Imaging syphilis uveitis

A 48-YEAR-OLD CAUCASIAN MAN WITH UNILATERAL "SMUDGE" IN INFERIOR VISUAL FIELD

PURPOSE

To report an increasingly prevalent fundoscopic manifestation of syphilitic uveitis.

METHODS

Case report of a patient with acute retinal necrosis secondary to syphilis.

RESULTS

A 48-year-old man presented with decreased vision, anterior segment inflammation, and a wedge-shaped retinal lesion in the superior periphery, with a diaphanous leading edge extending down toward the superior arcade. The patient was HIV+ and poorly compliant with therapy. The top three differential diagnoses were herpetic necrotizing retinitis, syphilis, and lymphoma. An extensive lab workup was positive for syphilis. The patient was treated with IV penicillin G and demonstrated improvement in visual acuity and examination.

CONCLUSION

There have been an increasing number of reports of syphilis patients, especially in the population of men who have sex with men, who present with fundus findings similar to acute retinal necrosis. These findings include a characteristic ground glass, translucent appearance of unifocal or multifocal lesions, primarily affecting the inner retina and sometimes associated with co-localizing occlusive vasculitis. Treatment with IV penicillin G is warranted and has demonstrated good visual recovery.

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.

Spectral optical coherence tomography findings in an elderly patient with syphilitic bilateral chronic panuveitis

Purpose

To report the spectral domain optical coherence tomography (SD-OCT) features of a focal retinitis in an elderly male patient with bilateral syphilitic panuveitis.

Observations

In the left eye (LE), spectral domain SD-OCT images during the active period revealed hyperreflectivity extending through the full thickness of the retina with no individualization of the layers, except for the retinal pigment epithelium. Once the lesion healed, SD-OCT imaging revealed an inner retinal atrophy and a mild disruption of the retinal pigment epithelium.

Conclusions and importance

In our patient, treponemal infection seemed to produce full-thickness retinal damage with partial involvement of the retinal pigment epithelium. The severe retinal damage, in this case, led to a poorer visual outcome than in other forms of syphilitic retinal involvement.

MULTIMODAL IMAGING OF SYPHILITIC MULTIFOCAL RETINITIS

PURPOSE

To describe multimodal imaging of syphilitic multifocal retinitis.

METHODS

Observational case series.

RESULTS

Two patients developed multifocal retinitis after treatment of unrecognized syphilitic uveitis with systemic corticosteroids in the absence of appropriate antibiotic therapy. Multimodal imaging localized the foci of retinitis within the retina in contrast to superficial retinal precipitates that accumulate on the surface of the retina in eyes with untreated syphilitic uveitis. Although the retinitis resolved after treatment with systemic penicillin in both cases, vision remained poor in the patient with multifocal retinitis involving the macula.

CONCLUSION

Treatment of unrecognized syphilitic uveitis with corticosteroids in the absence of antitreponemal treatment can lead to the development of multifocal retinitis. Multimodal imaging, and optical coherence tomography in particular, can be used to distinguish multifocal retinitis from superficial retinal precipitates or accumulations.

Ocular syphilis

PURPOSE OF REVIEW

Review current literature relevant to syphilitic uveitis utilizing Medline search and online governmental resources relevant to the diagnosis and management of syphilis presenting with ocular manifestations.

RECENT FINDINGS

There is a trend for increasing frequency of primary and secondary syphilis in developed countries, especially in young men. Ocular manifestations of syphilis are rare, occurring in less than one in 1 million persons in the United Kingdom. Distinctive patterns of syphilitic uveitis include white, focal preretinal opacities, and acute posterior placoid uveitis. Enhanced imaging can facilitate clinical diagnosis. Definitive diagnosis remains serologic. The Centers for Disease Control currently recommends reverse sequence testing with initial treponemal antibodies, followed by a quantitative nontreponemal test, which, if negative, triggers a confirmatory treponemal pallidum agglutination test. Persons testing positive for syphilis should also be tested for HIV. Recommendations of the Centers for Disease Control for treatment are unchanged: all ocular syphilis should be treated according to neurosyphilis regimens and should receive cerebrospinal fluid testing.

SUMMARY

Increased case numbers of syphilitic uveitis have stimulated interest in this old disease. This locally destructive ocular inflammation with the potential for severe systemic complications is curable with treatment and should have the highest priority for prompt recognition and treatment.