Clinical and laboratory characteristics of ocular syphilis, co-infection, and therapy response

The Role of Corticosteroids and Immunomodulatory Therapy in the Management of Infectious Uveitis

PURPOSE

The index review aims to provide an update on the role of corticosteroids and steroid-sparing immunomodulatory therapy (IMT) in managing patients with infectious uveitis.

METHOD

Narrative literature review.

RESULTS

Corticosteroids and immunomodulatory therapy (IMT) focus on the host defense system instead of the pathogen, adjusting exaggerated inflammatory reactions to reduce potential harm to ocular tissues. Systemic or local corticosteroids are primarily selected as adjunctive medication for infectious uveitis. Concomitant corticosteroids have also been used in cases of paradoxical worsening in ocular tuberculosis and immune recovery uveitis in cytomegalovirus (CMV) retinitis. While there is no well-established evidence to support the use of IMT in infectious uveitis, it is occasionally used in clinical settings to treat persistent inflammation following resolution of infection such as cases of ocular tuberculosis and ocular syphilis where an insufficient response is observed with corticosteroids.

CONCLUSION

There is no consensus on the position of immunomodulatory therapy in the management of infectious uveitis with different etiologies. The index review provides an overview of available adjunctive corticosteroids and IMT options to assist clinicians in managing such disease entities more efficiently.

Multimodal Imaging Features of the Posterior Segment in Ocular Syphilis and HIV Co-Infection: A Single Center Case Series

OBJECTIVE

To analyze the frequent multimodal imaging features in posterior syphilitic uveitis.

PURPOSE

Syphilis infection has re-emerged as a global health problem. Multimodal imaging approach has been proposed for diagnosis and follow-up; there are not previous reports dedicated to the anatomic and visual outcomes in patients diagnosed with ocular syphilis and concomitant HIV infection.

METHODS

All demographic information was recovered; a complete ophthalmological examination and multimodal imaging evaluation (retinal fluorescein angiography (FA), autofluorescence (AF), optical coherence tomography (OCT)) were performed on initial visit and 1 month after antibiotic therapy.

RESULTS

   18 eyes of 9 patients were included. The most frequent features observed were: Hyperfluorescence on optic disk on FA, Hyperautofluorescence punctate pattern on AF, Vitritis on SD-OCT. After treatment, there was a functional and anatomical improvement.

CONCLUSION

Ocular syphilis represents a diagnostic challenge. Multimodal imaging approach allows identification of structural changes, follow-up and early detection of complications.

Syphilitic scleritis and episcleritis: A review

Scleritis and episcleritis are rare, but potentially sight-threatening forms of syphilis. To provide a full description of this neglected subset of ocular syphilis, we evaluated the English literature for reports of syphilitic scleritis and episcleritis, recording the demographics, clinical characteristics, serological data, management practices, treatment responses, and visual outcomes. Previously published descriptions of 44 patients with syphilitic scleritis (50 eyes) and 9 patients with syphilitic episcleritis (14 eyes) were identified. The predominant type of scleritis was anterior scleritis, accounting for 92.9% of cases, with nodular anterior scleritis being the most frequent subtype at 58.1%. Almost one-quarter of patients were co-infected with human immunodeficiency virus (HIV). Initial misdiagnosis was common and led to delays in initiating treatment with appropriate antibiotics. Visual outcomes were often good in both scleritis and episcleritis, irrespective of HIV infection status, although complications including scleral thinning, keratitis, and uveitis, along with permanent visual loss and an association with neurosyphilis, were reported. Response to antibiotic treatment was typically rapid, often within 1 week. With the rising global incidence of syphilis, testing patients with scleritis or episcleritis for this infectious disease is important to ensure prompt diagnosis and treatment for best ocular and systemic outcomes.

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.

Ocular sarcoidosis in adults and children: update on clinical manifestation and diagnosis

Sarcoidosis-associated uveitis, is the predominant ocular sarcoidosis presentation, which affects both adults and children. For adults, international ocular sarcoidosis criteria (IWOS) and sarcoidosis-associated uveitis criteria (SUN) are defined. However, for children they are not yet established internationally. Due to the specificity of pediatric manifestations of sarcoidosis, this task is even more challenging. In children, sarcoidosis is subdivided into Blau syndrome and early-onset sarcoidosis (BS/EOS) affecting younger children (< 5 years) and the one affecting older children with clinical presentation resembling adults. Differential diagnosis, clinical work-up as well as diagnostic criteria should be adapted to each age group. In this article, we review the clinical manifestation of sarcoidosis-associated uveitis in adults and children and the sensitivity and specificity of various ocular sarcoidosis diagnostic modalities, including chest X-ray and CT, FDG PET-CT, gallium-67 scintigraphy, bronchoalveolar lavage fluid, genetic testing for NOD2 mutations and serum biomarkers, such as ACE, lysozyme and IL2R.

