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North Carolina had a 40% increase in early syphilis from 2014 to 2015, with 90% of cases among men who have sex with men (MSM). Ocular syphilis cases have also increased, primarily involving HIV-infected MSM; we report a case of ocular syphilis in a HIV-negative heterosexual male.
Case Description:
A 33 year-old male was admitted to the hospital after three weeks of progressive photophobia and blurry vision. The day of admission, he presented to his ophthalmologist. Ophthalmologic examination demonstrated bilateral panuveitis and acute retinal necrosis. He was also found to have a hypertrophic scaly rash on his back, palms, soles, genitals and buttocks.
He was empirically started on intravenous (IV) acyclovir and ophthalmic prednisolone. An anterior chamber paracentesis was performed. Testing of his aqueous humor for herpes simplex virus, varicella-zoster virus, cytomegalovirus, enterovirus, and toxoplasma by polymerase chain reactions were negative. His serum erythrocyte sedimentation rate, C-reactive protein, anti-nuclear cytoplasmic and myeloperoxidase antibodies were within normal range. His HIV, urine and pharyngeal chlamydia and gonorrhea testing were negative. However, his serum RPR was 1:512 and TP-PA was positive. Cerebrospinal fluid evaluation showed 75 nucleated cells (78% lymphocytes), normal protein and glucose with a VDRL of 1:2.
Aqueous penicillin G 24 million units IV daily x 14 days was given for ocular syphilis treatment. On further questioning, he admitted to a prior painless penile lesion and sexual contact with two female partners in the past year. Upon hospital discharge, he had not reported any visual improvement.
Discussion:
Ocular syphilis, a form of neurosyphilis, can occur during early syphilis when there is dissemination of Treponema pallidum. Uveitis is the most common presentation, but other manifestations include panuveitis, episcleritis/scleritis, optic neuritis, and retinal necrosis. Ocular syphilis should be recognized in both HIV-positive and HIV-negative patients to avoid delays in treatment and possible irreversible vision loss.