Unusual central chorioretinitis as the first manifestation of early secondary syphilis

Ocular vs neurosyphilis. are they the same? A guide to investigation and management

This article reviews key concepts in the epidemiology, clinical features, diagnosis and management of ocular syphilis. It is not a systematic review or meta-analysis, but highlights the critical clinical features and investigations in patients with ocular syphilis. It reviews the overlap and interplay between ocular and neuro syphilis and provides practical guidance to diagnose and manage patients with ocular syphilis.

The Great Imitator Masquerading as Autoimmune Hepatitis and Demystifying as Fulminant Syphilitic Retinitis

PURPOSE

Syphilis is a "Great Masquerader" because of its versatile clinical manifestations. We aim to report a patient whose first presentation was with presumed autoimmune hepatitis. Fulminant retinitis subsequently ensued, thus enabling correct diagnosis and treatment.

METHODS

Case description.

RESULTS

A 62-year-old male presented with bilateral drop in vision. One month earlier, right eye (RE) arteritic ischemic optic neuropathy was suspected because of severe headache, sudden drop in vision, relative afferent pupillary defect, and elevated inflammatory markers. Systemic steroids were instituted. Brain imaging and temporal artery biopsy were unyielding. Four months earlier, liver biopsy performed because of elevated cholestatic liver enzymes, revealed granulomatous hepatitis. After ruling out viral hepatitis, autoimmune etiology was presumed, and prednisone was started. On presentation, visual acuity (VA) was counting fingers in RE and 6/20 in the left eye (LE). Bilateral panuveitis with punctate inner retinitis, placoid chorioretinitis was diagnosed. Serological tests were strongly positive for syphilis. Lumbar puncture confirmed the existence of neurosyphilis. Systemic penicillin was initiated. One month later, VA improved to RE 6/10, LE 6/7.5, with marked resolution of posterior uveitis. No recurrence was observed over 27-month-period.

CONCLUSION

Acquired syphilitic hepatitis is rarely reported. Administering steroids potentially aggravated the infection. The characteristic features of placoid chorioretinitis and punctate inner retinitis connected the pieces of the puzzle together to the diagnosis of ocular and neurosyphilis. Intrahepatic cholestasis with negative serological panel of hepatotropic pathogens should raise the suspicion of non-hepatotropic pathogens especially syphilis.

Value and Significance of Hypofluorescent Lesions Seen on Late-Phase Indocyanine Green Angiography

Background and Purpose

The hypofluorescence of fundus lesions observed during the late phase of indocyanine green angiography (ICGA) in various diseases has often been overlooked or misinterpreted. This article explores the significance of fundus lesions that are initially isofluorescent during the early phase of ICGA but become hypofluorescent later in the examination.

Findings

Pathologies such as multiple evanescent white spot syndrome, acute posterior placoid syphilitic chorioretinitis, chronic central serous chorioretinopathy, choroidal hemangioma, and some fundus with drusen, present this phenomenon of late hypofluorescence.

Interpretation

The interpretation of ICGA images and the role of indocyanine green (ICG) uptake by the retinal pigment epithelium (RPE) in late fundus fluorescence is debated. Experimental evidence suggests that ICG accumulates progressively in the RPE after intravenous injection of the dye or after direct contact in vitro, making it a potential marker of RPE activity. Although the exact mechanisms of ICG diffusion through the choroid and its binding to the RPE require further investigation, the late hypofluorescence observed in certain ICGA diseases provides information on different modalities of RPE dysfunction.

Financial Disclosures

The author has no proprietary or commercial interest in any materials discussed in this article.

Presentation of Ocular Syphilis with Bilateral Optic Neuropathy

A 60-year-old otherwise healthy male presented with a 1 year history of bilateral progressive visual loss. His best-corrected visual acuity was counting fingers at 2 m with his right eye and counting fingers at 0.5 m with his left eye. Visual field testing revealed bilateral near-total loss of visual fields. Slit-lamp examination was unremarkable, apart from bilateral grade two nuclear sclerotic cataracts. Both optic discs were pale-looking with some retinal pigment epithelial alterations at the left papillomacular region. Enhanced depth imaging optical coherence tomography depicted punctate hyperreflective dots at the inner choroidal level corresponding to the retinal pigment epithelial changes in the left eye. Fundus autofluorescence imaging revealed patchy hyper-autofluorescent and hypo-autofluorescent areas, and there was mild staining in the early and late phases of the fluorescein angiogram at the papillomacular region in the left eye. A diagnosis of bilateral optic neuropathy was made. A full systemic work-up was carried out, and serological tests pointed out the presence of syphilis with normal cranial magnetic resonance imaging. He was treated accordingly. Our case clearly demonstrates the importance of a high clinical suspicion for syphilis in cases of optic neuropathy.

Use of optical coherence tomography angiography in the uveitis clinic

As optical coherence tomography angiography is revolutionizing the ophthalmology world, the uveitis community is learning to understand where and how this new powerful imaging tool fits into the management of the panorama of ocular inflammations and infections. A non-invasive method of studying the retinal and choroidal vasculature, OCTA allows for the assessment of vessel density changes during active and inactive uveitis making it the natural imaging application of choice in uveitis clinical trials. However, these data and results are of limited utility to the ophthalmologists who are looking to apply OCTA in their everyday uveitis clinic. If employed strategically, OCTA can be a powerful tool for the uveitis specialist to evaluate iris involvement in viral uveitis; to assess the integrity of the vascular layers in the settings of white dot syndromes; to distinguish inflammatory choroidal neovascularization from outer retinal avascular inflammatory material; and to diagnose and follow infectious choroidal granulomas and satellite foci of chorioretinal inflammation without the need to administer dyes. The present review will analyze all the recent publications that apply OCTA in uveitis to offer the reader a guide on how to maximize the utility of this imaging modality in a clinical practice.

Spectrum of Syphilitic Chorioretinitis and Its Evolution Based on Multimodal Imaging

PURPOSE

To describe the different phenotypes of syphilitic chorioretinitis (SCR) and its clinical features in multimodal imaging (MI).

