Ocular syphilis. Curr Opin Ophthalmol. 2014;25:513-518. [PMID: 25237932 DOI: 10.1097/icu.0000000000000099]

Diagnosis and treatment of syphilitic uveitis: Taiwan experts consensus

A recent resurgence in the incidence of syphilis has sparked a new interest in this old disease. Syphilitic uveitis remains a challenging disease, among the variable syphilis infections, due to the diagnostic complexity and the wide clinical manifestations. Here, we provide recommendations regarding clinical manifestations, diagnosis, and treatment for patients with syphilitic uveitis in Taiwan based on an expert meeting and consensus from experienced uveitis specialists.

Clinical Insights: Antimicrobial Therapy for Infectious Uveitis

Infectious uveitis is a major global cause of vision impairment. Despite the eye's immune privilege, afforded by the blood-ocular barrier that restricts microbial entry, several pathogens such as bacteria, viruses, fungi, and parasites can still infiltrate and cause ocular infections and complications. Clinicians often encounter significant challenges in treating infectious uveitis due to limited or ineffective treatment options. Modern molecular techniques and imaging can aid in diagnosing and assessing intraocular infections. Various antimicrobial therapies exist, spanning topical and systemic treatments, but these are constrained by issues like drug concentration, penetration, effective duration, toxicity, and side effects. Treatment approaches also differ based on the infection's etiology. This review provides recent updates on antimicrobial therapies from a clinical perspective, covering topical, systemic, and regional treatments for infectious uveitis.

Sexually transmitted infections and HIV in ophthalmology

The ocular and periocular manifestations of sexually transmitted infections are heterogeneous in etiology, manifestations, and complications. Etiologic agents include bacteria, viruses, parasites, and protozoa, which are most frequently transmitted via direct ocular contact with an active lesion or infected bodily fluid, autoinoculation, or dissemination from a distant site. Vertical transmission most commonly occurs perinatally during vaginal delivery. The complications of ophthalmia neonatorum can be severe, with the potential for permanent blindness or life-threatening systemic involvement if untreated. Clinical features, diagnostic modalities, and therapeutic regimens vary based on etiology and are summarized in this review. Prompt diagnosis is imperative, given the severe sequelae that may result from ocular involvement in these infections, including permanent vision loss. A multidisciplinary approach, involving both ophthalmology and dermatology, to diagnosis and management is essential to mitigate the risk of morbidity associated with sexually transmitted infections resulting in eye disease.

Demystifying Ocular Syphilis - A Major Review

Syphilis, caused by the spirochaete, Treponema pallidum, continues to be a public health challenge globally with its rates steadily increasing in the past few years. The disease is transmitted through small breaks in the skin during sexual contact, or via congenital transmission in utero, either across the placenta or by contact with an active genital lesion during delivery. Estimated 5.7-6 million new cases are detected every year worldwide in the 15-49 years age group. An increased incidence has been reported in most populations with particular clusters in special groups like men who have sex with men, female sex workers, and their male clients. Ocular syphilis has a varied presentation and is considered a great mimicker in all cases of uveitis. The laboratory diagnosis of syphilis is predominantly based on serological tests including TPHA and VDRL. Parenteral penicillin is the cornerstone of treatment for all stages of ocular syphilis.

Clinical Features and Possible Origin of Preretinal Deposits in Different Ocular Diseases and Events: A Narrative Review

Preretinal deposits (PDs) are a rare condition among fundus diseases. We found that preretinal deposits have some features in common that can provide clinical information. This review affords an overview of PDs in different but related ocular diseases and events, and summarizes the clinical features and possible origin of PDs in related conditions, providing diagnostic clues for ophthalmologists when facing PDs. A literature search was performed using three major electronic databases (PubMed, EMBASE, and Google Scholar) to identify potentially relevant articles published on or before June 4, 2022. Most of the cases in the enrolled articles had optical coherence tomography (OCT) images to confirm the preretinal location of the deposits. Thirty-two publications reported PD-related conditions, including ocular toxoplasmosis (OT), syphilitic uveitis, vitreoretinal lymphoma, human T-cell lymphotropic virus type 1 (HTLV-I) associated uveitis or HTLV-I carriers, acute retinal necrosis, endogenous fungal endophthalmitis, idiopathic uveitis, and exogenous materials. Based on our review, OT is the most frequent infectious disease to exhibit PDs, and silicone oil tamponade is the most common exogenous cause of preretinal deposits. PDs in inflammatory diseases are highly suggestive of active infectious disease and are preferentially accompanied by a retinitis area. However, PDs will largely resolve after etiological treatment in either inflammatory or exogenous conditions.

Appraisal of vitreous syphilis antibody as a novel biomarker for the diagnosis of syphilitic uveitis: a prospective case-control study

PURPOSE

To determine the sensitivity and specificity of syphilis antibody tests in vitreous samples and to propose an algorithm using vitreous syphilis antibody as a supplementary test to confirm syphilitic uveitis (SU).

METHODS

A prospective case-control study was conducted at the Retina and Uveitis Clinic from May 2017 to January 2020. Initially, patients were classified based on syphilis serology into group 1 (positive testing) and group 2 (negative testing). Group 1 was further divided into 2 subgroups (group 1A and 1B) depending on their relevant clinical manifestations and clinical improvement. Group 2 served as a control group.

