Ocular syphilis

Macular Optical Coherence Tomography Findings in Patients With Syphilitic Optic Neuropathy-A Case Series and Systematic Review

BACKGROUND

Syphilis is a sexually or congenitally acquired infectious disease that can affect multiple organs systems, including the eye. When left undiagnosed and untreated, it can lead to significant morbidity and mortality. Syphilitic optic neuropathy can be difficult to diagnose because it can mimic many other nonsyphilitic causes of optic nerve involvement, leading to delay in treatment. Diagnosing ocular syphilis may be facilitated by assessing for specific outer retina abnormalities on macular optical coherence tomography (OCT).

METHODS

This was a case series and case-based systematic review. For the case series, a retrospective chart review was conducted of all patients who presented to a tertiary university-affiliated neuro-ophthalmology practice over 6 months with undifferentiated optic neuropathy and were eventually diagnosed with syphilitic optic neuropathy. For the systematic review, OVID MEDLINE, EMBASE, and COCHRANE CENTRAL databases were searched to identify all cases of syphilitic optic neuropathy with macular OCT. The primary research outcome was the prevalence of cases with outer retinal abnormalities on OCT.

RESULTS

Four cases were identified that were eligible for inclusion. The ages ranged from 27 to 62 years old, and 2 of the patients were female. On examination, vision ranged from Snellen 20/50 to hand motion; all patients had optic neuropathy, and macular OCT revealed chorioretinitis characterized by retinal pigment epithelium (RPE) excrescences. The patients subsequently underwent uveitis workup and were diagnosed with syphilis. They were treated with intravenous penicillin and showed improvement in outer retina appearance on follow-up. The systematic review consisted of 24 cases and 35 eyes with syphilitic optic neuropathy and reported macular OCT findings. Eighty-three percent (20/24) were males, and the mean age was 47.7 years (SD: 49.2). The mean visual acuity at presentation was Snellen 20/57. On fundoscopy, 25.7% (9/35) of eyes had vitritis, whereas 22.8% (8/35) had placoid chorioretinal lesions. On OCT, 45.7% (16/35) of eyes had abnormal outer retina findings, most commonly disruption of the ellipsoid zone (EZ) and/or RPE excrescences. All patients were treated with penicillin or ceftriaxone, and final mean visual acuity was Snellen 20/29.

CONCLUSIONS

All 4 patients identified in the case series, and nearly half of patients with syphilitic optic neuropathy described in the literature had concurrent-specific outer retina abnormalities (disruption of EZ and/or placoid chorioretinitis in the form of RPE excrescences) seen on macular OCT. We recommend that clinicians obtain macular OCT for all patients presenting with undifferentiated optic neuropathy.

Severe Sexually Transmitted Infections: Neurosyphilis, Mpox, and the Tubo-ovarian Abscess

Most sexually transmitted infections (STIs) are rarely seen by medical providers as life-threatening or as a source of severe sequelae. Human immunodeficiency virus and syphilis screening are still not universal and are affected by provider and patient misconceptions. We chose to discuss 3 STIs that can lead to significant morbidity and even mortality: neurosyphilis, due to its resurgence in the past years, Mpox due to its changing epidemiology and clinical presentation, and tubo-ovarian abscess due to its huge impact on female fertility and morbidity in general.

Comment on Dutta Majumder et al.'s 2019 'Ocular Syphilis: An Update'

The article 'Ocular Syphilis: An Update (2019)' provides a thorough review of the challenges in diagnosing ocular syphilis. However, our research on 'Dermatological and Ocular Manifestations of Syphilis,' identifies a significant gap in both literature and clinical practice: the lack of recognition of dermatological signs during ophthalmological assessments. Ocular syphilis often mimics other conditions and can remain undiagnosed for months or years. Detecting dermatological signs, such as the characteristic palmar rash of secondary syphilis and extragenital chancres, could prompt earlier investigation and serological testing, reducing unnecessary diagnostic workups and inappropriate management. Early recognition would facilitate timely administration of Penicillin G, helping prevent vision loss, which is often reversible with prompt treatment. We urge Ocular Immunology and Inflammation to highlight the importance of incorporating dermatological assessments in future ocular syphilis publications to improve diagnostic protocols and patient outcomes.

