An immunocompetent migrant presenting with neurosyphilis with an unusual unilateral papillitis: a case report

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.

Blind spot enlargement: A differential diagnosis challenge

A 39-year-old woman, without any systemic or ocular history, presented with a paracentral scotoma in her right eye with normal visual acuity. Humphrey's visual fields showed a reversible enlargement of the right blind spot. The final diagnosis was acute idiopathic blind spot enlargement which was successfully treated with intravenous steroids. Although differential diagnosis of blind spot enlargement can be challenging, multimodal imaging with combination of visual field's assessment can help us make the right diagnosis.

Secondary Syphilis Presenting as Bilateral Simultaneous Papillitis in an Immunocompetent Individual

Ocular syphilis is a common presentation for patients with secondary or tertiary syphilis and usually includes posterior uveitis or panuveitis, though a myriad of symptoms have been associated. We report the case of a 58-year-old Caucasian male who presented with fast-progressing vision loss and a new onset of floaters in both eyes. An initial fundus exam revealed only bilateral optic disc edema, and neurological evaluation was negative. Subsequent ophthalmology evaluation in the clinic revealed a ragged retinal pigmented epithelium on optical coherence tomography (OCT) and posterior placoid chorioretinitis, raising suspicion of syphilis. Intravenous penicillin therapy was immediately initiated based on high clinical suspicion of ocular syphilis while awaiting lab confirmation, which was later confirmed as a new syphilis infection. He was subsequently given oral prednisone 48 hours into penicillin therapy for a significant posterior inflammatory response in both his eyes. His visual recovery was drastic due to the timely use of oral steroids. Classical findings such as ragged retinal pigmented epithelium on OCT and posterior placoid chorioretinitis demonstrate strong clinical suspicion of ocular syphilis. Oral prednisone when used timely with penicillin therapy in special situations such as bilateral severe posterior uveitis, panuveitis, or optic neuritis may aid in a faster and smoother visual recovery. A high index of clinical suspicion of ocular syphilis should be maintained in patients with human immunodeficiency virus (HIV) infection presenting with uveitis, posterior placoid morphology, or optic disc edema. Oral prednisone may be an effective adjuvant treatment for immunocompetent patients who mount a strong inflammatory response to ocular syphilis infection.

A peculiar case of syphilis infection: The great imitator is on the rise

The incidence of syphilis is on the rise worldwide and can pose many diagnostic and therapeutic difficulties for doctors. Given the wide variety of presenting symptoms, syphilis is also known as the great imitator, which in turn frequently leads to a pronounced diagnostic- and therapeutic delay for patients. Here we present a case report of syphilitic uveitis and papillitis accompanied by acute vision loss, a rare presentation of a tertiary syphilis infection that clinically mimicked a giant cell arteritis (GCA) or arteritic anterior ischemic optic neuropathy (AAION). The patient was treated with high-dose intravenous benzyl penicillin after which full vision was restored. By presenting this case, we hope to raise awareness for the increasing incidence of syphilis infections and stress the importance of syphilis testing in patients with otherwise unexplained uveitis.

Incipient Syphilitic Papillitis

Patients with syphilis can present with optic disc oedema (ODE) without visual compromise, which has been primarily attributed to papilloedema from raised intracranial pressure or optic perineuritis from optic nerve sheath inflammation. We report four cases of ODE in the setting of syphilis with preserved visual function, normal intracranial pressure, and no enhancement of the optic nerve or sheath on magnetic resonance imaging. We propose the term "incipient syphilitic papillitis" for cases presenting with ODE, preserved vision and absence of optic nerve sheath enhancement, which is likely a more common presentation than syphilitic optic perineuritis.

Neurosyphilis is more common in malignant syphilis: A case series and review of the literature

Malignant syphilis is a rare skin manifestation of secondary syphilis, which has been reported primarily in the HIV-infected population. This study aimed to investigate the relationship between HIV infection, malignant syphilis, and neurosyphilis through a systematic chart review of 26 malignant syphilis patients seen at our hospital. We also performed a literature review of 83 reported malignant syphilis cases since 1987, when the first case of malignant syphilis co-infected with HIV was reported. We found there was no direct association between HIV infection and malignant syphilis or neurosyphilis. In contrast, we found that much higher proportion (30%) of malignant syphilis patients develop concurrent neurosyphilis compared to those with the common type of secondary syphilis (13.1%). Physicians should be aware of the fact that neurosyphilis is more common among patients with malignant syphilis and the importance of investigating for neurosyphilis in such patients.

Changes in neurosyphilis presentation: a survey on 286 patients

Although neurosyphilis (NS) keeps plaguing worldwide, often with oligosymptomatic and atypical manifestations, the most recent reports fail to provide useful information, like details of the clinical history and even of the previous early therapy. We conducted a survey of the literature of the last 5 years on the clinical presentation of NS, recording the aforementioned inaccuracies. One hundred and thirty-seven articles were collected, reporting on 286 patients. General paresis was the commonest form (49%), often manifesting with cognitive impairment and psychiatric symptoms. Syphilitic meningitis was found in 63 patients (22%), mainly with ocular or auditory involvement. Meningovascular and tabetic form were both found in 12% of cases. Gummatous and epileptic manifestations were rare. Perusal of the literature confirms that NS prevalence is increasing, often with manifestations that are atypical for timing and type of lesions. Unfortunately, many articles are lacking of critical information, like an accurate clinical history and timing of the therapy making difficult to assess the effectiveness of penicillin in preventing NS.

Unilateral swollen optic disc: do not forget neurosyphilis

A 51-year-old man presented with a 3 month history of progressive right visual loss. On examination, the only abnormal findings were a right visual acuity of 4/10 and a swollen right optic disc. The patient had previously undergone MRI that had been reported as being normal and a trial of corticosteroids under the care of the referring ophthalmologist. An extensive battery of blood tests was normal apart from a rapid plasmatic reagin titre of 1:64. ELISA revealed elevated levels of total and immunoglobulin M antibodies against Treponema pallidum. Cerebrospinal fluid analysis revealed a mild leucocytosis and mildly elevated protein content. The patient was treated with a 5 week course of penicillin. Three months after starting treatment, his right visual acuity had improved to 8/10 and his right optic disc swelling had resolved.