RESULTS

Thirty-eight patients were enrolled in the study: 14 in group 1A, 5 in group 1B, and 19 in group 2B. No patient was assigned to group 2A. All patients in group 1A, representing definite SU, completed syphilis test (rapid plasma reagin [RPR], enzyme immunoassay [EIA], and fluorescent treponemal antibody-absorption [FTA-ABS]) for vitreous, and all vitreous samples yielded positive results. Of the 5 subjects in group 1B, 3 cases were considered to be not SU with different conditions, and 2 were indeterminate for SU. They presented with different features not typical of SU, and they had variable and fewer positive syphilis antibody responses. The most sensitive test for detecting syphilis antibodies in vitreous was EIA (90.9%), followed by RPR (80.0%) and FTA-ABS IgG (78.9%). EIA and FTA-ABS had the highest specificity, detecting 100% of the syphilis antibody.

CONCLUSIONS

Vitreous analysis of syphilis antibody can serve as a supplementary test to confirm SU in selected cases as the proposed algorithm.

Activation of Ocular Syphilis After Small-Incision Lenticule Extraction

A 41-year-old female presented to the Willis-Knighton Eye Institute to undergo evaluation for refractive surgery. The patient had a best-corrected visual acuity for a distance of 20/15-1 of the right eye (OD) and 20/15-1 of the left eye (OS) with a manifest refraction of -2.75 OD and -1.75 OS. Near visual acuity was J1+ in both eyes (OU). A trial of a monovision contact lens was successful with the dominant eye selected for distance. The patient was then planned for small-incision lenticule extraction (SMILE) OD only with a plano target. SMILE was performed and was uncomplicated with uncorrected visual acuity of 20/15- on postoperative day one. Two weeks after the initial SMILE procedure, the anterior segment was notable for 1-2+ cells OD. Topical prednisone was changed to difluprednate 0.05% TID OD with improvement in symptoms. However, the anterior chamber cell was never fully resolved by month three. A systemic workup revealed a positive rapid plasma reagin with 1:64 titer and a positive fluorescent treponemal antibody absorption in a patient never treated for syphilis. The patient was diagnosed with ocular syphilis and received a two-week course of intravenous penicillin G. A slow topical prednisone tapper was performed with the resolution of inflammation by one year. Anterior uveitis after refractive surgery is uncommon. The incidence of anterior uveitis after SMILE is even rarer with no previously documented incidence in the literature. As a result, persistent cell seen in refractive procedures, especially SMILE, is a concerning finding, warranting further workup to rule out underlying systemic diseases including syphilis.

Pars Plana Vitrectomy With Internal Limiting Membrane Peeling for the Treatment of Cystoid Macular Edema in a Patient With Syphilitic Uveitis and HIV Infection

We report a case of cystoid macular edema (CME) secondary to syphilitic uveitis that was successfully treated with pars plana vitrectomy with internal limiting membrane peeling. A 37-year-old male with a history of HIV developed a CME secondary to syphilitic panuveitis. His uveitis resolved following treatment with intravenous penicillin, yet his CME persisted and was refractory to four posterior sub-tenon triamcinolone acetonide injections. A pars plana vitrectomy with internal limiting membrane peeling was performed, resulting in lasting resolution of the CME and the improvement of his visual acuity at the two-month follow-up visit. Pars plana vitrectomy with internal limiting membrane peeling may be a viable alternative for the treatment of CME in patients with syphilitic uveitis. In particular, it may serve as a viable alternative for the treatment of CME in patients with a history of infectious uveitis or other comorbidities, such as HIV infection.

Infectious Posterior Uveitis - Toxoplasmosis, Treponema, Tuberculosis (TTT)

Toxoplasma gondii, Treponema pallidum and Mycobacterium tuberculosis are the most important infectious causes of posterior uveitis. The epidemiology, clinical picture, diagnostic and treatment strategies of these diseases are presented.

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.

Syphilitic Outer Retinopathy: A Case Report and Review of the Literature

Purpose:

This work presents a case of syphilitic outer retinopathy with findings similar to those of acute zonal occult outer retinopathy (AZOOR). We also discuss the clinical characteristics, treatment, and prognosis of this entity.

Methods:

A case report and systematic literature review are presented.

Results:

A 56-year-old woman presented with acute vision loss, localized photopsia, a central scotoma, and retinal findings that were all consistent with AZOOR. A further workup led to a diagnosis of syphilis. Oral prednisone and intravenous penicillin resulted in the resolution of the posterior uveitis and the restoration of visual acuity. However, the central scotoma remained at the 3-year follow-up visit.

Conclusions:

Syphilitic outer retinopathy is a distinct entity characterized by the disruption of the ellipsoid zone visible on optical coherence tomography and a corresponding increase in fundus hyperautofluorescence in the affected areas. Although some patients may present with a demarcation line, as is seen with AZOOR, the fundus is oftentimes unremarkable or may show only subtle retinal pigment epithelium changes. Uveitis resolution and visual acuity restoration may be expected following treatment; however, visual field disturbances may persist.

