Neurosyphilis presenting as visually asymptomatic bilateral optic perineuritis

Optic neuritis secondary to syphilis

Optic neuritis is a rare manifestation of syphilis, and the involvement of the central nervous system should be considered synonymous with neurosyphilis. This infectious disease, well known as the great imitator, can affect any structure and produce multiple clinical symptoms. Here, we report a case of a 62- year-old male patient who presented to our service with decreased vision and myodesopsias in right eye. The posterior segment showed a hyperemic nerve with peripapillary hemorrhages and retinal pigment epithellium hyperplasia. The patient was recently diagnosed with HIV. Serology for syphilis was positive with posterior decreased levels of nontreponemal test following treatment with ceftriaxone. Optic neuritis can occur at any stage of syphilis and must always be considered a differential diagnosis.

Prognostic effect of HIV on visual acuity in ocular syphilis: a systematic review

BACKGROUND/OBJECTIVES

Ocular syphilis is a vision-threatening disease that can lead to permanent blindness if left untreated. The global re-emergence of syphilis warrants greater investigations into the visual prognosis of eyes affected by this potentially devastating disease. This systematic review investigates the impact of HIV on visual acuity (VA) outcomes in ocular syphilis.

METHODS

A literature search of Medline, PubMed, Embase, Clinicaltrials.gov and Cochrane Reviews was conducted for studies published between 01 January 2011 and 19 March 2022, reporting non-aggregate initial and post-treatment VA data of eyes with ocular syphilis and corresponding HIV status in patients ≥ 18 years.

RESULTS

A total of 95 studies, including 364 patients and 568 eyes, were evaluated. Among people living with HIV with a diagnosis of ocular syphilis, affected eyes were more likely to have optic nerve involvement and panuveitis. However, HIV status, CD4 cell count, and HIV viral load were not predictive of VA outcomes of treated ocular syphilis. Prognostic factors of final VA worse than 1.00 logMAR were female sex, the presence of macular edema, and VA ≥ 1.00 at presentation. The strongest predictor of a worse final VA was VA ≥ 1.00 at presentation.

CONCLUSIONS

This systematic review demonstrates that HIV status, CD4 cell count, and HIV viral load are not significant factors impacting VA outcomes of eyes with ocular syphilis. While visual prognosis is generally good, poor visual outcome is most strongly predicted by poor VA at presentation. This underscores the importance of early recognition and treatment prior to permanent vision loss.

Ophthalmologic Assesment of Patients with Syphilitic Optic Neuropathy

PURPOSE

To assess the different clinical findings and symptoms of patients with optic neuritis (ON) and uveitis, who were diagnosed with syphilis.

METHODS

The medical records of patients, who had ocular involvement of syphilis, were retrospectively reviewed. Thirteen patients with syphilitic optic neuropathy (SON) were enrolled and underwent complete ophthalmological examinations and auxiliary laboratory testing.

RESULTS

Nine patients (69.2%) had comorbidities in addition to syphilis. One patient (with two eyes) presented with retrobulbar neuritis, and 12 patients (with 17 eyes) presented with anterior optic neuritis. Three patients (23.1%) had no uveitis, and 10 patients (76.9%) had uveitis in cases with SON. Four eyes (16.6%) had subretinal fluid, and three eyes (12.5%) had cystoid macular edema.

CONCLUSIONS

Visual function can be preserved with early diagnosis and proper treatment. Accordingly, newly diagnosed patients with ON and uveitis should undergo syphilitic investigation in routine practice.

Optic perineuritis: A Canadian case series and literature review

BACKGROUND

Optic perineuritis (OPN) is a rare orbital inflammatory disorder that primarily involves the optic nerve sheath (ONS). This study aimed to describe the clinical features of idiopathic OPN as well as OPN secondary to other infectious and inflammatory conditions in a Canadian case series as current literature on secondary OPN in Western countries is mostly limited to case reports.

METHODS

Retrospective case series of all patients seen in a tertiary neuro-ophthalmology practice with a diagnosis of OPN from 2014 to 2020.

RESULTS

A total of 21 patients (14 women, mean age 55.8) corresponding to 29 eyes with OPN were identified. Fifteen cases were associated with inflammatory or infectious conditions and only 6 were idiopathic. All idiopathic cases were unilateral. The most common secondary causes of OPN were anti-myelin oligodendrocyte glycoprotein (MOG) antibody disease (n = 4), syphilis (n = 3), sarcoidosis (n = 3), and giant cell arteritis (n = 3). At initial presentation, best-corrected visual acuity (BCVA) was 20/20 or better in 24% (n = 7) and visual field mean deviation (VF MD) was better than -5 dB in 34% of eyes (10/29). Treatment consisted of intravenous penicillin for syphilitic OPN and high-dose corticosteroids followed by oral taper with or without immunosuppressive therapy for non-syphilitic OPN. BCVA improved in 34% (10/29) and VF MD improved in 45% (13/29) eyes.

CONCLUSION

OPN primarily occurred in association with systemic inflammatory conditions, especially in bilateral cases. Syphilis must be ruled out in all patients. Anti-MOG antibody disease is an important, newly recognized secondary cause of OPN, and serologic testing should be included in the investigation of all patients with OPN.

Bilateral optic disc swelling resulting from lymphocytic meningitis and posterior uveitis secondary to syphilis

Idiopathic intracranial hypertension (IIH) is being diagnosed more often in the UK due to the rise in obesity. In fact, patients who present with bilateral optic disc swelling are habitually put on the papilloedema pathway, often without consideration of other diagnoses. We report the case of a middle-aged woman diagnosed with papilloedema and managed as IIH, until, cerebrospinal fluid (CSF) analysis revealed evidence of lymphocytic meningitis secondary to syphilis. The patient was treated successfully with intravenous antibiotics. Syphilis is the great masquerader and should be a diagnosis to consider in patients who have CSF findings incongruent with their clinical presentation.

Approach to patient with unilateral optic disc edema and normal visual function

In patients with swollen optic nerve head and normal visual function, optic disc drusen (ODD) is the most common diagnosis. The best tests for detecting ODD are funds autofluorescence and enhanced-depth imaging ocular coherence tomography (EDIOCT). After ODD has been ruled out, asymmetric papilledema should be assumed to be the cause and MRI of the brain and orbits with contrast and venography should be performed in all patients. It allows one to look for indirect signs of increased inctracranial pressure (ICP), optic perineuritis, and other inflammatory or compressive processes affecting optic nerve or its sheath such as optic nerve sheath meningioma. If imaging signs of raised ICP are present, lumbar puncture should be performed with measurement of opening pressure and analysis of cerebrospinal fluid (CSF) contents in all patients with fever, meningismus or neurologic deficits as well as patients who are not in the typical demographic group for idiopathic intracranial hypertension (IIH). Optic nerve sheath enhancement on MRI should prompt work-up for causes of optic perineuritis. When the appropriate neuroimaging is normal, the differential diagnosis is limited and ophthalmological consultation is necessary to determine whether other subtle ocular abnormalities are present on biomicroscopic and dilated fundus examination.