Figure 4 - available via license: Creative Commons Attribution 4.0 International
Content may be subject to copyright.
OCT of the lesion: irregular retinal contour with areas of retinal elevation. The individual retinal layers could not be distinguished due to infiltration with multiple hyperreflective dots. Diffuse thickening at the retinal nerve fiber layer. Irregular vitreo-retinal interface with traction by partial PVD together with moderate hyperreflective dots in the vitreous.
Source publication
Background
Syphilis is a multisystem bacterial infection caused by Treponema pallidum. The incidence of infection in the United States has risen by more than 75% since the year 2000, when it was at a low of 2.1 per 100,000 people. Ocular involvement may occur in any stage of infection and may present in a variety of ways, with posterior uveitis bei...
Similar publications
Awareness of the spectrum of clinical manifestations of syphilis, especially uncommon changes, is essential for diagnosis and effective management of patients. A 48-year-old Han businessman presented to the ear, nose and throat surgeons with an eight-week history of epigastric pain, a four-week history of a widespread non-itchy rash including the s...
Citations
... Co-infection of HIV and syphilis can potentiate the clinical manifestations and complications of each pathogen, and such an interaction may lead to a more pronounced ocular inflammatory response [4]. Existing case reports have documented anterior uveitis in patients infected with either HIV or syphilis, but BAU cases in the setting of concurrent HIV and syphilis infection remain underrepresented in the literature [5][6]. HIV and syphilis co-infection typically present with posterior uveitis, especially in patients with low CD4 counts [6]. ...
... Existing case reports have documented anterior uveitis in patients infected with either HIV or syphilis, but BAU cases in the setting of concurrent HIV and syphilis infection remain underrepresented in the literature [5][6]. HIV and syphilis co-infection typically present with posterior uveitis, especially in patients with low CD4 counts [6]. In this case report, we detail the clinical findings of a patient diagnosed with BAU alongside HIV and syphilis co-infection. ...
... Ground glass retinal opacification associated with retinal vasculitis has also been described and is considered to be characteristic for syphilitic uveitis. 59 Acute syphilitic posterior placoid chorioretinitis (ASPPC) ( Figure 6) typically presents as large, placoid, yellow lesions with faded centers at the level of pigment epithelium in the macular and juxtapapillary area with similar characteristic angiographic pattern and was first used by Gass et al in six patients with systemic syphilis infection. 60 OCT reveals disruption of the outer retina to the superficial choriocapillaris 61 and characteristic findings include disruption of the EZ/IZ band with subretinal RPE hyperreflective excrescences (Figures 7 and 8). ...
Syphilis, caused by the spirochaete, Treponema pallidum, continues to be a public health challenge globally with its rates steadily increasing in the past few years. The disease is transmitted through small breaks in the skin during sexual contact, or via congenital transmission in utero, either across the placenta or by contact with an active genital lesion during delivery. Estimated 5.7-6 million new cases are detected every year worldwide in the 15-49 years age group. An increased incidence has been reported in most populations with particular clusters in special groups like men who have sex with men, female sex workers, and their male clients. Ocular syphilis has a varied presentation and is considered a great mimicker in all cases of uveitis. The laboratory diagnosis of syphilis is predominantly based on serological tests including TPHA and VDRL. Parenteral penicillin is the cornerstone of treatment for all stages of ocular syphilis.
... veitis is the most common manifestation of syphilis infection in the eye. 1 Syphilis patients with human immunodeficiency virus (HIV) coinfection are more likely to have neurosyphilis and syphilitic uveitis. 2,3 As many as 20-30% of cases of uveitis are idiopathic. The 4 It was estimated that 3% of patients with syphilis have ocular uveitis globally. ...
Introduction: Ocular syphilis is a rare manifestation of syphilis. Ocular syphilis manifestations vary and can occur at all stages of the disease. Syphilis can affect all eye structures, the main complaint is blurred vision, accompanied by non-specific symptoms such as pain in the eye, and does not respond to steroids. Case: The male patient, 54 years old, presents with complaints of both eyes slowly getting worse with a history of sexual multi-partners. Visual acuity in both eyes were light perception bad projection, ophthalmological examination showed cloudy lens, cloudy vitreous, cell (+) flare (+) right eye optic nerve, hyperemia, and left eye optic nerve, pale at temporal. VDRL results: reactive> 1: 512 and TPHA: reactive> 1: 5120. The patient was diagnosed with late latent syphilis and neurosyphilis observation from the Dermatology and Venereology Department and received benzathine penicillin injection therapy. From the Neurology Department the patient was diagnosed with neuro-syphilis and was consulted to VCT department with pre-HAART Stage IV HIV infection (WHO). After receiving penicillin therapy and topical steroids, the patient was experienced improvement in visual acuity. Conclusion: In HIV patients without antiretroviral therapy, Treponema pallidum infection is more common and has manifestations such as ocular syphilis and neurosyphilis. Treatment of ocular syphilis using topical steroids to reduce inflammation and penicillin as the main antibiotic.
