Syphilitic retinitis in a patient with acquired immunodeficiency syndrome-related complex

A Case of Traction Retinal Detachment Accompanied by Ocular Syphilis

Purpose: We report a first case of traction retinal detachment accompanied by ocular syphilis in Korea.Case summary: A 20-year-old male visited with poor left-eye vision. His best-corrected visual acuity was 0.3; no inflammation was evident in the anterior chamber, but many inflammatory cells were found in the vitreous cavity. Fundus examination revealed inferior exudative and tractional retinal detachment. Optical coherence tomography revealed an epiretinal membrane; fluorescein angiography showed that the inferior (detached) retina did not fluoresce. Syphilis was serologically detected; ceftriaxone (2 g daily) was intravenously injected for 14 days. The vitreous cavity inflammation improved, but the tractional membrane proliferation triggered tractional retinal detachment. We performed vitrectomy to remove the tractional membrane and prescribed intravitreal antibiotics. The patient was discharged after intravenous injection of penicillin G (20 MU daily) for 14 days. Three months after surgery, the best-corrected left-eye visual acuity had improved to 0.8, and no recurrence of the retinal detachment was noted.Conclusions: Patients with ocular syphilis may evidence retinal detachment despite initial prescription of systemic antibiotics. A possible need for surgery should be kept in mind; the prognosis is good if an operation is performed in a timely manner.

Ocular syphilis in patients with Human Immunodeficiency Virus infection

As Acquired Immunodeficiency Disease (AIDS) turns thirty-years old, much progress has been made. 56,000 new cases of the Human Immunodeficiency Virus (HIV) infection are expected in Americans this year. At least half or more will be in African Americans. Reports of the association between syphilis and HIV infection are well documented. We present a case of bilateral optic neuritis and panuveitis as the initial presentation in a previously undiagnosed patient with human immunodeficiency virus (HIV) and syphilis.

[Bilateral panuveitis with papillary swelling]

Lues (syphilis) is a chronic cyclic infectious disease which can continue for decades if untreated. A simultaneous HIV infection can result in false negative results in serological tests for lues. The occurrence of neurolues has frequently been described in HIV positive patients. In the differential diagnosis an early ocular manifestion of lues should be considered. A 40-year-old homosexual patient presented in our hospital with bilateral pain-free increasing loss of vision. The ophthalmological examination revealed an intermediately expressed panuveitis with streaky opacity of the vitreous body and pronounced bilateral papillary swelling. Following systemic anti-inflammatory therapy with cortisone the situation worsened after initial improvement. The serological investigations revealed both HIV and lues infections. Intravenous therapy with mega units of penicillin led to a slow improvement of clinical symptoms and also vision. In cases of uveitis of unclear origin together with a HIV infection and suspected lues, regular serological testing should be carried out because the occurrence of late complications of lues can be avoided by the diagnosis of lues and adequate treatment.

Ocular manifestations and treatment of syphilis

Syphilis is a sexually transmitted, chronic, systemic infection caused by the spirochete Treponema pallidum. If left untreated, the disease progresses through four stages, with the potential to cause significant morbidity to any major organ of the body. Frequent syphilitic ocular manifestations, which can occur at any stage of the disease, include interstitial keratitis, anterior, intermediate, and posterior uveitis, chorioretinitis, retinitis, retinal vasculitis and cranial nerve and optic neuropathies. Diagnosis is centered around a high level of clinical suspicion and includes treponemal specific and non-treponemal serologic tests. All patients with newly diagnosed syphilis should be tested for co-infection with human immunodeficiency virus, as the risk factors are similar for both diseases. Additionally, all patients with ocular syphilis should be tested for neurosyphilis. The preferred treatment for all stages of syphilis remains parenteral penicillin G. With proper diagnosis and prompt antibiotic treatment, the majority of cases of syphilis can result in a cure.

Posterior segment manifestations of HIV/AIDS

The ocular posterior segment manifestations of AIDS may be divided into four categories: retinal vasculopathy, unusual malignancies, neuro-ophthalmologic abnormalities, and opportunistic infections. Microvasculopathy is the most common manifestation. Opportunistic infections, particularly cytomegalovirus retinitis and progressive outer retinal necrosis, are the most likely to result in visual loss due to infection or subsequent retinal detachment. Diagnosis and treatment are guided by the particular conditions and immune status of the patient.

