acuity significantly improved in most patients (p < 0.05). Conclusion Ocular syphilis was found in one‐quarter of the patients diagnosed with systemic syphilis and preceded the diagnosis of systemic disease in one‐half of them. Optic nerve involvement was a common manifestation. A high index of suspicion for Treponema infection is required in patients presenting with optic nerve involvement to facilitate prompt diagnosis and treatment. Post‐treatment visual outcome was good.

Secondary syphilis presenting with acute unilateral vision loss and a widespread maculopapular rash

“…Visual symptoms may be the presenting feature of multisystem disease caused by syphilis. It has been reported that ocular symptoms develop after a median time of 11 months from the time of syphilis infection onset8 and that ocular syphilis may precede a diagnosis of systemic syphilis in half of syphilis patients 9. For patients presenting with ocular syphilis, the most common concurrent complaints are a skin rash and headache 3.…”

Neurosyphilis presenting as visually asymptomatic bilateral optic perineuritis

“…Due to the frequency of eye involvement and optic nerve involvement in syphilis, health practitioners should have a low threshold to refer patients to an ophthalmologist for a comprehensive dilated examination with any eye symptoms reported by affected patients. 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…”

Syfilis med synstap

“…Det vanligste er en form for uveitt. Betennelse i synsnerven, slik vår pasient hadde, forekommer også hyppig (5). Vår pasient hadde alvorlig synstap på ett øye og ble først feildiagnostisert med iskemisk optikusnevropati.…”