METHODS

Complete ophthalmological examination and MI including spectral domain optic coherence tomography (SD-OCT), fundus autofluorescence (FAF) and fluorescein angiography (FA) were performed at diagnosis and during follow-up in patients diagnosed with SCR.

RESULTS

17 eyes of 10 patients were included. Clinical phenotypes included acute syphilitic posterior placoid chorioretinopathy (ASPPC), syphilitic outer retinitis (SOR) and punctate inner retinitis (PIR). Disruption of outer retinal layers were visible in all patients in SD-OCT. Inner retinal layers were only affected in PIR. FAF revealed macular hyperautofluorescence in all patients. FA showed maintained hyperfluorescence in ASPPC and SOR.

CONCLUSIONS

ASPPC, SOR and PIR are different phenotypes of syphilitic chorioretinitis and present common features in SD-OCT and FAF. MI provides useful information to help the clinician during diagnosis and follow-up of these entities.

Reversible Choriocapillaris Flow Voids in Acute Syphilitic Posterior Placoid Chorioretinitis

PURPOSE

To report two cases of acute syphilitic posterior placoid chorioretinitis (ASPPC) with choriocapillaris flow voids that partially resolved with systemic antibiotic treatment.

METHODS

Observational case report with multimodal imaging.

RESULTS

Two young healthy men suffered an acute monocular loss of vision. Spectral domain optical coherence tomography (SD-OCT) and OCT angiography (OCT-A) revealed outer retinitis with loss of the ellipsoid layer and choriocapillaris flow voids. Systemic work-up revealed syphilis. Upon systemic treatment with antibiotics, the patients recovered their vision and the OCT and OCT-A abnormalities partially resolved.

CONCLUSIONS

Transient choriocapillaris flow voids characterize ASPPC and may be responsible for the visual loss seen in these patients.

Optical Coherence Tomography Findings in Infectious Posterior Uveitis

PURPOSE

To describe and illustrate the main optical coherence tomography (OCT) findings of infectious uveitis.

METHODS

Narrative review.

RESULTS

Posterior segment OCT in patients with infectious uveitis reveals posterior hyaloid face precipitates, superficial retinal precipitates and infiltrates, foveolitis, retinitis, neuro-retinitis, choroidal granulomas, and choroiditis as main imaging biomarkers. Some of these features are specific to the underlying causing etiology and may support the diagnosis and the initiation of treatment. Some OCT features disappear completely with resolution; some others are associated with irreversible retinal damage.

CONCLUSIONS

OCT identifies different features of infectious uveitis into the vitreous, the retina, and the choroid. OCT characteristics, combined with other multimodal imaging features, are helpful in the differential diagnosis of infectious uveitis, the early detection of complications, and the assessment of the response to therapy.

Acute syphilitic posterior placoid chorioretinitis: when the great mimicker cannot pretend any more; new insight of an old acquaintance

Purpose

To review the multimodal imaging patterns of Acute Syphilitic Posterior Placoid Chorioretinitis (ASPPC).

Methods

A systematic review.

Results

Syphilis has started to attract the attention of researchers once again due to recent surges, with The World Health Organization (WHO) reporting around 12 million new cases per year. When left untreated, syphilis has a mortality rate of 8–58%, with a higher death rate in males. Eye manifestations occur both in secondary and tertiary stages of syphilis, although ocular involvement may occur at any stage of the disease.

Syphilis has been always recognized as “the great mimicker” since it can have multiple clinical patterns of presentation.

However, Acute Syphilitic Posterior Placoid Chorioretinitis (ASPPC) represents the typical pattern of the disease and can be easily distinguished.

In addition, the advent of modern technologies and the progress made in multimodal imaging have provided more details on its identikit: the pattern of pre-retinal, retinal, retinochoroidal and optic nerve involvement can be identified before going through the laboratory work-up for a correct and appropriate investigation of the disease.

Conclusion

This review highlights the peculiar pattern of ASPPC, by reporting the diagnostic process made by all the imaging techniques used for a correct multimodal imaging assessment.

ACUTE SYPHILITIC POSTERIOR PLACOID CHORIORETINITIS: MULTIMODAL IMAGING AND ELECTROPHYSIOLOGIC FINDINGS BEFORE AND AFTER TREATMENT

PURPOSE

To describe the clinical course of acute syphilitic posterior placoid chorioretinitis (ASPPC) in the preplacoid stage, placoid stage, and after treatment with penicillin.

METHOD

A retrospective case report of serial multimodal imaging and electrophysiology studies of a patient with ASPPC, with 18 months of follow-up.

RESULTS

A 47-year-old man presented with bilateral panuveitis. The patient defaulted follow-up and returned when his vision deteriorated. Tests for neurosyphilis and retroviral disease were positive, and treatment was initiated. The earliest change on serial optical coherence tomography was loss of the signal from the reflective band corresponding to the ellipsoid zone. In the placoid stage, there was nodular thickening of the retinal pigment epithelium. The ellipsoid zone signals reappeared after treatment. Fundus fluorescein angiogram at presentation showed peripapillary vasculitis and disk leakage; indocyanine green angiography revealed multiple hypofluorescent spots in the peripapillary region and posterior pole that was not visible clinically. The angiographic abnormalities resolved after treatment. Electrophysiology demonstrated bilateral maculopathy and reduction of both a- and b-waves from dark-adapted and light-adapted responses at presentation. The b-waves (inner retina) recovered partially with treatment.

CONCLUSION

To the best of our knowledge, this is the first case report of the multimodal imaging and electrophysiology findings in a patient with acute syphilitic posterior placoid chorioretinitis, before the development of the classic placoid lesion. Improvement of structural and functional pathology after systemic treatment is demonstrated.