Syphilitic Posterior Uveitis: Correlative Findings and Significance

Twenty-one patients with syphilitic posterior uveitis were investigated retrospectively to study the disease spectrum, associations with neurosyphilis, and therapeutic implications. Ophthalmologic manifestations of syphilitic posterior uveitis are differentiated into acute and chronic uveitides. The several distinct acute uveitic syndromes are usually florid and are associated with early syphilis, with VDRL-positive syphilitic meningitis, and frequently with human immunodeficiency virus coinfection. The chronic posterior uveitides are often insidious, a manifestation of late syphilis, and associated commonly with subclinical neurosyphilis. All patients with acute cases and 54% of patients with chronic cases in our study received penicillin therapy appropriate for neurosyphilis. The frequent association of syphilitic posterior uveitis with neurosyphilis and the analogous spirochetal sequestration beyond the blood-brain and the blood-ocular barriers suggest that all patients with syphilitic posterior uveitis, irrespective of ocular disease intensity, should undergo evaluation of cerebrospinal fluid and be treated with penicillin regimens appropriate for neurosyphilis.

Posterior segment manifestations of active ocular syphilis, their response to a neurosyphilis regimen of penicillin therapy, and the influence of human immunodeficiency virus status on response

OBJECTIVE

To determine the relative frequencies of signs in posterior segment ocular syphilis, the response to a neurosyphilis regimen of penicillin, and differences in findings between human immunodeficiency virus (HIV)-coinfected and -noncoinfected patients in a community setting.

DESIGN

Retrospective, noncomparative, consecutive case series.

PARTICIPANTS

Fourteen consecutive patients with posterior segment ocular syphilis over a 14-year period within or during the acquired immune deficiency syndrome era.

INTERVENTION

Neurosyphilis intravenous penicillin regimen.

MAIN OUTCOME MEASURES

Initial and final visual acuity; treponemal and nontreponemal serologic analyses; cerebrospinal fluid cell count, protein, and Venereal Disease Research Laboratory analyses; posterior segment signs; and relapses and recurrences.

RESULTS

Blacks and males were predominantly affected. Five (36%) of patients were HIV coinfected, and ocular syphilis led to the HIV infection diagnosis in three. Four (29%) patients had received previous antibiotic therapy for primary or secondary syphilis, raising the suspicion of relapse. Two patients had negative nontreponemal serologic results. All patients responded rapidly to neurosyphilis therapy. One patient subsequently relapsed after neurosyphilis therapy, and a second was reinfected with recurrence of ocular involvement. One previously undescribed retinal manifestation was discovered: a sectorial retinochoroiditis with delayed retinal circulation in the involved area.

CONCLUSIONS

Ocular syphilis is a form of neurosyphilis and requires neurosyphilis therapy regardless of when it develops after primary infection. Conventional syphilis staging is of little use in understanding ocular syphilis. A high suspicion for this diagnosis is appropriate, especially in poorer black males with posterior segment inflammatory disease. Human immunodeficiency virus coinfection with ocular syphilis is common, but does not affect response to a neurosyphilis regimen of penicillin in the short term. Awareness of the multiple presentations of posterior segment ocular syphilis will aid ophthalmologists in averting misdiagnosis or delayed diagnosis.

Vitritis as the primary manifestation of ocular syphilis in patients with HIV infection

PURPOSE

To describe dense vitritis as the primary manifestation of ocular syphilis in three human immunodeficiency virus (HIV)-positive patients and to determine the response of these patients to the established regimen for neurosyphilis.

METHODS

Anti-Toxoplasma gondii IgM and IgG antibody titers, tuberculin skin test, chest radiograph, and serum angiotensin-converting enzyme level were obtained because tuberculosis, sarcoidosis, and toxoplasmosis were in the differential diagnosis. Two of the three patients were not known to have HIV infection at the time of initial examination and consented to HIV testing. Treponemal and nontreponemal tests were performed on serum and cerebrospinal fluid to establish a definitive diagnosis. Treatment for neurosyphilis was initiated, and daily ophthalmic examinations were performed, with careful attention to signs commonly associated with syphilitic eye disease.

RESULTS

All three patients exhibited improvement in visual acuity and resolution of vitreous haze. There was no evidence of other signs of posterior uveitis. The one patient for whom there has been a 6-month follow-up showed no sequelae of his eye disease.

CONCLUSIONS

Human immunodeficiency virus-positive patients with syphilis may present atypically dense vitritis. In these patients, vitritis may be the first manifestation of syphilis. The regimen for neurosyphilis provides effective therapy. Moreover, in some patients, syphilitic vitritis may be the initial manifestation of HIV disease.

Ophthalmic complications of HIV infection

HIV retinopathy, a noninfectious microangiopathy, is the most common ocular manifestation of HIV infection. Opportunistic infections, neoplasms, neuro-ophthalmic lesions, and drug-induced lesions may also cause ocular problems. Opportunistic ocular infections, particularly CMV retinitis, are a major cause of morbidity in patients with AIDS. Because of the underlying chronic and progressive immune dysfunction, the ocular symptoms, signs, clinical course, and treatment are often atypical and severe, requiring protracted medical therapy.