Ocular Syphilis - Clinical Features and Outcome in HIV Positive and HIV Negative Patients from a Tertiary Eye Center from India - A Comparative Study

PURPOSE

To study and compare the clinical characteristics and outcome of ocular syphilis between HIV positive and HIV negative patients.

METHODS

Retrospective hospital-based case series from a tertiary eye care hospital in India. Patients with uveitis and positive syphilis serology were included. Demographics, clinical features, investigations, imaging and treatment modalities were noted.

RESULTS

Hundred and five (105) eyes of 66 patients were analyzed. Males were predominantly affected (n = 57/66, 86.4%). Secondary syphilis was the most common stage of presentation (n = 48/66, 72.7%). Two groups were identified: HIV positive (HIVP) patients (n = 39/66, 59%) and HIV negative (HIVN) patients (n = 27/66, 41%). 12/39 (30.8%) patients were newly diagnosed with HIV at the time of ocular presentation. Panuveitis was the most common presenting feature in both groups (n = 66/105 eyes, 62.8%). Diffuse necrotizing retinitis was more common in HIV patients (HIVP - 15 Vs HIVN - 5 eyes). Ocular co-infections were more common in HIV patients, ocular tuberculosis, the commonest in both groups. Intravenous penicillin and titrated dose of systemic steroids were the mainstay of treatment. Improvement in mean logMAR was noted from 1.415 to 0.828 with p-value < 0.001. At final follow-up, 71.8% patients showed visual improvement. Complete resolution of ocular inflammation was noted in 95.5% patients.

CONCLUSION

Ocular syphilis poses a diagnostic challenge considering the varied presentations and clinical course both in immunocompromised and immunocompetent groups. Clinical presentations are not always classical. High index of suspicion with supportive laboratory investigations and with characteristic OCT features helps diagnosis. All uveitis patients, especially with those suspected with infectious etiology, need to be tested for syphilis serology to prevent vision loss in this resurgent disease.

Anterior Non-Necrotizing Scleritis with Active Uveitis in Cases of Ocular Syphilis

PURPOSE

To study clinical characteristics and management outcomes of cases of ocular syphilis co-presenting with scleritis and active uveitis.

METHODS

A retrospective analysis of cases diagnosed with ocular syphilis between January 2020 and December 2023 was conducted at a tertiary eye care centre. Clinical records, investigations, and outcomes were reviewed to identify cases with scleritis with active uveitis. Demographic data, clinical features, treatment modalities, and resolution patterns were analyzed.

RESULTS

Among the 135 eyes of 95 cases of ocular syphilis studied, scleritis with uveitis was observed in 3.70% of eyes (five eyes). All cases with scleritis and uveitis were unilateral and male, with ages ranging from 32 to 61 years. Concurrent features included placoid chorioretinitis, retinal vasculitis, and anterior uveitis. Misdiagnosis with subsequent oral steroid therapy precipitated scleritis as an exacerbation in two cases. Three cases, which were previously undiagnosed, were found to be HIV-positive. Scleritis manifested as anterior, non-necrotizing inflammation, often accompanied by chemosis, and responded rapidly to antibiotic and non-steroidal anti-inflammatory therapy. Scleritis resolution preceded that of chorioretinitis and retinal vasculitis.

CONCLUSIONS

Non-necrotizing anterior scleritis with chemosis can be a rare presentation of active syphilitic uveitis. Large placoid chorioretinitis lesions, preceding inadvertent oral steroid and/or undiagnosed HIV status were the possible risk factors for the development of concurrent scleritis.

Parkinsonism plus syndrome in neurosyphilis: Clinical insights and brain imaging

BACKGROUND

While Parkinsonism plus syndrome (PPS) is one of several atypical manifestations in neurosyphilis patients, its clinical features and brain-related manifestations are inadequately documented. In this cross-sectional study, we endeavored to indicate some key clinical and imaging features of neurosyphilis patients, particularly those specific to PPS.

