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Abstract
Ocular manifestations of syphilis are uncommon. Five cases of ocular syphilis are presented, in four of which there was a delay in diagnosis. Four of the patients were men who have sex with men (MSM), and four patients were HIV negative.
- Syphilis
- T pallidum
- ophthalmic
- ocular
- MSM, gay men
- oculo-genital infec
- syphilis
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Introduction
A large outbreak of syphilis was first described in Dublin in 2001.1 The incidence of infection decreased until 2007, when a further increase was reported.2 Ocular manifestations of syphilis are uncommon.3 We present five cases diagnosed as ocular syphilis, in four of which there was a delay in diagnosis. These patients presented over an 8-month period, during which 118 diagnoses of early infectious syphilis were made in our centre. Four of the patients were men who have sex with men (MSM). Four patients were HIV negative.
Ocular syphilis has a broad spectrum of presentation. Posterior uveitis, retinal vascular involvement, placoid maculopathy, retinal detachment, involvement of the cornea, episcleritis and scleritis, and interstitial keratitis presenting as open-angle glaucoma have all been described.4 5 Delay in the diagnosis of ocular syphilis can lead to irreversible visual loss due to optic nerve and retinal atrophy.6
Case reports
All five patients presented with decreased visual acuity. All were men, mean age 44.2 years (range 40–50), and four identified MSM as a risk for syphilis infection. Patient characteristics are outlined in table 1. All of the patients described systemic symptoms before the onset of visual symptoms (table 1). One patient was known HIV positive: CD4 398 cells/mm,3 virally suppressed on antiretroviral therapy. Three of five patients underwent lumbar puncture; all had cerebrospinal fluid pleocytosis. All patients received parenteral penicillin (either procaine penicillin and probenecid or benzylpenicillin for 14 days).
Characteristics of patients presenting with ocular syphilis
All of the HIV-negative patients had a delay in the diagnosis of their syphilis. The time from onset of ocular symptoms to diagnosis ranged from 6 weeks to 4 months. The HIV-positive patient had no delay in diagnosis. Three HIV-negative patients attended for repeat HIV testing; all remained seronegative.
Discussion
Ocular manifestations of sexually acquired syphilis can occur at any stage of the disease. The presentation of ocular involvement is variable; however, the most common presentation of syphilis in the eye is uveitis. This can occur as early as 6 weeks after primary infection. When uveitis occurs in secondary syphilis, it often follows the resolution of other signs and symptoms. The most common manifestations in patients with uveitis who presented to a New York clinic over a 5-year period were granulomatous iridiocyclitis, non-granulomatous iridiocyclitis, panuveitis, posterior uveitis and keratouveitis.7 Anterior segment inflammation may be associated with a vitritis. Posterior uveitis is most commonly manifested as chorioretinitis. As the clinical manifestations of syphilitic uveitis are non-specific, the work-up for patients presenting with unexplained uveitis should include testing for syphilis.
Sexual history may give a clue to the possible aetiology of a patient's uveitis: four of our patients were MSM and all reported episodes of unprotected sexual intercourse in the months preceding the onset of symptoms. These details were not elicited at initial presentation. Ocular involvement may be more severe in patients with HIV coinfection and is related to immune status.8 Syphilis is now more common than cytomegalovirus as a cause of uveitis among patients receiving anti-retroviral therapy.9
As ocular syphilis is a manifestation of neurosyphilis, it should be treated with parenteral penicillin daily for a period of 10–17 days. Patients with reported penicillin sensitivity should be desensitised and treated with penicillin. The Jarisch–Herxheimer (JH) reaction, a systemic reaction following antibiotic therapy, can occur in the treatment of any stage of syphilis, but is most common in secondary syphilis. It occurs 1–2 h after administration of treatment. There are case reports of significant deterioration in symptoms or serious adverse events secondary to the JH reaction following treatment.10 Steroid therapy before antibiotic therapy is recommended in patients with ophthalmic syphilis.
Ocular syphilis can be difficult to diagnose, and, if left untreated, can lead to irreversible visual loss. If not considered during the evaluation of patients presenting with ocular symptoms of unclear aetiology, the diagnosis may be missed. Four of our patients had a delay in the diagnosis of ocular syphilis after presenting with ophthalmic symptoms; all were HIV negative. Careful history taking regarding risk factors, history of possible chancrous lesions or systemic illness and or rash before the onset of visual symptoms may offer vital clues in making the diagnosis of this treatable disease.
Key messages
Syphilis should be considered as an important treatable cause of uveitis. Untreated, it could lead to irreversible vision loss.
Careful history taking may give clues to the diagnosis; systemic symptoms are common before the onset of ocular syphilis.
HIV-negative patients also present with ocular syphilis.
Sexual health history should be incorporated into the evaluation of all patients.
Footnotes
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.