Clinical expression of secondary syphilis in a patient with HIV infection

There are increasing reports of unusual clinical features and atypical courses of syphilis in patients with acquired immunodeficiency syndrome. Recently, we had the opportunity to study an HIV-positive female patient with strong manifestations of secondary syphilis. The case is discussed together with the implications of secondary syphilis in her concomitant ocular affliction. Moreover, we comment on the clinico-therapeutic controversies brought about by the association of infection with Treponema pallidum and HIV.

Response of latent syphilis or neurosyphilis to ceftriaxone therapy in persons infected with human immunodeficiency virus

OBJECTIVE

To evaluate the effect of ceftriaxone in treating latent syphilis or asymptomatic neurosyphilis in patients infected with the human immunodeficiency virus (HIV).

DESIGN

Follow-up study of patients treated at two HIV-based clinics during 16 months from 1989 to 1991.

PATIENTS

Patients were those in whom a clinical diagnosis of latent syphilis or asymptomatic neurosyphilis was made, who received all recommended doses of antimicrobial therapy, and who returned for follow-up visits for 6 or more months.

RESULTS

Forty-three patients were treated with ceftriaxone, 1 to 2 g daily for 10 to 14 days. Thirteen underwent lumbar puncture before treatment; 7 (58%) had documented neurosyphilis (pleocytosis in 5, elevated protein levels in 6, VDRL reactive in cerebrospinal fluid [CSF] in 7), and 6 had documented latent syphilis (entirely normal CSF). The remaining 30 were said to have presumed latent syphilis. There was no relation between the diagnosis and the selected dosage of ceftriaxone. Response rates were similar in those who had documented neurosyphilis and documented or presumed latent syphilis. Overall, 28 patients (65%) responded to therapy, 5 (12%) were serofast, 9 (21%) had a serologic relapse, and 1 (2%) who experienced progression to symptomatic neurosyphilis was a therapeutic failure. Thirteen patients received benzathine penicillin for presumed latent syphilis; results were similar to those observed after ceftriaxone therapy, with 8 (62%) responders, 1 (8%) serofast, 2 (15%) relapses, and 2 (15%) failures. CD4 cell counts in responders were not different from those who failed to respond.

CONCLUSIONS

Even in the absence of neurologic symptoms, half of the HIV-infected persons who have serologic evidence of syphilis may have neurosyphilis. Although ceftriaxone achieves high serum and CSF levels, 10 to 14 days of treatment with this drug were associated with a 23% failure rate in HIV-infected patients who had latent syphilis or asymptomatic neurosyphilis. Three doses of benzathine penicillin did not have a significantly higher relapse rate and may provide appropriate therapy, at least for documented latent syphilis in persons co-infected with HIV. Studies comparing ceftriaxone with 10 to 14 doses of procaine penicillin are needed to determine the most cost-effective treatment for asymptomatic neurosyphilis or presumed latent syphilis in this group of patients.

Ocular syphilis

There has been a steady increase in the number of cases of syphilis in the United States since the middle 1980s, with a dramatic rise in incidence among heterosexual men and women and of congenital syphilis. There also have been changes in geographic distribution of cases and an association with cocaine use. The ophthalmologic manifestations of syphilis are broad. There is anecdotal evidence that the natural history of syphilitic infection is altered by coinfection with human immunodeficiency virus. The potential of coinfection with HIV makes the clinical evaluation, treatment, and assessment of therapeutic outcome of syphilitic infection more confounding and controversial. This article provides a review of the changing demographics and ophthalmic manifestations of syphilis, the current status of laboratory testing techniques, and management approaches to various types of ocular syphilis.

Syphilis in adults

This article reviews the clinical manifestations of syphilis, diagnostic tests that might help to diagnose accurately the disease, and current recommendations for therapy. The association of syphilis and human immunodeficiency virus infection raises additional questions related to transmission, diagnosis, and therapy of both diseases.

Ocular syphilis

The ability of syphilis to mimic different ocular disorders can lead to misdiagnosis and delay in appropriate antimicrobial therapy. The authors describe their experience over the past 5 years with the ocular manifestations of syphilis in 25 patients who comprised 2.45% of 1020 new patients. Uveitis was the most common ocular manifestation seen. All patients had positive results from FTA-ABS tests, whereas only 68% had reactive serum VDRLs. Two of five patients tested for human immunodeficiency virus (HIV) antibody were reactive. The authors recommend routine FTA-ABS and VDRL screening in patients with uveitis or unexplained ocular inflammation. They also recommend testing for HIV antibody in luetics and aggressive treatment with high-dose aqueous penicillin for syphilis.