Neurosyphilis Presenting as an Atypical Case of Posterior Placoid Chorioretinitis in a Young, HIV-Negative Male

Ocular syphilis can occur at any time after initial infection and most commonly presents as posterior uveitis or panuveitis, although many other ocular findings have been documented. We present the case of a young, otherwise healthy Caucasian HIV-negative male who presented with acute onset of photopsias, floaters, and a rapidly progressive unilateral scotoma who was originally diagnosed with acute zonal occult outer retinopathy (AZOOR) and started on a high dose prednisone taper. Although his clinical symptoms improved on corticosteroids, he was later switched to Penicillin G treatment when his blood and cerebrospinal fluid (CSF) testing demonstrated syphilis as his underlying diagnosis. Given his ocular findings on the exam and reactive syphilitic testing, he was ultimately diagnosed with acute syphilitic posterior placoid chorioretinitis (ASPPC). Our patient's clinical improvement after a high-dose prednisone trial offers further evidence of an autoimmune component to the pathophysiology of ASPPC.

Ocular syphilis

Multiple studies around the world suggest that syphilis is re-emerging. Ocular syphilis - with a wide range of presentations, most of which are subtypes of uveitis - has become an increasingly common cause of ocular inflammation over the past 20 years. Its rising incidence, diagnostic complexity, and manifestations that have only recently been characterized make ocular syphilis relevant from the public health, clinical, and scientific perspectives. We review the demographics, epidemiology, clinical features, ocular imaging findings, diagnosis, and medical management of this condition.

Optical Coherence Tomography Findings in Ocular Syphilis Involving the Posterior Segment of the Eye

Purpose: To analyse posterior segment optical coherence tomography (OCT) findings in ocular syphilis.Methods: Medical records of 54 patients presenting consecutively with syphilitic uveitis were reviewed. Vitreous, retina and choroid (one eye/patient) were assessed by spectral-domain OCT on presentation (54 eyes) and after treatment (31 eyes). Improvement in signs and associations between presenting signs and final best corrected visual acuity (BCVA) were determined by McNemar's and Fisher's exact tests.Results: Early inner retinal OCT findings included hyperreflective dots (n = 49, 91%), tongue-like projections (n = 44, 81%) and large rounded spots (n = 41, 76%). Common outer retinal findings included thickening, irregularity, elevations and/or detachment of retinal pigment epithelium (n = 46, 85%), and disruption or loss of the ellipsoid zone (n = 33, 61%). Most outer retinal changes resolved with treatment (p < .05), and common presenting signs were not associated with poor final BCVA (p > .05).Conclusion: OCT findings have diagnostic value in ocular syphilis, but do not predict prognosis.

Placoid lesions of the retina: progress in multimodal imaging and clinical perspective

Placoid lesions of the retina may be secondary to a wide spectrum of acquired inflammatory conditions that have been reported as single entities with different presentation and clinical course. These conditions include acute posterior multifocal placoid pigment epitheliopathy, persistent placoid maculopathy, serpiginous choroiditis, serpiginous-like choroiditis, relentless placoid chorioretinitis and acute syphilitic posterior placoid chorioretinitis. In this article, we will group these conditions under the name of 'placoids'. The recognition of the specific condition may be challenging in clinical practice, often resulting in diagnostic and therapeutic delay. Given the complex nature of placoids and their similarities, a systematic approach including differentiating between infectious and non-infectious aetiologies increases the chance of reaching the correct diagnosis. Detailed history and comprehensive clinical examination are the first steps to formulate a diagnostic hypothesis that should be corroborated by multimodal imaging and appropriate investigations. The advent of multimodal imaging has made it possible to extensively study placoids and revealed a constellation of specific findings that may help clinicians in the diagnostic process. The treatment of the conditions other than syphilis is complex and sometimes challenging. Our article is aimed at giving an overview of the individual entities associated with placoids and discussing the differential diagnosis. A practical and systematic approach is then proposed.

Acute Syphilitic Posterior Placoid Chorioretinitis in a Saudi Patient

A 37-year-old otherwise healthy male presented with paracentral scotoma in his right eye for 1 day with a history of having unprotected sex with multiple partners. The patient was diagnosed to have acute syphilitic posterior placoid chorioretinitis with multimodal imaging including spectral-domain optical coherence tomography and fundus fluorescein angiography. His condition improved after 2 weeks course of intravenous benzyl penicillin 1.2 g every 4 h in collaboration with infectious disease physician.

Spontaneous resolution of acute syphilitic posterior placoid chorioretinitis: reappraisal of the literature and pathogenetic insights

Acute syphilitic posterior placoid chorioretinitis (ASPPC) is a rare clinical manifestation of ocular syphilis. Spontaneous resolution of this condition has been reported in a few cases. The aim of this manuscript is to report an additional case and to discuss the possible pathogenesis of this condition by reviewing the current evidence on this subject. A 45-year-old man presented to us with decreased vision in the right eye secondary to a placoid macular lesion. Fourteen days after presentation, there was a dramatic improvement of the vision, and multimodal retinal imaging showed almost complete spontaneous resolution of the placoid lesion. Syphilis serology turned out positive and a diagnosis of ASPPC was made. The pathogenesis of ASPPC is unclear, and there is contrasting evidence about the role of the cellular immune system. Since this condition may resolve spontaneously before systemic antimicrobial treatment, the presence of a placoid macular lesion should raise a high suspicion of ASPPC in order to make a timely diagnosis and to avoid progression of untreated syphilis.