Syphilitic uveitis in HIV-positive patients: report of a case series, treatment outcomes, and comprehensive review of the literature

AIM

To report the clinical characteristics, treatment and outcomes of active syphilitic uveitis in human immunodeficiency virus (HIV) positive patients and compare them with the previously published data.

METHODS

Retrospective analysis of the case series from an infectious disease center in southern China was conducted. Comprehensive review of previously published cases of HIV positive syphilitic uveitis was conducted using the PubMed and Web of Science databases and the references listed in the identified articles.

RESULTS

Twelve HIV positive patients with active syphilitic uveitis were collected. All were male, with age of 36.3y (range 27 to 53y). Five (41.7%) had a history of syphilis, and three of them had received anti-syphilis treatment. Ocular manifestations included corneal epithelial defect (13%), complicated cataract (17.4%), vitreous opacity (82.6%), optic disc edema (26.1%), macular edema (30.4%), neuro-retinitis (43.5%), and retinal hemorrhage (26.1%). After standardized syphilitic treatment, intraocular inflammation was reduced and vision improved in all cases. The literature review summarizes 105 previously reported cases of HIV positive syphilitic uveitis. High serum rapid plasma regain (RPR) titers may be associated with severe uveitis and poor vision. Treatment with penicillin, ceftriaxone sodium, or penicillin plus benzylpenicillin instead of using benzylpenicillin alone can significantly improve best-corrected visual acuity (BCVA) in HIV positive ocular syphilis patients.

CONCLUSION

For HIV positive syphilitic uveitis patients, prompt diagnosis and appropriate treatment and follow-up are paramount. In our series, the clinical manifestations are diverse. Syphilis patients treated by penicillin G or long-acting penicillin before may still develop syphilitic uveitis. Patients who relapse after long-term penicillin treatment can still benefit from penicillin G.

Syphilis-related Ocular Inflammation in HIV-positive and HIV-negative Patients

PURPOSE

To evaluate the clinical characteristics and visual outcomes of ocular syphilis in human immunodeficiency virus (HIV)-positive and negative patients.

METHODS

We performed a retrospective chart review of all patients with newly diagnosed ocular syphilis between January 2015 and August 2021.

RESULTS

68 eyes of 41 patients (22 eyes in 12 HIV-positive patients, 46 eyes in 29 HIV-negative patients) were included. The most common ophthalmic feature was posterior uveitis in HIV-positive and anterior uveitis in HIV-negative patients; 58.3% (7 out of 12 patients) of HIV-positive and 48.2% (14 out of 29 patients) of HIV-negative patients were diagnosed with neurosyphilis. There were no significant differences in laterality, presence of concurrent rash, rapid plasma reagin (RPR) titers, presenting, and final corrected visual acuity between both groups.

CONCLUSION

Nearly one-fifth of eyes may suffer from severe visual loss of ≤ 20/200. HIV co-infection may not result in visual outcomes in syphilis.

The importance of proper and prompt treatment of ocular syphilis: a lesson from permanent vision loss in 52 eyes

BACKGROUND

Ocular involvement can occur at any stage of syphilis. Prompt diagnosis and proper treatment of ocular syphilis are vital to avoid long-term consequences.

OBJECTIVES

To describe the risk factors for ocular syphilis and clinical features of blindness caused by syphilis.

METHODS

We report risk factors for ocular syphilis amongst patients seen at the Shanghai Skin Disease Hospital between October 2009 and October 2017. We identify patients with ocular syphilis resulting in blindness and report the clinical characteristics, laboratory findings and treatment outcomes of these patients.

RESULTS

A total of 8310 new cases of syphilis were seen, of which 213 patients had ocular disease and 50 patients had blindness due to syphilis. Increasing age and higher RPR titres were associated with ocular involvement but there was no association with HIV status. Blindness in syphilis was restricted predominantly to patients with optic nerve involvement and not patients with isolated uveitis. Fifty patients (and a total of 67 eyes) met the WHO definition of blindness prior to treatment for syphilis. At the end of follow-up, vision had improved in 24 of 67 eyes (35.8%) after treatment. Successful treatment of uveitis was associated with the best improvement in visual acuity, whilst patient with underlying optic atrophy prior to treatment had the worst visual outcome.

CONCLUSIONS

Ocular involvement is an important manifestation of syphilis which may result in blindness. Our data demonstrate outcomes for ocular syphilis are poor if detected late; early recognition and diagnosis is therefore vital to avoid permanent visual loss.