The ocular manifestations of syphilis in the human immunodeficiency virus type 1-infected host

Nine patients with active ocular or optic nerve involvement by syphilis who also had concurrent human immunodeficiency virus type-1 (HIV-1) infection are described. The ocular manifestations of syphilis led to the discovery of HIV-1 seropositivity in four of nine cases. Fifteen eyes were affected. Ocular manifestations were: iridocyclitis in three eyes, vitreitis in one eye, retinitis or neuroretinitis in five eyes, papillitis in two eyes, optic perineuritis in two eyes, and retrobulbar optic neuritis in two eyes. Three patients diagnosed with acquired immune deficiency syndrome (AIDS) had the worst initial visual acuities. Six of nine patients had evidence of concomitant central nervous syndrome (CNS) involvement with syphilis. Benzathine penicillin was administered intramuscularly to three patients. All three had relapses. Seven of nine patients treated intravenously with high-dose penicillin had dramatic responses to therapy with improvement in vision and serologies and no evidence of relapse. Regimens accepted for the treatment of neurosyphilis appear to be adequate for the treatment of ocular syphilis in HIV-1-infected patients though further long-term follow-up will be required.

Choroidal neovascular membrane and other chorioretinal complications of acquired syphilis

We reviewed ten patients who had posterior segment complications of acquired syphilis. Five of these patients had a neovascular membrane of the choroid associated with secondary or tertiary syphilis. Vision was stabilized after laser photocoagulation in one patient who had a choroidal neovascular membrane. Five additional patients had ocular manifestations including uveitis, optic neuritis, neuroretinitis, chorioretinitis, retinal hemorrhages, arterial and venous occlusion, vasculitis, and retinitis. Treatment of chorioretinal complications of syphilis with intravenous penicillin, if initiated early in the course of the disease, may result in excellent visual recovery.

Syphilitic retinitis in a homosexual man with concurrent HIV infection: case report

A case is reported of secondary syphilis with ocular signs in a patient who had antibodies to human immunodeficiency virus (HIV) and hepatitis B infections and from whose urine cytomegalovirus was cultivated. Treatment with penicillin resulted in rapid recovery from his retinitis and uveitis. The case highlights the importance of testing for syphilis in all patients with HIV infection.

Ocular manifestations of acquired immune deficiency syndrome

The ocular complications of acquired immune deficiency syndrome (AIDS) include: (1) a noninfectious microangiopathy, most often seen in the retina, consisting of cotton-wool spots with or without intraretinal hemorrhages and other microvascular abnormalities; (2) opportunistic ocular infections, primarily cytomegalovirus (CMV) retinitis; (3) conjunctival, eyelid, or orbital involvement by those neoplasms seen in patients with AIDS (i.e., Kaposi's sarcoma and lymphoma); and (4) neuro-ophthalmic lesions. In a series of 200 AIDS patients evaluated clinically, AIDS retinopathy was present in 66.5%. Sixty-four percent had cotton-wool spots, and 12% had intraretinal hemorrhages. Cytomegalovirus retinitis was diagnosed in 28% of AIDS patients. Neuro-ophthalmic lesions were found in 8% of all AIDS patients and were present in 33% of those patients with cryptococcal meningitis. Acquired immune deficiency syndrome retinopathy was present in 40% of 35 patients with the AIDS-related complex (ARC) and in 1.3% of 232 patients with asymptomatic human immunodeficiency virus (HIV) infection, evaluated photographically. These results suggest that the prevalence of AIDS retinopathy increases with increasing severity of HIV infection, and that CMV retinitis presents a significant vision-threatening problem in AIDS patients.

Ocular syphilis in patients with human immunodeficiency virus infection

We diagnosed ocular syphilis in three homosexual men infected with human immunodeficiency virus (HIV). Ocular inflammation included uveitis, optic neuritis, and retinitis. Dermatologic and central nervous system manifestations of secondary syphilis were also present. The history of homosexuality was difficult to obtain. Concomitant infection with HIV may alter the course of syphilis, obscure the diagnosis, and impair the response to therapy.

Unusual manifestations of secondary syphilis and abnormal humoral immune response to Treponema pallidum antigens in a homosexual man with asymptomatic human immunodeficiency virus infection

The case presented here involves a 32-year-old homosexual man with human immunodeficiency virus (HIV) seropositivity and unusual manifestations of secondary syphilis. The patient presented with syphilitic keratoderma and chorioretinitis, and his appearance superficially resembled that of a patient with Reiter's syndrome. Although nontreponemal and treponemal tests for syphilis showed reactivity, the patient's humoral immune response to individual polypeptides of Treponema pallidum, measured by Western blot analysis, was markedly abnormal. The possible relationship between asymptomatic HIV infection and an abnormal humoral immune response to a second pathogen, in this case T. pallidum, is discussed. Our case is one of several recent cases of active syphilis reported in individuals with HIV seropositivity.