[Ocular syphilis, the rise of a forgotten disease: Retrospective study of 18 cases diagnosed at Amiens University Hospital]

OBJECTIVES

A disturbing resurgence of syphilis has been observed in the past few years. Ocular involvement of syphilis is infrequent. The goal of our study was to analyze the demographic data and clinical features and to analyze visual outcomes in cases of ocular syphilis at Amiens UH between January 1, 2015 and December 31, 2019.

MATERIAL AND METHODS

This descriptive, observational, single-center study included a retrospective cohort of patients who were diagnosed with ocular syphilis. The data collected were demographic data (age, sex and sexual orientation), history of risky sexual behavior, HIV status and potential co-infections, stage of syphilis, chief complaint, initial and final logMAR visual acuity, biomicroscopic examination of the anterior segment, dilatated fundus examination, extraocular clinical manifestations and treatment initiated.

RESULTS

Twenty-four eyes of eighteen patients (17 men and 1 woman) with a mean age of 48±12 were included in the study. 9 patients were homosexual, and 9 were heterosexual. A history of risky sexual behavior was noted in 6 patients (33.3%), and 4 patients (22%) were HIV positive. 2 patients (11.1%) had primary syphilis, 14 patients (77.7%) had secondary syphilis and 2 patients (11.1%) had tertiary syphilis. All patients were symptomatic, and vision loss was the main ophthalmologic symptom. The mean initial visual acuity was -0.55±0.56 logMAR, and the final visual acuity was 0.04±0.07 logMAR. Posterior uveitis was the predominant type of involvement (42%), and 9 patients presented with neurosyphilis. 11 patients (61.1%) showed extraocular clinical manifestations. 9 patients (50%) received subcutaneous ceftriaxone 2g, 6 patients (33.3%) received daily intravenous benzylpenicillin G, 2.4 million IU, and 3 patients (16.6%) were treated with oral doxycycline 200mg.

CONCLUSION

Ocular syphilis remains a diagnostic and therapeutic challenge because of the various ocular manifestations it provokes. Since this pathology can result in severe damage, every clinician who diagnoses uveitis should consider the possibility of syphilis so as to avoid any delay in treatment. Even though ocular syphilis remains a rare clinical entity, it is a potentially devastating infection.

Spectrum of ocular manifestations and visual outcomes of neurosyphilis among 53 patients

BACKGROUND

In the era of the re-emergence of syphilis, ocular syphilis has gained attention because its prevalence has increased and it can cause blindness and disability.

OBJECTIVES

To investigate the clinical presentation and prognosis of ocular syphilis.

METHODS

Prospective study on 53 patients (90 eyes) with ocular syphilis diagnosed at the Santa Casa of Belo Horizonte, Brazil. The diagnosis was based on clinical manifestations of the disease and on serological markers (positive serum treponemal and non-treponemal tests or two positive treponemal tests).

RESULTS

Thirty-five eyes (66%) were from men and the mean age was 45.3 ± 12.0 years. HIV coinfection was confirmed in 10 patients (18.9%). Forty-four (84.9%) had VDRL titers ≥ 1:32. Bilateral ocular involvement occurred in 68%. Optic neuritis was diagnosed in 51.7% of the eyes and uveitis in 48.2%. Regarding visual acuity, the median baseline logarithm of the minimum angle of resolution (logMAR) was 1 (20/200 Snellen), while after antibiotic therapy, the median was 0.2 (20/30 Snellen). Poor visual acuity after treatment, defined as the best-corrected visual acuity (BCVA; logMAR 1; 20/200 Snellen) or worse, was associated with severe BCVA at presentation (below logMAR 1.3; 20/400 Snellen) (p = 0.001) and age over 50 years (p = 0.001).

CONCLUSIONS

This study confirms the wide spectrum of clinical manifestations of ocular syphilis. The most frequent form was optic neuritis, an important differential diagnosis from other causes of inflammatory neuritis. Early diagnosis is essential, given that this is a treatable condition with excellent visual recovery in most cases.

Hypopyon: Is-it Infective or Noninfective?

Hypopyon usually corresponds to the sedimentation of white blood cells, and it signifies severe intraocular inflammation. This key clinical sign may occur in association with a wide variety of infectious, inflammatory, and neoplastic conditions that may be sight- and, occasionally, life-threatening. A careful history and thorough clinical examination are the cornerstones for orienting the differential diagnosis, identifying the causative agent, and initiating prompt and appropriate treatment. This review outlines the clinical characteristics and management of hypopyon in relation with the underlying causative infectious or noninfectious ocular or systemic diseases.

A review of diseases of the retina for neurologists

Diseases of the retina are common and numerous, with causes ranging over inherited, inflammatory, vascular, infectious, neoplastic, traumatic, toxic, and idiopathic etiologies. A key issue in the diagnosis of retinal disease is the duration of symptoms, which can be acute, chronic, or acute presentations of chronic disease. Clinical examination with direct ophthalmoscopy or, even better, biomicroscopy with a slit lamp and condensing lens, is a key component of diagnosis, which can be enhanced through investigational methods such as fluorescein angiography, optical coherence tomography, or electroretinography. Consideration of the history, visual acuity and visual field, and fundoscopic findings is usually sufficient to determine whether patients need referral on an emergency, urgent, or routine basis. Emphasis is given to vascular disease, age-related macular degeneration, diabetic retinopathy, genetic eye disease, and retinal detachment.