Intermediate Uveitis as the Initial and Only Presentation of Syphilis

We report a patient with unilateral syphilitic intermediate uveitis without dermatological, neurological, or any systemic involvement. He presented to our clinic with complaints of eye floaters and worsening visual acuity in the left eye. He had intermediate uveitis and cystoid macular edema in that eye and both venereal disease research laboratory and microhemagglutination assay for Treponema pallidum serological tests were confirmatory for syphilis. Ocular manifestations of syphilis have variable presentations, and it should be considered when diagnosing unexplained ocular inflammatory diseases, even if the patient’s recent history and systemic evaluation are not compatible.

Ocular syphilis mimicking Vogt-Koyanagi-Harada disease

The study aimed to present a case of ocular syphilis mimicking Vogt-Koyanagi-Harada (VKH) disease. This is an observational case report. A 59-year-old female with Sicca syndrome and rheumatoid arthritis presented to the ophthalmologic department with blurred vision of the right eye for 5 days accompanied by color sensation loss in both eyes. Bilateral disc hyperemia and serous retinal detachment at the posterior pole were noted in her both eyes by fundus examination. Fluorescein angiography revealed bilateral late dye leakage from the disc and posterior choroid. Optical coherence tomography showed bilateral subretinal fluid and choroidal thickening. The impression of her condition was VKH disease initially. However, she was later diagnosed with bilateral ocular syphilis with optic neuritis which was proved by laboratory data. After appropriate antimicrobial agent treatment, her best-corrected visual acuity, serous retinal detachment, and disc hyperemia improved. There was no recurrent intraocular inflammation even without systemic steroid or immunosuppressive therapy control during the following 1 year. Ocular syphilis can mimic many other ocular inflammatory diseases including VKH disease. It is necessary to differentiate infectious causes from inflammatory origins due to the substantially different treatment and prognosis.

Acute syphilitic posterior placoid chorioretinopathy: An infectious or autoimmune disease?

PURPOSE

To report a case of acute syphilitic posterior placoid chorioretinopathy (ASPPC) that demonstrated partial resolution with immunosuppressive therapy secondary to a misdiagnosis as Behçet's disease followed by a relapse which was successfully treated with the appropriate treatment.

OBSERVATIONS

A 34-year-old female patient presented to our service with complaints of decreased vision in the left eye (OS). She initially developed similar symptoms seven months prior to presentation and was diagnosed as Behçet's disease based on the clinical picture of papillitis, vasculitis and placoid chorioretinitis in the posterior pole of OS. She was started on daily oral prednisone 60 mg and weekly methotrexate 10mg by her rheumatologist. The patient's ocular symptoms improved one month prior to presentation with resolution of the placoid lesion but persistence of vasculitis and papillitis. At that time, the dose of the prednisone was decreased to 30 mg which resulted in a relapse of the placoid chorioretinal lesions and worsened visual acuity at the time of presentation to us. Extensive laboratory workup demonstrated positive serology for syphilis. A diagnosis of syphilitic placoid chorioretinitis was made and the patient was treated with intravenous penicillin G for 2 weeks. The vitritis, papillitis, and placoid chorioretinitis resolved along with improvement in vision following the treatment.

CONCLUSIONS AND IMPORTANCE

Ocular findings in syphilis are heterogeneous and may mimic variety of ocular diseases. ASPPC is a rare ocular manifestation of syphilis and its natural course and underlying pathophysiology is not well understood. However, irrespective of the underlying mechanism of the disease, all patients with ASPPC should receive treatment to prevent recurrence and long-term functional damage.

Clinical Profile and Visual Outcomes of Ocular Syphilis: A Five-year Review in Hospital Universiti Sains, Malaysia

Introduction Ocular syphilis is a sight-threatening condition. It can occur at any stage of syphilis infection, which present either with acute inflammation during the primary, secondary, and early latent stages or with chronic inflammation during tertiary infection, affecting virtually every ocular structure. This study was to report on the clinical presentation of ocular syphilis that presented to eye clinic Hospital Universiti Sains Malaysia. Methodology This was a retrospective study where medical records of ocular syphilis patients who attended eye clinic in Hospital Universiti Sains Malaysia from January 2013 to June 2017 were reviewed. Results A total of 10 patients (13 eyes) with ocular syphilis were identified out of 106 cases that presented with ocular inflammation. The mean age of presentation was 69.8 ± 6.4 years and seven of them (70%) were female. All patients were Malay and human immunodeficiency virus (HIV) was negative. The ocular manifestations included panuveitis (four eyes, 30.8%), anterior uveitis (two eyes, 15.4%), posterior uveitis (seven eyes, 53.8%) and optic neuritis (two eyes, 15.4%). Seven (53.8%) eyes presented with visual acuity of worse than 6/60, five (38.5%) eyes had visual acuity between 6/15 to 6/60, and one (7.7%) eye had visual acuity of 6/12 or better. Nine patients received an intravenous benzylpenicillin regime and one patient received an intramuscular penicillin injection. Out of 13 eyes affected, 11 (84.6%) eyes had improved visual acuity of at least one Snellen line after treatment. Visual acuity of 6/12 or better increased to four (30.8%) eyes. Conclusions Posterior uveitis was the commonest presentation of ocular syphilis in HIV-negative patients. Early detection and treatment of ocular syphilis can result in resolution of inflammation and improvement of vision.