Retinal dysfunction of syphilitic outer retinopathy

PURPOSE

We present our findings in two cases of retinal dysfunction caused by syphilitic outer retinopathy. CASE 1: A 59-year-old man visited our clinic complaining of blurred vision in his left eye. Optical coherence tomography (OCT) demonstrated an absence of the ellipsoid zone (EZ) in the left eye. A round yellowish-white lesion was observed in the posterior pole of the left fundus. Fundus autofluorescence (FAF) showed hyperfluorescent areas in the posterior pole of both fundi although no specific ophthalmoscopic findings were seen in the right eye. The amplitudes of the LA 3.0 1 Hz and LA 3.0 30 Hz ERG responses were reduced with better preservation of the rod responses. Based on a strong positivity to the rapid plasma reagin (RPR) assay and the Treponema pallidum hemagglutination (TPHA) test, he was diagnosed with syphilitic outer retinopathy and treated with systemic antibiotics. The treatment resulted in a restoration of the retinal structures and cone function. CASE 2: A 47-year-old man was referred to our clinic complaining of reduced vision in both eyes. Although the ocular fundus appeared normal, FAF showed a diffuse hyperfluorescent area in the posterior pole and multiple hyperfluorescent spots. Indocyanine green angiography showed multiple confluent areas of hypofluorescence. OCT demonstrated irregular EZs in both eyes. The amplitudes of the LA 3.0 1 Hz and LA 3.0 30 Hz ERG responses were slightly reduced with prolonged implicit times. These findings are comparable to the findings in patients with multiple evanescent white dot syndrome. However, the strong positivity to the RPR and TPHA tests led us to diagnose the patient with outer retinopathy caused by syphilis. Systemic administration of antibiotics resulted in the restoration of the retinal structures and retinal function.

CONCLUSIONS

Syphilitic outer retinopathy affected the retinal structures and function that can be restored by antibiotic treatments.

Clinical Features of Ocular Syphilis: a Retrospective Clinical Study in an Italian Referral Centre

Purpose: To describe the clinical characteristics and visual prognosis of ocular involvement in syphilis.Design: A retrospective cohort study.Methods: We studied the charts of 24 patients who visited our Ophthalmological Centre in Rome, Italy. All patients with serological evidence of syphilitic infection were included.Results: Ocular involvement was the first manifestation of syphilitic disease in 96% and Human Immunodeficiency Virus (HIV) seropositivity was found in 29% of the cases. The most frequent ocular manifestation was posterior uveitis. Vitreous involvement was frequent. Patients with papillitis at onset showed better visual outcome with antisyphilitic treatment. Posterior uveitis at onset and HIV seropositivity were negative prognostic factors for visual outcome. HIV-positive patients showed more severe and frequent bilateral course of ocular involvement in syphilis.Conclusions: The ophthalmologist should suspect syphilis in patien ts with uveitis or optic neuropathy associated with high-risk sexual behaviour and/or HIV, or in patients with posterior placoid chorioretinitis, necrotising retinitis, or interstitial keratitis.

Multimodal Imaging Analysis of Acute Syphilitic Posterior Placoid Chorioretinitis: A Case Report

The authors report a multimodal imaging analysis of a case of acute syphilitic posterior placoid chorioretinitis (ASPPC) occurring in a 51-year-old man. Best-corrected visual acuity (BCVA) was 0.5 and 0.8 in the right and left eyes, respectively. The authors performed spectral-domain optical coherence tomography, fundus autofluorescence, fluorescein angiography, and indocyanine green angiography. All of the examinations were suggestive of the diagnosis of ASPPC, a rare manifestation of syphilis that has distinctive anatomical characteristics that are detectable early on with multimodal imaging. Moreover, serological tests were positive for syphilis infection, so the patient received intravenous penicillin G for 14 days. Final BCVA was 1.0 in the right eye and 0.9 in the left eye. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e179-e184.].

Multimodal imaging patterns of posterior syphilitic uveitis: a review of the literature, laboratory evaluation and treatment

PURPOSE

To review the multimodal imaging patterns of posterior syphilitic uveitis.

METHODS

A systematic review.

RESULTS

The percentage of syphilis has started to increase again: The World Health Organization has reported 12 million new cases of syphilis each year. In addition, syphilis was responsible for 0.3% of deaths globally in 2002. Eye manifestations happen prevalently in secondary and tertiary stages of syphilis, even though ocular involvement can occur in all stages. Syphilis has the nickname: "the great imitator" since it has no unique clinical presentation, even though posterior uveitis is considered the most common form. Syphilis is known as "the great imitator," making its diagnosis in the presence of posterior uveitis particularly challenging as it presents similarly to other ocular conditions such as acute retinal necrosis. However, with the advent of multimodal imaging some particular patterns of pre-retinal, retinal, retinochoroidal and optic nerve involvement from syphilis can be identified to guide the diagnosis and the laboratory workup.

CONCLUSION

This review highlights the various patterns of pre-retinal precipitates, multifocal retinitis, retinochoroiditis (confluent and placoid) and optic neuritis caused by syphilis, the appropriate laboratory work to be obtained and the treatment to be initiated.

Acute Syphilitic Posterior Placoid Chorioretinitis Misdiagnosed as Systemic Lupus Erythematosus Associated Uveitis

Purpose: The authors report a case of a systemic lupus erythematosus (SLE) patient who suffered rapid loss of vision after being misdiagnosed as SLE associated uveitis and treated with glucocorticoid. She was eventually diagnosed with acute syphilitic posterior placoid chorioretinitis (ASPPC) after further serological inspection and detailed ophthalmic examination, and gained improved visual acuity through massive penicillin G treatment. Methods: Retrospective review of a case note. Conclusions: Concealment of syphilis history and absence of serological examination, coupled with its rarity, can make the diagnosis of ASPPC extremely difficult, especially when combined with simultaneous systemic or immune diseases. A high index of suspicion for syphilis and timely serological examination are crucial for early diagnosis and prompt treatment. Even if the ASPPC shows signs of spontaneous improvement, prompt and sufficient antibiotic treatment remains essential to prevent sight-threatening complications.

Acute syphilitic posterior placoid chorioretinopathy: An infectious or autoimmune disease?

PURPOSE

To report a case of acute syphilitic posterior placoid chorioretinopathy (ASPPC) that demonstrated partial resolution with immunosuppressive therapy secondary to a misdiagnosis as Behçet's disease followed by a relapse which was successfully treated with the appropriate treatment.