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.

Ocular syphilis in patients with human immunodeficiency virus/acquired immunodeficiency syndrome in the era of highly active antiretroviral therapy

Purpose:

Re-emergent ocular syphilis in patients with Human immunodeficiency virus (HIV) co-infection has both diagnostic and management difficulties because of the overlapping risk factors. The clinical manifestations described in non-HIV may not be the same in patients with HIV coinfection. Immune recovery uveitis (IRU) may also alter the course of the disease causing recurrences. We studied the clinical features in correlation with CD4 counts, systemic immune status, sexual preferences and management outcomes in HIV/AIDS patients with ocular syphilis in the highly active antiretroviral treatment (HAART) era from a high endemic HIV population like India.

Methods:

Retrospective analysis of all patients with ocular syphilis and HIV/AIDS seen between 2016 and 2019 was done.

Results:

A total of 33 patients (56 eyes) with a CD4 count range of 42–612 cells/cu.mm were included. Ocular syphilis was found to be higher in individuals with high risk behavior such as men who have sex with men (MSMs) (45%). Panuveitis was the commonest manifestation (53.57%) and was even the presenting feature of HIV and syphilis in many patients. Significant vitritis, usually uncommon in HIV/AIDS immunocompromised patients was noted even with low CD4 counts in patients with ocular syphilis. Significant correlation was noted between ocular presentation and CD4 counts (P < 0.05).

Conclusion:

Ocular syphilis presents differently in patients with HIV/AIDS. Diffuse retinitis is seen commonly in low counts (<100 cells/cu.mm). Classical placoid chorioretinitis lesions usually described in non-HIV individuals is uncommon in HIV patients and is seen in higher CD4 counts ( >400 cells/cu.mm). Ocular manifestations can be an indicator of the immune status of the patient. Not all patients with ocular manifestations have associated features of systemic syphilis. Ocular manifestations can be the first presentation of HIV/AIDS. Although, there is good response to systemic penicillin and HAART, recurrences and immune recovery uveitis (IRU) can also occur.

Ocular syphilis

Syphilis is a sexually transmitted, systemic, inflammatory disease caused by the spirochaete, Treponema pallidum. The natural history of untreated syphilis progresses through four distinct stages: primary, secondary, latent, and tertiary syphilis. Ocular involvement can occur at any stage of syphilis and any part of the eye can be affected. With the exception of syphilitic posterior placoid chorioretinitis, the diverse manifestations of ocular syphilis have few distinct features that can be used to assist in clinical diagnosis. Therefore, ocular syphilis should always be a part of the differential diagnosis of most, if not all, ocular infectious and inflammatory presentations. Specifically, uveitis presentations, high-risk sexual history, illicit drug use history, treatment failure, prior history of syphilis should prompt further diagnostic workup for ocular syphilis. A presumptive diagnosis of ocular syphilis relies on serological testing, both treponemal and nontreponemal tests. All patients with ocular syphilis should have their cerebrospinal fluids tested for the co-existence of neurosyphilis and their blood tested for human immunodeficiency virus co-infection. In the United States, Centers for Disease Control and Prevention recommend that ocular syphilis be managed according to its treatment guidelines for neurosyphilis, with parenteral aqueous crystalline penicillin G the drug of choice. With the timely diagnosis and appropriate treatment, ocular syphilis is curable. However, delayed diagnosis of ocular syphilis may result in long-term visual impairment. Delayed diagnosis occurs because of its diverse presentations mimicking other ocular diseases, and failure of the clinician to order serological testing. With the recent worldwide resurgence of ocular syphilis, clinicians should be familiar with the manifestation, diagnosis, and treatment of ocular syphilis.

Bilateral retrocorneal hyaline scrolls secondary to asymptomatic congenital syphilis: A case report

BACKGROUND

Retrocorneal hyaline scrolls are a rare phenomenon. We report a case of bilateral retrocorneal hyaline scrolls that were likely induced by asymptomatic congenital syphilis.

CASE SUMMARY

A 71-year-old woman presented with blurred vision due to cataracts. Slit-lamp microscopy revealed bilateral hyaline scrolls with a dichotomous branching pattern extending to the anterior chamber or rods attaching to the rough posterior surface of the cornea. The patient was positive for syphilis-specific antibodies, with no ocular or systemic evidence of congenital or acquired syphilis. Binocular cataract, retrocorneal scroll, and corneal endothelial gutta were considered. The scroll of the right eye was removed during cataract surgery and further observed using hematoxylin–eosin staining and scanning electron microscopy. The cornea of the right eye remained transparent, and the residual scroll seemed stable, however, the corneal endothelial density declined at 13 mo after surgery. In vivo confocal microscopy revealed coalescence of corneal guttae at the level of the corneal endothelium or adhesion to the posterior surface of the endothelium, with enlarged endothelial cells in both eyes. Activated keratocytes in the stroma and a highly reflective acellular structure at the level of the Descemet’s membrane were observed. The removed scroll had a cartilage-like hardness and a circularly arranged fiber-like acellular structure.