METHODS

We retrospectively included all syphilis patients enrolled in the study from January 2021 to February 2024. All in all, 54 neurosyphilis patients with PPS were recruited. Their socio-demographical features, clinical status, presentations, laboratory manifestations and neuroimaging were analyzed retrospectively.

RESULTS

The predominant phenotype was general paresis (GP). Median age at onset was 50 years, and 87.0 % of the patients were male. Bradykinesia (53.7 %) was the most common manifestation of PPS in neurosyphilis patients. The most frequent physical sign was orofacial dyskinesia (the Candy sign), which accounted for 51.9 % of cases. In nearly three quarters (71.1 %), magnetic resonance imagery revealed temporal, hippocampal lobe, or whole brain atrophy, while 13.3 % exhibited basal ganglia lacunar infarction, and 22.2 % cases had focal demyelination in the cerebral peduncle, cerebellum, frontal lobe, parietal lobe, hippocampus and/or lateral vertical.

CONCLUSIONS

Neurosyphilis patients exhibited PPS in involving bradykinesia, tremor rigidity and, in most cases, GP. Brain atrophy and basal ganglia lesion were the most common imaging findings in neurosyphilis patients with PPS. Our results should help to elucidate PPS characteristics PPS and neuroimaging mechanisms in neurosyphilis patients with PPS.

Multimodal Imaging of a Unique Transitory Finding in Ocular Syphilis

Purpose: To describe a unique finding in ocular syphilis using multimodal imaging. Methods: A single case was analyzed. Results: A 52-year-old man presented with chronic syphilitic posterior uveitis and was treated with intravenous and intramuscular penicillin for systemic manifestations, topical steroids, and unilateral bevacizumab for secondary macular neovascularization. Bilateral transitory outer retinal microcysts were subsequently seen on optical coherence tomography, with an appearance distinct from outer retinal lesions found in other degenerative retinal diseases. Conclusions: Longstanding smoldering inflammation in this patient resulted in retinal pigment epithelial disruption and subsequent overlying photoreceptor rearrangement with microcyst formation. The spontaneous resolution and reappearance of these lesions elsewhere, despite previous treatment, may offer further insight into localized retinal tissue response from treponemal disease.

Persistent syphilitic ocular manifestations despite treatment: a case series

BACKGROUND

Penicillin has remained the most effective treatment for syphilis for several decades. Syphilitic retinal manifestations may persist following treatment and cause visual problems. In this case series, we describe three syphilis patients with persistent posterior segment manifestations due to chronic inflammation, incomplete treatment, and reinfection.

CASE SERIES

Recommended initial treatment for all patients was 14 days of intravenous penicillin. Oral prednisone was added 48 h after initiation of penicillin therapy. Case 1: A 48-year-old female presented with gradual vision loss for two months. Fundus imaging revealed syphilitic outer retinopathy (SOR), papillitis, and acute syphilitic posterior placoid chorioretinopathy (ASPPC). After treatment, she had persistent cystoid macular edema (CME) and was treated with intravitreal triamcinolone injections and ketorolac drops.

CASE 2

A 24-year-old male presented with sudden vision loss for two days. On imaging, he had ASPPC, papillitis, and SOR. IV penicillin treatment was given for 10 days only. He had persistent SOR and was retreated with doxycycline and prednisone. Case 3: A 52-year-old male presented with eye pain and visual loss for one week. There was evidence of ASPPC and papillitis on imaging. One month after treatment, he had persistent papillitis and was restarted on oral prednisone. One year later, he was found to have recurrent ASPPC and was confirmed to be reinfected with syphilis, for which he was retreated.

CONCLUSION

When treating persistent syphilitic ocular manifestations, we recommend checking that the penicillin treatment was complete and the RPR titers are declining. If both hold true, then the affected eye should be treated with anti-inflammatory therapy. Other factors that contribute to poor visual prognosis include treatment delay, poor initial visual acuity, macular edema, and HIV coinfection.

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.

