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The US Centers for Disease Control and Prevention (CDC) issued a clinical advisory late last year on ocular syphilis. Between December 2014 and March 2015, 12 cases of ocular syphilis were reported from two US cities, San Francisco and Seattle.1 Subsequent case finding identified more than 200 cases reported over the last 2 years from 20 states. Whether this is the result of one or more oculotropic strains (neuroinvasive strains have been described)2 or enhanced case detection due to, for example, the increasing use of the reverse sequence algorithm for syphilis screening, is unclear. In Maryland, to date, following the release of the advisory, 13 cases have been identified through careful record reviews with 9 (70%) of the 13 presenting as late ocular syphilis (personal communication Elisabeth Liebow and Alexandra Goode, Maryland Department of Health and Mental Hygiene). If this increasing case detection is the result of a circulating strain, the strain has been circulating for a while. Irrespective of the cause of this observed increase in the number of cases of ocular syphilis, there are several important yet unanswered clinical questions: what is the relationship between ocular and neurosyphilis? How does HIV impact ocular syphilis and this relationship? Is a lumbar puncture (LP) necessary for the evaluation of patients suspected of having ocular syphilis? What is the best treatment of ocular syphilis? Other issues to clarify include the relationship of ocular syphilis presentation to stage of syphilis infection, the risk of ocular syphilis in serofast patients, and whether ocular syphilis in patients with a previous record of treatment represents recrudescence or reinfection. Several studies have tried to address one or more of these questions. All of these studies suffered from a small sample size that limited their power to draw meaningful conclusions.
In this issue, Tsuboi et al …