CONCLUSION

Occult congenital syphilis could induce corneal endothelial gutta and the formation of retrocorneal scrolls without other signs of ocular syphilis.

Bilateral hypopyon in syphilitic uveitis

PURPOSE

To report an atypical bilateral hypopyon presentation of syphilitic uveitis.

OBSERVATIONS

A 38-year-old male presented with a 2-day history of bilateral progressive visual loss, conjunctival hyperemia, and photophobia. Initial ophthalmologic examination revealed bilateral hypopyon and vitritis that limited the examination of the posterior segment. The physical exam revealed cervical lymphadenopathy, glossal leukoplakia, erythematous maculae on the hard palate, erythematous macular lesions on both palms, onychodystrophy, onycholysis, and psoriasiform plaques on both plantar surfaces, testicular tenderness, and hypopigmented patches on the scrotal and perianal skin. A therapeutic and diagnostic vitrectomy was performed on the right eye, and the intraoperative findings were consistent with severe vitritis and pre-retinal precipitates. The cytopathologic analysis of the right vitreous revealed a mixed inflammatory process composed of lymphocytes, histiocytes, and neutrophils in a proteinaceous background. Laboratory testing revealed positive serum RPR, CSF FTA-Abs and VDRL, and HIV serology. Treatment with a 2-week course of intravenous penicillin G 4 million units every 4 hours and topical corticosteroids resulted in complete resolution of the uveitis.

CONCLUSIONS AND IMPORTANCE

Bilateral hypopyon uveitis may be a rare presentation of syphilitic uveitis. As with most forms of uveitis, syphilis should be considered in the differential diagnosis of patients presenting with bilateral hypopyon.

Epidemiology of Uveitis in a tertiary care centre in Portugal

Purpose: Evaluate the prevalence and incidence, demographic characteristics, anatomical classification, concomitant complications and treatment of uveitis, as well as its association with systemic diseases in the northern Portuguese population referred to a tertiary care centre (São João Hospital, Porto).Methods: A retrospective observational study of 545 consecutive uveitis cases was performed between 12th April 2012 and the 26th October 2017. Uveitis was classified according to Standard Uveitis Nomenclature, while aetiology and complications were diagnosed by specific clinical and laboratory testing.Results: Prevalence was calculated to be 12,4 cases per 100,000 people while incidence was 3.9 cases per 100,000 people annual incidence. The ratio of females to males was 1.32:1 and the mean age at diagnosis was 47,86 years. Anterior uveitis was the most common classification making up 47.5%, followed by non-infectious posterior uveitis 18,0%, infectious posterior uveitis 8,4%, intermediate uveitis 5,5% and panuveitis 4,2%. Extra-uveal entities made up the rest of the causes (16.4%). In terms of aetiology, the majority of uveitis was idiopathic (32,1%) followed by axial spondylarthritis (12.1%), Behçet's disease (8,8%), sarcoidosis (6,1%), tuberculosis (5,5%), herpes (5,1%), toxoplasmosis (3,1%) among other less frequent causes.Conclusion: In our referral region, 72% of uveitis cases were correctly identified surpassing other studies. There was a higher rate of intermediate uveitis and lower number of panuveitis cases when compared to a previous Portuguese study. Extensive monitoring of the development of uveitis by international multicentre prospective studies could be useful for increasing practitioner awareness and diagnostic approach.

Rational laboratory testing in uveitis: A Bayesian analysis

Uveitis encompasses a heterogeneous group of clinical entities with the common feature of intraocular inflammation. In addition to patient history and examination, a focused set of laboratory investigations is frequently necessary to establish a specific diagnosis. There is limited consensus among uveitis specialists regarding appropriate laboratory evaluation for many distinct patient presentations. The appropriateness of a laboratory test for a given case of uveitis will depend on patient-specific as well as epidemiologic factors. Bayesian analysis is a widely used framework for the interpretation of laboratory testing, but is seldom adhered to in clinical practice. Bayes theorem states that the predictive value of a particular laboratory test depends on the sensitivity and specificity of that test, as well as the prevalence of disease in the population being tested. In this review we will summarize the performance of commonly-utilized laboratory tests for uveitis, as well as the prevalence of uveitic diagnoses in different geographic practice settings. We will propose a logical framework for effective laboratory testing in uveitic disease through rigorous application of Bayesian analysis. Finally, we will demonstrate that while many highly sensitive laboratory tests offer an effective means to rule out associated systemic disease, limited test specificity and low pretest probability often preclude the diagnosis of systemic disease association with any high degree of certainty, even in the face of positive testing.

Acute syphilitic posterior placoid chorioretinopathy presenting as atypical multiple evanescent white dot syndrome

BACKGROUND

This paper reports the case of a young man who presented with syphilis masquerading as multiple evanescent white dots syndrome (MEWDS), which turned out to be an acute syphilitic posterior placoid chorioretinopathy (ASPPC) during follow-up.