OBSERVATIONS

A 34-year-old female patient presented to our service with complaints of decreased vision in the left eye (OS). She initially developed similar symptoms seven months prior to presentation and was diagnosed as Behçet's disease based on the clinical picture of papillitis, vasculitis and placoid chorioretinitis in the posterior pole of OS. She was started on daily oral prednisone 60 mg and weekly methotrexate 10mg by her rheumatologist. The patient's ocular symptoms improved one month prior to presentation with resolution of the placoid lesion but persistence of vasculitis and papillitis. At that time, the dose of the prednisone was decreased to 30 mg which resulted in a relapse of the placoid chorioretinal lesions and worsened visual acuity at the time of presentation to us. Extensive laboratory workup demonstrated positive serology for syphilis. A diagnosis of syphilitic placoid chorioretinitis was made and the patient was treated with intravenous penicillin G for 2 weeks. The vitritis, papillitis, and placoid chorioretinitis resolved along with improvement in vision following the treatment.

CONCLUSIONS AND IMPORTANCE

Ocular findings in syphilis are heterogeneous and may mimic variety of ocular diseases. ASPPC is a rare ocular manifestation of syphilis and its natural course and underlying pathophysiology is not well understood. However, irrespective of the underlying mechanism of the disease, all patients with ASPPC should receive treatment to prevent recurrence and long-term functional damage.

En-Face Optical Coherence Tomography of Acute Syphilitic Posterior Placoid Chorioretinopathy

PURPOSE

To report a unique case series of acute syphilitic posterior placoid chorioretinopathy (ASPPC) correlating en-face optical coherence tomography (OCT) with standard imaging modalities.

METHODS

In this retrospective case series, multimodal imaging was performed in three ASPPC patients at the time of disease presentation.

RESULTS

Clinical and laboratory findings were consistent with the diagnosis of ASPPC. In all the study patients, multiple hyperreflective dot-like lesions distributed in the macular area and observed with en-face OCT at the level of retinal pigment epithelium (RPE) corresponded to the nodular RPE elevations on cross-sectional OCT and to the hyperautofluorescent spots on fundus autofluorescence. In addition, the cross-sectional OCT scans showed disorganization of the outer retinal bands and punctate choroidal hyperreflectivity.

CONCLUSION

By combining en-face OCT with multimodal imaging analysis, we propose that a primary inflammation at the level of the choroid may be the pathogenic mechanism for the occurrence of outer retinal band abnormalities.

Ultra-Wide-Field Fundus Autofluorescence and Spectral-Domain Optical Coherence Tomography Findings in Syphilitic Outer Retinitis

BACKGROUND AND OBJECTIVE

To determine the ultra-wide-field fundus autofluorescence (UWFFAF) and optical coherence tomography (OCT) features of syphilitic outer retinopathy (SOR).

PATIENTS AND METHODS

Retrospective chart review.

RESULTS

Three patients with SOR were investigated. Treatment with parenteral penicillin led to improvement of outer retinopathy, visual acuity, and symptoms. UWFFAF showed speckled hyperautofluorescence, hypoautofluorescence, and normal autofluorescence, similar to what has been described as a trizonal pattern in acute zonal occult outer retinopathy (AZOOR) in the chronic case of SOR, but with hyperautofluorescent areas in the two acute cases. OCT showed disruption of the photoreceptor outer segment ellipsoid zone and external limiting membrane, which improved after penicillin treatment, and corresponded to normalization of the hyperautofluorescent areas on UWFFAF. There was irregularity and nodular thickening of retinal pigment epithelium on OCT in areas of mottled hyperautofluorescence.

CONCLUSION

SOR can present similarly to AZOOR on UWFFAF and should be highly suspected in cases presenting like AZOOR. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:208-215. ].

Characteristics of syphilitic uveitis in northern China

Background

To describe the characteristics of patients with syphilitic uveitis in northern China.

Methods

A case series of 21 patients (33 eyes) diagnosed with syphilitic uveitis from 2011 to 2016 at a tertiary center in northern China was retrospectively analyzed.

Results

Twenty-one patients (33 eyes) were diagnosed as syphilitic uveitis. Posterior segment involvement was found in 32 eyes (97.0%). Vitreous haze, neuroretinitis, and posterior placoid chorioretinitis were mainly found in patients with a relatively short duration of the disease, while diffuse chorioretinitis, pseudoretinitis pigmentosa, cystoid macular edema, and epiretinal membrane were found in patients with relatively long duration of ocular involvement. A low best-corrected visual acuity (P = 0.022) and a delay of syphilis treatment (P < 0.001) were associated with a significantly worse visual outcome.

Conclusions

Syphilitic uveitis should be included in the differential diagnosis of any form of posterior ocular inflammation. The pattern of ocular involvement may change with the disease progression.

Multimodal imaging analyses of hyperreflective dot-like lesions in acute syphilitic posterior placoid chorioretinopathy

BACKGROUND

Retrospective review of one acute syphilitic posterior placoid chorioretinitis (ASPPC) case with serological evidence of syphilis who had ocular signs and symptoms not attributable to other diseases. Enface and spectral-domain optical coherence tomographySD-OCT were analyzed at the time of presentation and at 1-month visit following initiation of treatment. The study patient underwent standard treatment for neurosyphilis.

RESULTS

Ophthalmic examination and imaging studies were consistent with the diagnosis of ASPPC. The patient age was 33 year-old and the baseline visual acuity was 20/400 and 20/80 in the right and left eyes, respectively. At presentation, SD-OCT scans showed disruption and loss of the ellipsoid zone (EZ), small nodular elevations on retinal pigment epithelium (RPE) and punctate hyperreflectivity in the choroid. Enface OCT at the level of RPE and EZ demonstrated multiple hyperreflective dot-like lesions simmetrically distributed within the macular area. These dot-like lesions corresponded to the small nodular elevations on RPE and to disruption/loss of EZ observed with SD-OCT. One month after neurosyphilis therapy, the visual acuity improved and the outer retinal changes partially reversed in both eyes.

CONCLUSIONS

We report the outer retinal findings and its correlation using both en-face and SD-OCT in a patient with ASPPC. En-face OCT imaging provides a more precise outer retinal layers analyses allowing a better understanding of the ASPPC pathophysiology.

