Necrotizing retinitis due to syphilis in a patient with AIDS

Rhegmatogenous retinal detachment with giant retinal tear masked by dense vitritis in active toxoplasma retinochoroiditis

A male patient presented with a decreased vision in his right eye since 2 weeks. The best corrected visual acuity was a Snellen's equivalent of 20/200 in the right eye and 20/20 in his left eye. Retinal evaluation of the right eye revealed dense vitritis and a solitary yellowish retinochoroiditis lesion. An ultrasound B scan of the right eye revealed a suspicious high amplitude membranous echo in the posterior vitreous cavity. The patient was diagnosed as having toxoplasma retinochoroiditis and was started on appropriate medical therapy. Within a week of starting treatment, the vision had dropped significantly and a rhegmatogenous retinal detachment with a giant retinal tear was noted. The patient underwent vitreoretinal surgery with silicone oil as endotamponade. The patient did well in the postoperative period maintaining a visual acuity of 20/100 at 4 weeks follow-up and also at 3 months.

Syphilitic Retinitis: A Rare Presentation of a Resurgent Sexually Transmitted Infection in an HIV-Negative Individual

We present a rare presentation of isolated syphilitic retinitis in an HIV-negative man. A 47-year-old male presented to our ophthalmology center with complaints of blurred vision, pain, and redness in the left eye for the past seven days. The best corrected visual acuity for distance was 6/6 and best corrected near visual acuity for near was N6 in the right eye. The best corrected visual acuity for distance was finger counting at 1 m and best corrected near visual acuity for near was 1:32), the Treponema Pallidum Hemagglutination Assay was positive, and the patient tested negative for human immunodeficiency virus antibodies. Based on these findings, a diagnosis of syphilitic retinitis was made. The patient was given three doses of 2.4 million units of benzathine penicillin intramuscularly (once a week) and doxycycline 100 mg twice daily for the same period. After completion of treatment, the best corrected visual acuity for distance improved to 6/9 and the best corrected near visual acuity for near improved to N6 in the right eye, and the lesions in the eye resolved. The best corrected visual acuity for distance improved to 6/12 and the best corrected near visual acuity for near improved to N10 in the left eye. If a patient presents with unexplained ophthalmic findings such as uveitis, vitritis, or retinitis, then a diagnosis of syphilis should be considered even if the patient does not give a history of high-risk sexual behaviour. Thus, both the physician at the sexually transmitted infection clinic and the ophthalmologist should be aware of these symptoms and signs and consider this as a potential diagnosis. This will result in prompt investigations, appropriate diagnosis, and clinical management, and eventually prevent loss of vision.

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.

Acute syphilitic posterior placoid chorioretinopathy presenting as atypical multiple evanescent white dot syndrome

BACKGROUND

This paper reports the case of a young man who presented with syphilis masquerading as multiple evanescent white dots syndrome (MEWDS), which turned out to be an acute syphilitic posterior placoid chorioretinopathy (ASPPC) during follow-up.

CASE PRESENTATION

A 59-year-old healthy male consulted for a three days' history of visual impairment in both eyes. On multimodal imaging, he was diagnosed as MEWDS. Fundus fluorescein angiography (FFA) showed early peripheral bilateral granular hyperfluorescence that correlated with the yellow-white dots found on fundus exam. Indocyanine green angiography (ICGA) depicted hypofluorescent dots on late phase. Spectral-domain optical coherence tomography (SD-OCT) revealed numerous inner retinal highly reflective deposits in the outer nuclear layer and disruption of the ellipsoid zone. After initial improvement, he presented again for a sudden visual loss at 3 weeks. FFA, ICGA and SD-OCT demonstrated the same but more numerous and outer lesions suggesting an ASPPC. A full inflammatory work-up revealed highly positive titers of rapid plasma regain (RPR) and fluorescent treponemal antibody absorption (FTA-Abs), suggesting a syphilis infection. The ophthalmological manifestations dramatically improved after the patient was admitted for high-dose intravenous penicillin G 24 million per day for 2 weeks.

CONCLUSION

This is the first case that reports an ocular syphilitic infection masquerading as MEWDS at presentation and that turns to be an ASPPC. Syphilis serology should be routinely done in every case of atypical MEWDS especially when unusually presented in a young healthy man, with bilateral involvement and a bad clinical evolution.

Ocular Syphilis Presenting as Acute Necrotizing Retinitis in a Human Immunodeficiency Virus-Positive Patient

The incidence of ocular syphilis is increasing in the developing world even in the era of effective human immunodeficiency virus (HIV) treatment, as there is a potential increase of high-risk sexual behavior. Ocular involvement in the form of uveitis is seen in all stages of syphilis. Diagnosis begins with ophthalmologic examination, but requires serologic testing for confirmation. Ocular syphilis presents with unusual presentations or mimics other diseases and is identified by serological screening. It is curable with a relatively short course of antibiotic treatment, making its recognition a priority. All ophthalmic manifestations of syphilis should be treated with a Centers for Disease Control and Prevention-approved neurosyphilis regimen. In this report, we present a case of necrotizing retinitis with no response to antiviral treatment. On subsequent serological testing it was proved as syphilis in a HIV-positive patient who responded well to intravenous antibiotics with rapid visual recovery. Hence, awareness of this disease will promote early diagnosis and treatment.

Miliary Retinal Lesions in Ocular Syphilis: Imaging Characteristics and Outcomes

Purpose: To describe full thickness miliary retinal lesions in ocular syphilis.Methods: Retrospective chart review of patients with serologically confirmed ocular syphilis. Retinal miliary lesions in three cases of Syphilitic uveitis, in immunocompetent individuals are described. Case 1 and case 2 were positive for both VDRL (venereal disease research laboratory) and TPHA (Treponema pallidum hemagglutination), case 3 was VDRL negative but TPHA positive.Results: Miliary lesions were small round to oval, yellow retinal lesions, measuring less than ¼ disc diameter size, with distinct margins, involving complete thickness of retina on OCT, in a pillar like manner, associated with ground glass retinitis, outer retinal placoid lesion or with retinal vasculitis. In cases 1 and 3, these healed with pigmentation.Conclusion: In contrast to similar lesions described, retinal miliary lesions seem to involve full thickness of the retina on OCT and may heal with pigmentation. These lesions may be characteristic of ocular 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.