CASE PRESENTATION

A 59-year-old healthy male consulted for a three days' history of visual impairment in both eyes. On multimodal imaging, he was diagnosed as MEWDS. Fundus fluorescein angiography (FFA) showed early peripheral bilateral granular hyperfluorescence that correlated with the yellow-white dots found on fundus exam. Indocyanine green angiography (ICGA) depicted hypofluorescent dots on late phase. Spectral-domain optical coherence tomography (SD-OCT) revealed numerous inner retinal highly reflective deposits in the outer nuclear layer and disruption of the ellipsoid zone. After initial improvement, he presented again for a sudden visual loss at 3 weeks. FFA, ICGA and SD-OCT demonstrated the same but more numerous and outer lesions suggesting an ASPPC. A full inflammatory work-up revealed highly positive titers of rapid plasma regain (RPR) and fluorescent treponemal antibody absorption (FTA-Abs), suggesting a syphilis infection. The ophthalmological manifestations dramatically improved after the patient was admitted for high-dose intravenous penicillin G 24 million per day for 2 weeks.

CONCLUSION

This is the first case that reports an ocular syphilitic infection masquerading as MEWDS at presentation and that turns to be an ASPPC. Syphilis serology should be routinely done in every case of atypical MEWDS especially when unusually presented in a young healthy man, with bilateral involvement and a bad clinical evolution.

Ocular Syphilis Presenting as Acute Necrotizing Retinitis in a Human Immunodeficiency Virus-Positive Patient

The incidence of ocular syphilis is increasing in the developing world even in the era of effective human immunodeficiency virus (HIV) treatment, as there is a potential increase of high-risk sexual behavior. Ocular involvement in the form of uveitis is seen in all stages of syphilis. Diagnosis begins with ophthalmologic examination, but requires serologic testing for confirmation. Ocular syphilis presents with unusual presentations or mimics other diseases and is identified by serological screening. It is curable with a relatively short course of antibiotic treatment, making its recognition a priority. All ophthalmic manifestations of syphilis should be treated with a Centers for Disease Control and Prevention-approved neurosyphilis regimen. In this report, we present a case of necrotizing retinitis with no response to antiviral treatment. On subsequent serological testing it was proved as syphilis in a HIV-positive patient who responded well to intravenous antibiotics with rapid visual recovery. Hence, awareness of this disease will promote early diagnosis and treatment.

Clinical and laboratory characteristics of ocular syphilis and neurosyphilis among individuals with and without HIV infection

BACKGROUND/AIMS

In the era of increasing incidence of syphilis globally, ocular syphilis is re-emerging as an important cause of uveitis. The aim of this study was to determine the clinical and laboratory characteristics of ocular- and neurosyphilis among individuals with and without HIV infection.

METHODS

Retrospective analysis of patients diagnosed with ocular syphilis presenting to Tygerberg Hospital, South Africa, over a 5-year period ending December 2018.

RESULTS

Two-hundred and fifteen eyes of 146 patients were included. HIV coinfection was present in 52.1% of the patients, with 23.7% of these patients being newly diagnosed on presentation. The median age was 36.5±9.8 years. Bilateral involvement occurred in 47.3%, with 68.1% of these patients being HIV positive. The most frequent form of intraocular inflammation was posterior uveitis (40.9%), followed by panuveitis (38.1%), both of which were more predominant in HIV-positive eyes. Seventy-four per cent of all eyes had a visual acuity ≤20/50 and 40% <20/200 at presentation. A lumbar puncture was performed in 113 patients (77.4%). Sixteen patients had confirmed neurosyphilis and 27 probable neurosyphilis according to the UpToDate algorithms.

CONCLUSION

This study included the largest number of ocular syphilis cases with the largest proportion of HIV infection to date. Forty-three of 146 patients (37.0%) had neurosyphilis. HIV status must be determined in all patients with ocular syphilis since almost ¼ of patients were newly diagnosed with HIV infection by doing so.

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.

VITREOUS TREPONEMAL ANTIBODY AS A SUPPLEMENTARY TEST TO SEROLOGY FOR THE CONFIRMATION OF SYPHILITIC CHORIORETINITIS

PURPOSE

To report the novel application of nontreponemal and treponemal antibody to confirm diagnosis of ocular syphilis from vitreous samples.

METHODS

Two distinct case reports emphasizing the importance of confirmatory vitreous treponemal antibody. Multimodal imaging of patients was also applied.

RESULTS

We report two distinct cases with positive serum treponemal antibody but opposing vitreous treponemal antibody results. One case with a positive vitreous test responded well to antisyphilitic treatment. By contrast, a case with a negative vitreous result was changed to serpiginous choroiditis, eventually cured by immunomodulatory treatment.

CONCLUSION

Intraocular fluid analysis of nontreponemal and treponemal antibody may play an important role in ruling out suspected ocular syphilis in settings without a polymerase chain reaction facility, especially immunocompromised patients who are at risk of multiple infections. Further studies are needed to establish the sensitivity and specificity of nontreponemal and treponemal antibody test on vitreous samples.