... All patients had anterior . This case was first described in [15]. A macular yellow placoid lesion is seen (a) that has early blockage (b) and late leakage (c). ...
PurposeTo describe two distinct presentations of syphilitic fundus features in a series of patients with ocular syphilis.Methods
This is a retrospective, interventional case series of 22 eyes from 16 serology confirmed cases. Clinical examination, fluorescein angiography, and optical coherence tomography were performed at presentation and following high-dose intravenous penicillin G.ResultsIn our cohort, the mean age was 47.6 years (range 24–59 years) and 14 patients were male (87.5%), 11 patients were positive for human immunodeficiency virus (68.8%), and 6 had bilateral involvement (37.5%). Mean best-corrected visual acuity improved from 0.99 ± 0.79 logarithm of the minimal angle of resolution (LogMAR) at the time of presentation to 0.29 ± 0.36 LogMAR on final visit (P < 0.01). Posterior segment examinations in eyes with retinitis showed two distinct types (1) discrete, placoid lesions in the macula consistent with acute syphilitic posterior placoid chorioretinitis or (2) punctate inner retinitis with corresponding fluorescein pooling in a segmental pattern. These findings rapidly resolved after antibiotic therapy.Conclusion
In the era of resurgence, ocular syphilis may present with two phenotypes of discrete retinal lesions. Recognition of the characteristic ocular features may help make the diagnosis and monitor treatment response.
... HIV-infected patients in particular are more prone to develop NS [5]. Ocular involvement is very rare in NS and accounts for only 1%-5% of the cases in the United States [6,7]. We report the case of a patient who presented with a "black spot" in his vision and was found to have ocular syphilis and NS. ...
In the pre-antibiotic era, neurosyphilis (NS) was common, occurring in 34% of patients with syphilis. Currently, there has been a rising trend in syphilis with HIV-infected patients being more prone to develop NS. Ocular involvement is very rare in NS and accounts for only 1%-5% of the cases in the United States. We report the case of a 53-year-old male with a past medical history of gastroesophageal reflux disease and hyperlipidemia who presented to his ophthalmologist for blurred vision in both eyes. He had been noticing a black spot in the visual field of his left eye for two weeks. He had also noticed a rash on his forearms. His past and social history was significant for treated Lyme disease, having pet cats. He identified as a heterosexual male, married, and with five children. However, on further history taking, he reported a homosexual exposure about five years prior. He denied any history of genital ulcer or penile discharge. On examination at the ophthalmology clinic, he was found to have a visual acuity of 20/20 right eye and 20/100 left eye. Posterior segment examination of the both eyes showed subtle neuritis and vasculitis. Fundus photography revealed subtle neuroretinitis bilaterally. Work up was initiated for inflammatory and infectious causes. His rapid plasma reagin and fluorescent treponemal antibody absorption showed positive titers for syphilis. His presentation was most consistent with ocular syphilis. A lumbar puncture (LP) was done with Venereal Disease Research Laboratory (VDRL) positivity in the spinal fluid. He was therefore initiated on intravenous (IV) penicillin four million units every four hours for 14 days. His ophthalmology follow-up after one month showed both subjective and objective improvement in his visual symptoms. He also followed with the infectious disease team and a repeat LP done three months later showed nonreactive VDRL in cerebrospinal fluid (CSF).
Ocular syphilis is increasing in incidence. Clinical presentation is variable, and a high index of suspicion with a low threshold for serological testing are important as early treatment can reverse retinal changes and restore visual acuity. There is a recommendation for CSF examination in all patients with ocular syphilis including HIV-negative cases. There have been studies showing a high CSF abnormal rate in HIV-negative patients with ocular syphilis. The recommended treatment for NS is aqueous crystalline penicillin G (18 to 24 million units per day, administered as three to four million units IV every four hours, or 24 million units daily as a continuous infusion) for 10 to 14 days. Follow-up is a key component of management with neurological examination and LP for CSF VDRL performed three months after treatment and every six months after, until the CSF is nonreactive for VDRL with normal white blood cell count.
It is important to be cognizant of the rising trend of ocular syphilis, even in HIV-negative individuals. Early treatment is time sensitive to preventing permanent vision loss. Our case also emphasizes on thorough history taking, even for patients who appear to be at a low risk for sexually transmitted infections.
... OKT açısından ise, Schlaen ve ark., sifilitik retinit odağının SD-OKT görüntülerinde tam kat retina tutulumu şeklinde bir hiperreflektivite gözlendiğinde görmenin daha düşük olabileceğini bildirmişlerdir [36] . Ancak, fokal retinit odağında eşlik eden çoklu hiperreflektif noktalar nedeniyle hangi katmanın tutulduğu belirlenemeyecektir [37] . ...