Clinical Manifestations and Treatment Outcomes of Syphilitic Uveitis in a Chinese Population

Purpose. To describe the clinical manifestations and treatment outcomes of syphilitic uveitis in a Chinese population. Methods. This is a retrospective case series of 15 consecutive patients with syphilitic uveitis treated at a uveitis referral center between 2012 and 2015. Results. Fifteen patients were diagnosed with syphilitic uveitis based on positive serological tests. Nine patients were male. Coinfection with human immunodeficiency virus was detected in two patients. Twenty eyes presented with panuveitis and all patients had posterior involvement. The most frequent manifestations were retinal vasculitis and papillitis, while syphilitic posterior placoid chorioretinitis was only found in three eyes. All patients received systemic penicillin therapy according to CDC guidelines. Nine patients were misdiagnosed before presenting to our center and the delay in treatment with penicillin was associated with poor final visual outcomes (P < 0.05). Conclusions. In our series, both male and female were almost equally affected and coinfection of syphilis with human immunodeficiency virus was uncommon. All patients in this study had posterior involvement and the most common manifestations were retinal vasculitis and papillitis. Syphilis should be considered as an important differential diagnosis especially for posterior uveitis and panuveitis. Early diagnosis and appropriate treatment are important for visual prognosis.

Severe acute syphilitic posterior placoid chorioretinitis with complete spontaneous resolution: The natural course

PURPOSE

We report on a case of unilateral acute syphilitic posterior placoid chorioretinitis (ASPPC) with spontaneous resolution of the lesions, and discuss the role of an altered versus adequate immune response as the major pathogenic factor.

METHODS

We describe a case of acute loss of visual acuity (VA) in the left eye (LE) in a 55-year-old healthy man.

RESULTS

The patient presented with VA of 20/20 in the right eye (RE) and hand movements in the LE. Fundoscopy revealed a large yellowish placoid macular lesion with subretinal fluid in the LE, with no abnormalities detected in the RE. Fluorescein angiography showed early hypofluorescence with late staining in the affected area. The clinical findings progressed fast during the first week, with extension of the initial lesion outside the temporal retinal vascular arcades and the appearance of new lesions in the same eye. The patient abandoned the clinic for two weeks with no treatment. When observed again, VA of the LE had recovered to 20/20 and the lesions had completely resolved. Venereal disease research laboratory (VDRL) and fluorescent treponemal antibody absorption (FTA-ABS) tests results were positive and HIV antibody test titers negative. The diagnosis of ASPPC in the left eye was made. The patient accepted treatment with penicillin G only 45 days after the initial presentation. AV remained stable at 20/20 both eyes and no relapses of the lesions were observed during this period without therapy. The patient was followed for 3 months after treatment. He remained asymptomatic and the ophthalmic examination was unremarkable.

CONCLUSIONS

The pathogenesis of ASPPC is still not understood. Our case showed a sequential pattern of the chorioretinal lesions, with initial aggravation and complete posterior spontaneous resolution, showing the natural course of the disease. These findings suggest the presence of an adequate ocular immune response in patients with ASPPC, not supporting the initially proposed hypothesis of the importance of a modified immune response as the major pathogenic factor.

Nodular syphilitic scleritis masquerading as an ocular tumor

Background

Scleritis may be the initial or only presenting feature of systemic, autoimmune, or infectious disorders. Corticosteroids are the mainstay of treatment for immune-mediated scleritis. However, steroids could prove detrimental when used to treat infectious scleritis. Hence, infectious causes of scleritis should be ruled out.

Findings

A 47-year-old male from central India presented with swelling, pain, and redness in the left eye since 2 months. The patient was diagnosed elsewhere as having an extraocular extension of intraocular tumor and advised radiation brachytherapy for the same. Clinical examination revealed nodular scleritis in the left eye. The patient did not have any systemic illness or complaints suggestive of connective tissue disease. Laboratory investigations ruled out the same. However, Venereal Disease Research Laboratory (VDRL) test was positive. Rapid plasma reagin (RPR) test and Treponema pallidum hemagglutination assay (TPHA) were also positive, confirming the diagnosis of syphilis. Ultrabiomicroscopy (UBM) and ultrasound scan of the eye ruled out intraocular tumor. Treatment was initiated with benzathine penicillin 2.4 million units per week for 3 weeks to which the patient responded remarkably well.

Conclusions

Although rare, syphilis can present as nodular scleritis masquerading as ocular tumor. Syphilis must be considered in the list of etiological diagnoses in patients presenting with nodular scleritis, and testing for this disease should be a part of routine investigation in patients with scleritis.

Clinical features and incidence rates of ocular complications in patients with ocular syphilis

PURPOSE

To describe the clinical outcomes of ocular syphilis.

DESIGN

Retrospective chart review.

METHODS

The charts of patients with ocular syphilis (regardless of human immunodeficiency virus [HIV] status) seen in a uveitis referral center between 1984 and 2014 were reviewed.

RESULTS

The study included 35 patients (61 eyes). Panuveitis was the most common type of ocular inflammation (28 eyes), independent of HIV status. Thirty-three of 35 patients received systemic antibiotics with 24 patients treated with intravenous (IV) penicillin only. When compared to the HIV-positive patients, HIV-negative patients with ocular syphilis were older (P < .001), were more likely to be female (P = .004), and had poorer visual acuity at presentation (P = .01). During follow-up, the incidence rates of visual impairment were 0.29 per eye-year (EY; 95% confidence interval [CI]: 0.06/EY-0.86/EY) and 0.12/EY (95% CI: 0.01/EY-0.42/EY) among the HIV-negative and the HIV-positive patients, respectively. The incidence of blindness was 0.07/EY (95% CI: 0.009/EY-0.27/EY) and 0.06/EY (95% CI: 0.002/EY-0.35/EY) among the HIV-negative and the HIV-positive patients, respectively. Longer duration of uveitis prior to diagnosis and chorioretinitis in the macula at presentation were associated with ≥ 2 Snellen lines of visual loss (P < .01) and visual acuity loss to 20/50 or worse (P = .03) in HIV-negative patients, respectively.