Bilateral exudative retinal detachment in undiagnosed ocular syphilis after treatment with corticosteroids

A case of a young Caucasian male who presented bilateral papilledema is described. He was misdiagnosed with bilateral anterior optic neuritis, developing panuveitis and exudative bilateral retinal detachment after being treated with megadoses of corticosteroids. He was finally diagnosed with ocular syphilis and treated with intravenous aqueous crystalline penicillin for 14 days, with complete resolution of his symptoms.

Neurosyphilis cerebrospinal fluid findings in patients with ocular syphilis

Purpose: To evaluate neurosyphilis cerebrospinal fluid (CSF) findings and initial ophthalmic manifestations in patients with syphilitic uveitis.Methods: We retrospectively reviewed the records of CSF analysis of 14 patients with syphilitic uveitis with treponemal analysis - chemiluminescent immunoassay and TPHA- and non-treponemal analysis - Rapid Plasma Reagin test - RPR.Results: 86% were males and 43% HIV+. Ocular signs of syphilis lead to the diagnosis of syphilis in 78% of patients. Typical syphilitic uveitis presentations included: acute syphilitic posterior placoid chorioretinitis (50% of patients), retinitis (21% of patients) and punctate inner retinitis (7% of patients). 57% of patients had definite neurosyphilis by the CDC criteria, while 71% had CSF abnormalities suggestive of central nervous system involvement.Conclusion: Based on international guidelines, the frequent CSF abnormalities found in syphilitic uveitis patient supports the diagnosis of neurosyphilis in a majority of patients.

Concurrent Primary Chancre and Ocular Syphilis in an Human Immunodeficiency Virus-Negative Man

We believe this to be the first report of coexisting polymerase chain reaction (PCR)-confirmed primary genital and ocular syphilis in a patient with penicillin allergy treated with doxycycline. The case examines the use of nonpenicillin and corticosteroid treatment of ocular syphilis and highlights the risk of eye involvement early in the disease process.

The Eye as a Window to Systemic Infectious Diseases: Old Enemies, New Imaging

BACKGROUND

Syphilis, tuberculosis and toxoplasmosis are major infectious diseases worldwide; all of them are multisystem pathologies and share a possible ocular involvement. In this context, a fundamental help for the definitive diagnosis is provided by the ophthalmologist, through clinical evaluation and with the aid of a multimodal imaging examination.

METHODS

We hereby describe selected cases who came to our attention and were visited in our eye clinic. In all clinics, the use of retinal and optic disc multimodal imaging during ophthalmological evaluation allowed to make a diagnosis of an infectious disease.

RESULTS

In our tertiary referral center more than 60 patients with syphilis, tuberculosis and toxoplasmosis have been evaluated in the last two years: In 60% of cases the ophthalmological evaluation was secondary to a previous diagnosis of an infectious disease, while in the remaining cases the ophthalmologist, with the help of a multimodal imaging examination and clinical evaluation, represented the physician who leads to the diagnosis.

CONCLUSION

Our results confirm how in these life-threatening pathologies a prompt diagnosis is mandatory and may benefit from a multidisciplinary and multimodal imaging approach, especially during ophthalmological evaluation.

Spectral optical coherence tomography findings in an adult patient with syphilitic bilateral posterior uveitis and unilateral punctate inner retinitis

Purpose

To describe the spectral domain optical coherence tomography (SD-OCT) features of a punctate inner retinitis, a rare ocular manifestation of syphilis, in an HIV positive adult patient.

Observations

In the right eye, SD-OCT images during the active period showed hyperreflectivity of the full thickness of the inner retina, precluding the individualization of the layers. In addition, multifocal areas with higher hyperreflectivity were identified within the affected retina. Once the lesion became inactive, SD-OCT images revealed inner retina layers atrophy, disruption of the ellipsoid layer, and multifocal damage to the retinal pigment epithelium layer.

Conclusion and importance

Punctate inner retinitis affects the full thickness retina, leading to severe retinal damage, along with multifocal damage of the retinal pigment epithelium. The multifocal white retinal lesions observed within the affected retinal area correlated with the presence of intense hyperreflective dots within the retina showed by SD-OCT. These lesions are deeper than was described in other reports.

Interstitial keratitis diagnosis and treatment

Interstitial keratitis is a non-ulcerative, non-suppurative, more or less vascularized inflammation of the corneal stroma. The corneal lesions result from the host response to bacterial, viral (40% of cases) or parasitic antigens, or from an autoimmune response (1% of cases) without active corneal infection. The natural history of the disease is divided into two phases: acute and cicatricial. This type of keratitis is less common than ulcerative bacterial keratitis, but it is a non-negligible cause of visual loss. It is associated with systemic or infectious disease and requires early diagnosis and appropriate treatment to optimize visual prognosis and avoid other complications.

Current ophthalmology practice patterns for syphilitic uveitis

Background

Syphilitic uveitis is re-emerging alongside the systemic infection. In July 2017, an international group of uveitis-specialised ophthalmologists formed the International Ocular Syphilis Study Group to define current practice patterns.

Methods

103 Study Group members based in 35 countries completed a 25-item questionnaire focused on case load, clinical presentations, use and interpretation of investigations, treatment and clinical indicators of poor prognosis.

