Three cases of ocular syphilis and the resurgence of the disease in Queensland

Insights into ocular syphilis in Nepal

PURPOSE

This study aims to elucidate the demographic characteristics, clinical features, diagnostic approaches, and medical management of patients with ocular syphilis, known as 'the great masquerader,' at a tertiary eye care center in Nepal.

METHODS

We conducted a retrospective review involving 15 eyes from ten patients with ocular syphilis treated at a uveitis referral center between 2020 and 2022. Lumbar puncture was performed if neurosyphilis was suspected. Treatment success was defined as the absence of ocular inflammation in both eyes and a decrease in Veneral disease research laboratory (VDRL) titres after completing therapy.

RESULTS

A total of 15 eyes of 10 patients were diagnosed with syphilitic uveitis based on positive treponemal and non-treponemal serological tests. The mean age of the patient was 39.9 years (range 22-54 years) with an equal distribution between males and females. HIV coinfection was not found in any of the patients. Syphilitic uveitis was the primary presentation in nine patients (90%), while one patient presented with recurrent nodular scleritis. Ocular involvement was bilateral in 50% (5 patients). The mean duration between the initial symptom and the first presentation was 8.7 weeks (range: 4 days to 24 weeks). The most common ocular findings was panuveitis (6 eyes). Eight patients with early syphilis received weekly intramuscular injections of benzathine penicillin G for 3 weeks whereas 2 patients with neurosyphilis were treated with intravenous ceftriaxone 1 gm twice a day for 14 days. Signs and symptoms of majority of patients improved with systemic therapy for syphilis.

CONCLUSIONS

Syphilitic uveitis should be included in the differential diagnosis of any form of ocular inflammation.

Not a Rare Disease Anymore? A Case of Ocular Syphilis at the Correctional Facility

Los Angeles County has been facing a syphilis crisis since 2018. Cases of ocular syphilis have become increasingly identified and reported in the past few years, predominantly in HIV-positive men. Here we report a case of ocular syphilis in an otherwise healthy 49-year-old male in the Los Angeles County jail. This case study emphasizes the importance of increasing awareness of ocular syphilis so that it can be diagnosed promptly to prevent irreversible vision loss. Health care providers who work in the correctional facility setting need to be aware of this disease entity given that they serve a population with high risk of sexually transmitted diseases (STDs). This case study further stresses the importance of initial screening for sexual history and/or history of STDs within this population.

Rhegmatogenous Retinal Detachment in Syphilitic Uveitis: A Case Series and Comprehensive Review of the Literature

PURPOSE

Uveitis is the most common ocular manifestation of syphilis. However, an association between syphilitic uveitis and rhegmatogenous retinal detachment (RRD) is not widely recognized. We report a consecutive series of six new cases of syphilitic uveitis complicated by RRD and describe the typical characteristics, clinical course, and surgical management of such cases.

METHODS

Consecutive case series and comprehensive review of the literature.

RESULTS

We identified a total of 19 cases (23 eyes) with syphilitic uveitis subsequently complicated by RRD, including six new cases (seven eyes) reported here and 13 cases (16 eyes) previously reported in the literature. Fifteen patients (79%) were positive for human immunodeficiency virus (HIV) and not on combination antiretroviral therapy. Most retinal detachments developed within two months of uveitis presentation; retinal breaks were often found in areas of previous retinitis. Sixteen eyes (70%) were complicated by early proliferative vitreoretinopathy. Twenty-one eyes underwent surgical repair, of which six (26%) suffered re-detachment. Surgical management commonly involved pars-plana vitrectomy and silicone oil tamponade, with or without scleral buckling. Visual outcomes were generally poor: only six eyes (26%) attained visual acuity of 20/40 or better and 11 eyes (48%) remained 20/200 or worse.

CONCLUSIONS

Patients with syphilitic uveitis, as with viral retinitis, should be monitored closely for the development of retinal tears and RRD. A combination of pars plana vitrectomy with silicone oil tamponade and/or scleral buckle placement is a prudent surgical approach to most cases of syphilitic RRD, although visual prognosis remains guarded.

Neurosyphilis in a suspected case of giant cell arteritis

A 67-year-old man had a few month history of deteriorating visual acuity. He had originally presented to ophthalmology with right-sided visual blurring. This subsequently progressed to involve the left eye. At this point, he was empirically treated with high-dose glucocorticoids, both orally and intravenously, with the suspicion that giant cell arteritis was causing acute visual deterioration of his left eye. Unfortunately, his symptoms did not improve. During an admission to hospital for a pneumonia, he underwent further investigations for this bilateral visual loss. He was diagnosed with left neuroretinitis and right vitritis. A thorough workup revealed positive syphilis serology and cerebrospinal fluid was positive on venereal disease research laboratory testing. He was diagnosed and treated for neurosyphilis with intravenous benzylpenicillin 4 million units 4 hourly for 14 days. His left-sided vision improved but he still suffers from severe visual impairment in his right eye.

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.

Clinical Characteristics of a Case Series of Ocular Syphilis With 3 Cases Requiring Multiple Vitrectomies After Late Diagnosis

Purpose:

This work describes the characteristics and unique features of ocular syphilis.

Methods:

Ten serologically proven cases of ocular syphilis were retrospectively analyzed.

Results:

Eighteen eyes of 10 patients were affected. Nine of 10 patients were male and the mean age was 58 years (range, 36-81 years). HIV antibody testing was positive in 3 patients (30%). Five cases were first diagnosed by an ophthalmologist. One patient presented with a syphilitic rash. The most common ocular findings were panuveitis (n = 6) and cystoid macular edema (n = 4). Ocular involvement was unilateral in 2 cases and bilateral in 8. Best-corrected visual acuity improved in 13 of 18 eyes (72%) after treatment. Three cases developed recurrent retinal detachments that required repair with silicone oil.

Conclusions:

Most cases were HIV negative. Syphilitic uveitis can be the initial presentation of syphilis without classic systemic manifestation. Ophthalmologists play an important role in the diagnosis and treatment of syphilis.

Syphilis-Related Eye Disease Presenting as Bilateral Papilledema, Retinal Nerve Fiber Layer Hemorrhage, and Anterior Uveitis in a Penicillin-Allergic Patient

Purpose. Treponema pallidum is known as the “great masquerader” for its many presentations and ocular findings in patients who are infected and develop secondary and tertiary stage of syphilis. Syphilitic ocular manifestations include uveitis, chorioretinitis, retinitis, vasculitis, vitritis, and panuveitis all with or without decreased visual acuity. Human immunodeficiency virus (HIV) is known to expedite the progression of syphilis when patients are coinfected, thus compounding the potential ophthalmic presentations. This report summarizes the presentation, management, and clinical course of a patient with known HIV and penicillin allergy that presented with bilateral optic nerve edema, retinal hemorrhages, and iritis without vision loss.