CONCLUSIONS

Syphilis is an uncommon cause of ocular inflammation in both HIV-negative and HIV-positive patients. Visual loss and ocular complications were common among HIV-negative patients even with systemic antibiotic treatment. Delay of diagnosis and chorioretinitis in the macula were associated with visual loss in these patients.

Sequential spontaneous resolution of acute syphilitic posterior placoid chorioretinitis

PURPOSE

Acute syphilitic posterior placoid chorioretinitis (ASPPC) is a distinctive manifestation of ocular syphilis characterized by the development of a placoid macular deposit in the outer retina. Fundus autofluorescence descriptions suggest it may result from subretinal deposition of retinal pigment epithelium (RPE)-photoreceptor complex material and incomplete phagocytosis of outer segments. A 14-day therapy with systemic penicillin is essential for prompt control of the infection and to limit substantial retinal damage and irreversible visual loss. We report on the spontaneous sequential resolution of ASPPC in a patient with HIV coinfection.

METHODS

Descriptive case report.

RESULTS

A 55-year-old man presented with profound decrease in vision in his left eye secondary to ASPPC. Nine days later, ASPPC resolved, and a similar process developed in the right eye. Four years earlier, HIV infection had been diagnosed, and the patient was maintained on antiretroviral therapy with good immune recovery (CD4+ T-cell count 204 cells/µL). Spontaneous resolution ensued in the right eye and vision was restored.

CONCLUSIONS

Ocular immune privilege probably contributed to the spontaneous resolution of ASPPC in this patient, who experienced immune recovery following antiretroviral therapy. The RPE immunologic characteristics likely contained the infectious/inflammatory infiltrate in this patient and prevented extension to inner retina and optic disc. Despite the uniqueness of the present case and the spontaneous resolution and excellent visual outcome, it remains essential to promptly manage patients with ocular syphilis because of the possible sight-threatening complications and to prevent potentially fatal disease.

Spectral domain optical coherence tomography findings in acute syphilitic posterior placoid chorioretinitis

Background

We describe the spectral domain optical coherence tomography (SD-OCT) findings in three patients with acute syphilitic posterior placoid chorioretinitis (ASPPC). The SD-OCT images demonstrate the pathologic changes in ASPPC with a high level of anatomic detail and may provide information about the pathophysiology of the disease.

Findings

We report a series of three consecutive patients seen at the Wilmer Eye Institute in 2012 and 2013 who presented with clinical and laboratory findings consistent with a diagnosis of unilateral ASPPC. Two of the three patients had HIV co-infection with good immune recovery. SD-OCT images from their initial (pre-treatment) presentation demonstrated thickening and hyperreflective nodularity of the choroid-retinal pigment epithelium (RPE) complex, with focal disruption of the overlying photoreceptor inner segment-outer segment junction in the areas corresponding to the retinal lesions seen on clinical examination. These changes improved with intravenous antibiotic treatment over a 3-month period of follow-up.

Conclusions

SD-OCT imaging in ASPPC demonstrates reversible, focal thickening, and nodularity of the RPE with disruption of the overlying photoreceptor inner segment-outer segment junction. We believe that these SD-OCT images support the concept that ASPPC involves an inflammatory process at the level of the choroid-RPE with resultant structural and functional changes in the retinal photoreceptors. Further study with OCT imaging may be helpful in better understanding this disease.

Acute syphilitic posterior placoid chorioretinitis: report of a case series and comprehensive review of the literature

PURPOSE

To describe the clinical and angiographic features of a series of patients with acute syphilitic posterior placoid chorioretinitis (ASPPC) in the context of previously published cases.

METHODS

A retrospective, noncomparative, multicenter chart review was performed on 16 patients with active ASPPC. Positive serologic tests supported the diagnosis in all patients. Color and red-free photographs as well as fluorescein angiography were obtained in each case. Indocyanine green angiography, optical coherence tomography, and fundus autofluorescence were performed on selected patients. A total of 44 previously published cases of ASPPC were identified using both a Medline Search and references listed in articles identified.

RESULTS

Ocular involvement was bilateral in 9 of our 16 patients (56.3%). The mean and median ages at presentation were 40 and 38 years, respectively (range 28-57 years). Nine patients (56.3%) were human immunodeficiency virus positive, with most recent CD4 cell counts ranging from 160 cells/μL to 450 cells/μL and a median CD4 cell count of 250 cells/μL. Seven of 16 patients (43.8%) had a history of mucocutaneous manifestations of secondary syphilis, whereas 4 (25.0%) had evidence of neurosyphilis. Anterior chamber and/or vitreous inflammation was evident in 13 patients (81.3%). Fifteen of 16 patients had positive venereal disease research laboratory or rapid plasma regain titers, and 13 of 13 tested patients had a positive serum fluorescent treponemal antibody absorption. The initial vision in the 25 affected eyes ranged from 20/20 to counting fingers, with a median of 20/80. In all patients, posterior segment examination in the involved eyes revealed a large, yellowish, placoid, outer retinal lesion. Fluorescein angiography showed progressive hyperfluorescence in the area of the lesion, often with scattered focal hypofluorescence, or leopard spotting. Inflammation subsided, the yellowish lesions resolved, and vision improved shortly after antibiotic therapy in 20 of 25 affected eyes. Visual acuity at last visit ranged from 20/20 to 20/150, with a median final vision of 20/25. A review of the literature revealed 44 previously reported cases of ASPPC. Shared demographic, clinical, and angiographic features were summarized.

CONCLUSION

Acute syphilitic posterior placoid chorioretinitis is an uncommon but clinically and angiographically distinct manifestation of ocular syphilis. All patients with characteristic clinical and angiographic findings of ASPPC should be tested for both neurosyphilis and human immunodeficiency virus coinfection. Vision recovery typically followed completion of appropriate antibiotic therapy.