Results

Members managed a mean of 6.1 patients with syphilitic uveitis in clinics that averaged 707 annual cases of uveitis (0.9%); 53.2% reported increasing numbers over the past decade. Patients presented to more members (40.2%) during secondary syphilis. Uveitis was usually posterior (60.8%) or pan (22.5%); complications included optic neuropathy, macular oedema and posterior synechiae. All members diagnosed syphilitic uveitis using serological tests (simultaneous or sequential testing algorithms), and 97.0% routinely checked for HIV co-infection. Cerebrospinal fluid (CSF) analysis was ordered by 90.2% of members, and 92.7% took uveitis plus Venereal Disease Research Laboratory test (VDRL) or fluorescent treponemal antibody absorption test (FTA-ABS) to indicate neurosyphilis. Patients were commonly co-managed with infectious disease physicians, and treated with penicillin for at least 10–14 days, plus corticosteroid. Features predicting poor outcome included optic neuropathy (86.3%) and initial misdiagnosis (63.7%). Reasons for delayed diagnosis were often practitioner-related. 82.5% of members tested every patient they managed with uveitis for syphilis.

Conclusion

This comprehensive report by an international group of uveitis-specialised ophthalmologists provides a current approach for the management of syphilitic uveitis.

Neurosyphilis and ocular syphilis clinical and cerebrospinal fluid characteristics: a case series

BACKGROUND

During the first decade of this century, a significant increase in the incidence of syphilis was documented.

OBJECTIVE

To study clinical and laboratory characteristics of central nervous system and ocular syphilis.

METHODS

A retrospective case series of 13 patients with a clinical and laboratory diagnosis of neurosyphilis and/or ocular syphilis who had been admitted to the Neurology and Neuro-ophthalmology Service of the Hospital de Clínicas, Federal University of Paraná.

RESULTS

Nine patients had a diagnosis of neurosyphilis and two of them also had ocular syphilis. Four patients had a diagnosis of ocular syphilis alone. Among the patients with a diagnosis of neurosyphilis, six had symptomatic syphilitic meningitis, of whom one manifested as cranial nerve palsy alone, one as cranial nerve palsy plus ocular syphilis, two as transverse myelitis (syphilitic meningomyelitis), one as meningitis worsening the patient's myasthenia gravis symptoms and one as meningitis plus ocular syphilis. Additionally, we diagnosed three patients with meningovascular neurosyphilis. In the univariate analysis, patients without ocular syphilis showed greater levels of total protein and white blood cells in the cerebrospinal fluid than patients with ocular syphilis.

CONCLUSION

This Brazilian case series of patients with neurosyphilis and ocular syphilis highlights the wide variability of this disease. A high degree of diagnostic suspicion is necessary when facing neurological and ocular symptoms for rapid diagnosis and appropriate management of patients.

Clinical Manifestations and Cerebrospinal Fluid Status in Ocular Syphilis

PURPOSE

To review the clinical manifestations, cerebrospinal fluid findings and outcomes of patients diagnosed with ocular syphilis.

METHODS

Retrospective case review of all patients treated with ocular syphilis at Groote Schuur Hospital in Cape Town, South Africa between January 2008 and January 2013.

RESULTS

A total of 77 eyes of 49 patients were included. Panuveitis was the most common presenting sign (48.9%). A lumbar puncture was performed on 37 patients (75.5%) and 64.8% (24/37) of samples had positive treponemal testing (CSF-FTA) while 24.3% (9/37) had positive non-treponemal testing (CSF-VDRL). Elevated CSF lymphocyte cell count was a strong predictor of neurosyphilis (p = 0.06 for CSF-FTA positive samples and p = 0.03 for CSF-VDRL positive samples).

CONCLUSION

The majority of patients (64.8%) who underwent lumbar puncture had cerebrospinal fluid findings suggestive of neurosyphilis. Elevated CSF lymphocyte cell count and total protein count are highly suggestive of neurosyphilis.

Clinical Manifestations and Ophthalmic Outcomes of Ocular Syphilis at a Time of Re-Emergence of the Systemic Infection

Recent reports from different world regions suggest ocular syphilis is re-emerging, in parallel with an increasing incidence of the systemic infection globally. We conducted a large observational study of 127 persons consecutively treated for ocular syphilis at public medical centers in Brazil over a 2.5-year period ending July 2015. Of 104 individuals serologically tested for human immunodeficiency virus (HIV), 34.6% were positive. Ophthalmological evaluations included measurement of Snellen visual acuity and intraocular pressure, and assessment of inflammation by slit lamp examination and dilated posterior eye examination. Involvements in 214 eyes were anterior (6.1%), intermediate (8.4%), posterior (76.2%) and pan- (8.4%) uveitis, and scleritis (0.9%). Multiple anterior and posterior eye complications were observed, including cataract in the anterior eye (incidence rate, 0.18/eye-year) and epiretinal membrane in the posterior eye (incidence rate, 0.09/eye-year); incidence rates of reduction in best-corrected visual acuity to ≤20/50 and ≤20/200 were 0.10 and 0.06/eye-year, respectively. Rates of complications and visual acuity loss did not differ significantly between HIV- positive and negative individuals. In an era of re-emergence, syphilis has ocular complications that may compromise vision, despite treatment with appropriate anti-microbial drugs.