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.

[Atypical acute syphilitic posterior placoid chorioretinitis]

Syphilis is an infectious disease that can cause a wide variety of ocular signs. One of the rarest manifestations of ocular syphilis is acute syphilitic posterior placoid chorioretinitis (ASPPC). We report the case of an immunocompetent 38-year-old woman diagnosed with unilateral, atypical, acute syphilitic posterior placoid chorioretinitis. Fundoscopic examination revealed a yellow-white, subretinal, placoid lesion at the posterior pole, which is typical sign of ASPPC. In the periphery of the retina, multifocal choroiditis was also found. Fundus and angiographic changes in ASPPC may mimic other chorioretinal diseases. Accurate diagnosis of ASPPC as a presenting sign of syphilis is important for the prompt initiation of systemic antibiotic treatment.

Increase in Ocular Syphilis Cases at Ophthalmologic Reference Center, France, 2012-2015

We describe the frequency, demographic and clinical features, and visual outcomes of ocular syphilis infections observed during 2012-2015 at a tertiary reference center in Paris, France. Twenty-one cases (29 eyes) were identified. The occurrence of ocular syphilis increased from 1 case in 2012 to 5 cases in 2013, 6 cases in 2014, and 9 cases in 2015 (2.22-25.21/1,000 individual patients/year for the period). Among case-patients, an annual 20%-33% were co-infected with HIV. Seventy-six percent of ocular syphilis infections occurred in men who have sex with men. Seventy-five percent of case-patients had a good final visual outcome (best-corrected visual acuity >0.3 logMAR score). Visual outcome was worse for HIV-positive patients than for HIV-negative patients (p = 0.0139). At follow-up, the best visual outcomes were observed in patients whose mean time from first ocular symptom to consultation was 15 days (SD +19 days).

Clinical Features and Treatments of Syphilitic Uveitis: A Systematic Review and Meta-Analysis

PURPOSE

To investigate the clinical features and efficacies of treatments for syphilitic uveitis.

METHODS

PubMed was searched for studies of syphilitic uveitis published between January 1990 and October 2016. The clinical features were summarized and appraised. The pooled success rate was defined as an improved or maintained final visual acuity and was calculated with 95% confidence intervals (CIs). Heterogeneity, subgroup analysis, sensitivity analysis, and publication bias were assessed.

RESULTS

Thirty-two studies involving 670 patients were analyzed. The most common type of syphilitic uveitis was papillitis. The pooled success rate was 0.91 (95% CI 0.84-0.97) for antibacterial agents alone (15 studies, 286 patients); 0.95 (95% CI 0.91-0.98) for antibacterial agents and systemic corticosteroids combined (11 studies, 245 patients); and 0.91 (95% CI 0.80-0.98) for antibacterial agents, systemic corticosteroids, and other immunosuppressants combined (3 studies, 73 patients). Subgroup analyses revealed no correlations of the efficacy of antibacterial agent monotherapy with study characteristics, such as human immunodeficiency virus coinfection status.

CONCLUSIONS

This systematic review and meta-analysis revealed the efficacy of antibacterial agents for treating syphilitic uveitis. Coadministration of systemic corticosteroids or immunosuppressants did not elicit further improvements in the clinical outcomes of antibacterial agents.

Syphilitic posterior placoid chorioretinitis as initial presentation of early neurosyphilis

CASE REPORT

A 36 year-old male with a recent HIV diagnosis, presented with loss of vision of his left eye. Ophthalmoscopy revealed a unilateral yellowish placoid lesion in the macula. After fluorescein angiography, optical coherence tomography, optical coherence tomography angiography, syphilis serology, and cerebrospinal fluid results, he was diagnosed with neurosyphilis and syphilitic posterior placoid chorioretinitis.

DISCUSSION

Acute syphilitic posterior placoid chorioretinitis is a rare ocular manifestation of syphilis. All patients with characteristic clinical and angiographic findings of acute syphilitic posterior placoid chorioretinitis should be tested for a neurosyphilis and human immunodeficiency virus co-infection. Early treatment with intravenous penicillin is usually effective with good visual results.