Syphilis is an important etiology of uveitis because of its curable nature. The prevalence of the syphilis is increasing in the
developed countries especially among young males. A special consideration to its coexistence with the “Human immunodeficiency
virus” (HIV) should be given. Since ocular syphilis can mimic most of the types of uveitis, it should be considered in the
differential diagnosis of all types of uveitis. Syphilis causes posterior uveitis and panuveitis more frequently and its main clinical
findings are focal preretinal white opacities and acute posterior placoid uveitis. Although imaging methods are utilized in the
diagnosis, serological tests performed after clinical suspicion should be the main diagnostic approach. Knowing the pearls of
the nontreponemal and treponemal serological tests is very important. All cases with ocular syphilis should be treated like
neurosyphilis. Cerebrospinal fluid sampling should be performed in all ocular syphilis patients and all patients should be
screened for HIV infection.
... The most common presentation of syphilis in the eye is uveitis 5 . Uveitis develops in about 10% of cases of secondary syphilis and in up to 5% of cases who progress to the tertiary stage 6 . ...
... Syphilitic ocular inflammation may be unilateral or bilateral and it can involve the anterior, intermediate, or posterior segment5 . The predominant type of syphilitic uveitis diverges in different case series[6][7][8] . ...
Purpose: To describe the spectral domain optical coherence tomography (SD-OCT) features of a punctate inner retinitis, a rare ocular manifestation of syphilis, in an HIV positive adult patient.
Observations: In the right eye, SD-OCT images during the active period showed hyperreflectivity of the full thickness of the inner retina, precluding the individualization of the layers. In addition, multifocal areas with higher hyperreflectivity were identified within the affected retina. Once the lesion became inactive, SD-OCT images revealed inner retina layers atrophy, disruption of the ellipsoid layer, and multifocal damage to the retinal pigment epithelium layer.
Conclusion and importance: Punctate inner retinitis affects the full thickness retina, leading to severe retinal damage, along with multifocal damage of the retinal pigment epithelium. The multifocal white retinal lesions observed within the affected retinal area correlated with the presence of intense hyperreflective dots within the retina showed by SD-OCT. These lesions are deeper than was described in other reports.
... 14,15 In contrast, the term papillitis has typically been used in the setting of patients with ODE and vision loss, 16,17 although there are recent reports of papillitis similar to our patients with preserved vision. 18,19 There is a single prior report of a patient with radiological evidence of optic nerve sheath enhancement from neurosyphilis resulting in bilateral ODE and preserved vision. 20 However, based on our case series and a review of the literature, this may represent the minority of cases of asymptomatic ODE in the setting of neurosyphilis. ...
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.
... In the current era, HIV-infected patients are more prone to develop NS, with higher risk in patients with CD4 cell counts ⩽350 cells/μL and RPR titer >1:32 [3,4]. Ocular involvement is very rare in NS and accounts for only 1%-5% of the cases in the United States [5,6]. ...
Neurosyphilis (NS) is more frequently seen in patients with human immunodeficiency virus (HIV) infection, especially those not on antiretroviral therapy or with a low CD4 cell count. Ocular syphilis is an unusual and early form of neurosyphilis. Lumbar puncture should be considered in all HIV infected patients who present with neurologic or ocular disease. A 47-year-old homosexual male with HIV-1 infection, on antiretroviral therapy (last CD4 cell count 1022 cells/μL) presented to our emergency department with a five-day history of headache, blurry vision, pain and redness of the left eye. He had unprotected anal sex with a new partner four months before presentation. Based on the fundoscopy findings as well as the cerebrospinal fluid (CSF) analysis on initial evaluation, a repeat serum rapid plasma reagin (RPR) along with microhemagglutination assay for treponema pallidum (MHA-TP) were done due to high suspicion of syphilis, even though an RPR five months prior to this visit was negative. Both RPR and MHA-TP were positive and the patient was treated for neurosyphilis. The patient's symptoms as well as the RPR titers improved significantly thereafter. A high index of suspicion for neurosyphilis should be maintained in HIV-infected patients presenting with ocular symptoms even if they are compliant with retroviral therapy with good CD4 cell counts. Physicians must be mindful of this uncommon presentation and consider a lumbar puncture in any patient with suspicion of neurosyphilis for prompt diagnosis and treatment to avoid further neurological complications.
... Ocular involvement of syphilis tends to occur in secondary and more often in latent and late stages of the disease although very rarely it may occur in the primary stage of the infection. Ocular syphilis is a rare complication of syphilis accounting for less than 1% of syphilis cases but this rate may reach up to 5% in patients progressing to tertiary stage [2] . In up to 40% of cases, concomitant neurosyphilis may be present [3]. ...