Spectral-domain optical coherence tomography features of acute syphilitic posterior placoid chorioretinitis: the role of autoimmune response in pathogenesis

PURPOSE

Syphilis is an infectious disease that can cause a wide variety of ocular signs. One of the rarest manifestations of ocular syphilis is acute syphilitic posterior placoid chorioretinitis (ASPPC). We report on the spectral-domain optical coherence tomography (SD-OCT) features of a case diagnosed with unilateral ASPPC.

METHODS

A 64-year-old man presented with a sudden loss of visual acuity (VA) in the right eye. His only clinical sign was a large, geographic, yellow-white lesion centered on the right fovea. Our patient was studied with SD-OCT on presentation and during follow-up, as well as with fluorescein and indocyanine green angiography, electrophysiological study, and serologic and autoimmune screening.

RESULTS

Laboratory workup revealed positive serology for active syphilis and elevated anti-beta2 glycoprotein I antibodies. SD-OCT showed a marked distortion of both the choroidal and outer retinal architecture. After treatment, best-corrected VA improved to 20/25. Pattern electroretinography displayed a severe reduction of P50 amplitude, which improved in late follow-up. Six months after presentation, VA was 20/25 and anti-beta2 glycoprotein I antibodies returned to normal levels.

CONCLUSIONS

Our findings are compatible with immunologically mediated temporary physiological impairment of the neuroretina, since the changes seen by SD-OCT could not have normalized if they were due to anatomical injury. The results of our study provide clues to understanding the pathogenesis of this disease and allow us to define a characteristic temporal sequence of events in ASPPC.

Acute syphilitic posterior placoid chorioretinitis following intravitreal triamcinolone acetonide injection

BACKGROUND

We describe the ophthalmic features and clinical course of two cases of acute syphilitic posterior placoid chorioretinitis (ASPPC) that developed after intravitreal triamcinolone acetonide (IVTA) injection.

METHODS

Case report.

RESULTS

Two patients with ocular inflammation of unknown origin developed severe chorioretinitis after IVTA injection. Multiple retinal infiltrates, placoid subretinal lesions, and ground-glass opacity of the retina with hyperemic optic discs were observed in both patients. The etiology of the chorioretinitis was confirmed by serology to be syphilis. Appropriate treatment for neurosyphilis was instituted. Both eyes became atrophied and had poor visual outcome: 10/200 in one patient and no light perception in the other at 6 months after IVTA injection.

CONCLUSIONS

The fundus picture shown in these cases may be typical of ASPPC after IVTA injection. Clinical suspicion of ASPPC upon observation of these characteristic features is crucial for early diagnosis and treatment.

Syphilitic acute posterior placoid chorioretinitis in nonimmuno-compromised patients

PURPOSE

To describe the clinical and angiographic features of three cases of secondary syphilis in immunocompetent patients, which presented as acute posterior placoid chorioretinitis (APPC) to the ophthalmologist.

METHODS

Interventional case series. The aetiology of the APPC was confirmed by serology to be secondary syphilis. Optical coherence tomography, electrophysiology, fundus fluorescein, and indocyanine green (ICG) angiography were performed at presentation and after resolution. Appropriate treatment for secondary syphilis was instituted in each patient.

RESULTS

The clinical features, fundus fluorescein and ICG angiography, multifocal electroretinography (mfERG), and optical coherence tomography findings of APPC are described. All three patients had a satisfactory resolution of the APPC with improvement in visual acuity.

CONCLUSIONS

APPC in secondary syphilis can occur even in immunocompetent patients. A high index of suspicion is required for early diagnosis of this condition resulting in a good visual outcome with adequate treatment. mfERG and optical coherence tomography are useful in the diagnosis and follow-up of these patients.

Syphilis and HIV: a dangerous combination

HIV and syphilis affect similar patient groups and co-infection is common. All patients presenting with syphilis should be offered HIV testing and all HIV-positive patients should be regularly screened for syphilis. Syphilis agent may enhance the transmission of the other, probably through increased incidence of genital ulcers. Detection and treatment of syphilis can, therefore, help to reduce HIV transmission. Syphilis may present with non-typical features in the HIV-positive patient: there is a higher rate of symptomless primary syphilis and proportionately more HIV-positive patients present with secondary disease. Secondary infection may be more aggressive and there is an increased rate of early neurological and ophthalmic involvement. Diagnosis is generally made with serology but the clinician should be aware of the potential for false-negative serology in both primary and, less commonly, in secondary syphilis. All HIV-positive patients should be treated with a penicillin-based regimen that is adequate for the treatment of neurosyphilis. Relapse of infection is more likely in the HIV-positive patient and careful follow-up is required.

Choriorétinite syphilitique chez l’immunodéprimé

Syphilitic chorioretinitis is a rare manifestation of secondary syphilis. The Authors report a case of a patient tested positive for human immune deficiency virus. A 26-Year-old man presented with a history of suddenly blurred vision in the right eye. Because of a central scotoma, visual acuity was reduced to counting fingers. Slit-lamp examination found one-plus anterior chamber cells and one-plus vitreous cells. Results of ophthalmoscopic examination showed a large yellow lesion in the macular area with a papillar edema and peripheral vasculitis. Serum and cerebrospinal fluid were positive for syphilitic serology. Visual acuity improved to 20/20 after three courses of intravenous ceftriaxone (2g/day for 15 days). The fundus lesion resolved almost completely, resulting in slight pigmentary changes in the macular area. This case report highlights the need for syphilitic serology in cases of uveitis in immunocompromised patients.

Corticosteroid-induced modulation of acute syphilitic posterior placoid chorioretinitis

PURPOSE

To report a case of corticosteroid-induced modulation of acute syphilitic posterior placoid chorioretinitis.

DESIGN

Interventional case report.

METHOD

A 38-year-old homosexual male who presented with a unilateral uveitis secondary to syphilis developed large placoid macular lesions after treatment with oral prednisone that resolved when the corticosteroids were discontinued.

RESULTS

A cause-and-effect relationship was demonstrated between oral prednisone and the appearance of acute syphilitic posterior placoid chorioretinitis.

CONCLUSIONS

The clinical appearance of posterior placoid chorioretinitis in syphilis may be modulated by the immune status of the patient.