Acute vision changes as the presenting symptom of ocular syphilis - A case series of two

Introduction

Syphilis, a bacterial infection caused by Treponema pallidum, can affect a wide variety of organ systems of its host. We aim to present the cases of two patients who presented to an urban, tertiary care, academic Emergency Department with ocular symptoms who underwent imaging, laboratory, and specialist evaluation and were ultimately diagnosed with ocular syphilis.

Case Report

The first patient is a 46-year-old female who presented to the Emergency Department with painless complete vision loss in a unilateral eye. Her exam was significant for bilateral papilledema, and further workup revealed a retinal detachment in the affected eye. Rapid plasma reagin (RPR) titers resulted positive with 1:128 and a reactive fluorescent treponemal antibody (FTA). Further workup including lumbar puncture and magnetic resonance imaging were unable to be obtained due to patient refusal and multiple discharges against medical advice. The second patient is a 38-year-old female with a history of intravenous drug use who presented for bilateral circumferential peripheral vision loss with central sparing. The examination showed bilateral papilledema. Lumbar puncture was performed with normal intracranial pressure. RPR titers resulted positive with 1:128. MRI and ophthalmology evaluation did not reveal any other etiology or explanation for papilledema.

Conclusion

This case series highlights the importance of considering syphilis as a possible cause of ocular symptoms in high risk patient populations and the need for prompt and appropriate treatment given the increasing prevalence of syphilis worldwide.

Infectious eye disease in the 21st century-an overview

Infectious diseases affecting the eye often cause unilateral or asymmetric visual loss in children and people of working age. This group of conditions includes viral, bacterial, fungal and parasitic diseases, both common and rare presentations which, in aggregate, may account for a significant portion of the global visual burden. Diagnosis is frequently challenging even in specialist centres, and many disease presentations are highly regional. In an age of globalisation, an understanding of the various modes of transmission and the geographic distribution of infections can be instructive to clinicians. The impact of eye infections on global disability is currently not sufficiently captured in global prevalence studies on visual impairment and blindness, which focus on bilateral disease in the over-50s. Moreover, in many cases it is hard to differentiate between infectious and immune-mediated diseases. Since infectious eye diseases can be preventable and frequently affect younger people, we argue that in future prevalence studies they should be considered as a separate category, including estimates of disability-adjusted life years (DALY) as a measure of overall disease burden. Numbers of ocular infections are uniquely affected by outbreaks as well as endemic transmission, and their control frequently relies on collaborative partnerships that go well beyond the remit of ophthalmology, encompassing domains as various as vaccination, antibiotic development, individual healthcare, vector control, mass drug administration, food supplementation, environmental and food hygiene, epidemiological mapping, and many more. Moreover, the anticipated impacts of global warming, conflict, food poverty, urbanisation and environmental degradation are likely to magnify their importance. While remote telemedicine can be a useful aide in the diagnosis of these conditions in resource-poor areas, enhanced global reporting networks and artificial intelligence systems may ultimately be required for disease surveillance and monitoring.

Characteristic Profiling of Soluble Factors in the Cerebrospinal Fluid of Patients With Neurosyphilis

BACKGROUND

Soluble inflammatory factors in the cerebrospinal fluid (CSF) of patients with neurosyphilis have been investigated with low-throughput technology. This study aimed to illustrate the characteristics of soluble factor profiles in CSF of patients with neurosyphilis.

METHODS

We measured the concentrations of 45 cytokines, chemokines, and growth factors in CSF from 112 untreated syphilis cases, including latent syphilis (LS), asymptomatic neurosyphilis (ANS), meningeal neurosyphilis (MNS), meningovascular neurosyphilis (MVNS), paralytic dementia (PD), and ocular syphilis (OS).

RESULTS

Thirty-three differentially expressed soluble factors (DeSFs) were categorized into 3 clusters. DeSF scores of clusters 1 and 2 (DeSFS1 and DeSFS2) were positively correlated with elevated neopterin and neurofilament light subunit (NF-L) concentration, respectively. DeSF scores of cluster 3 were positively correlated with white blood cells, protein, NF-L, and neopterin. Patients with LS, ANS, and OS exhibited an overall lower abundance of DeSFs. Patients with PD exhibited significantly increased levels of clusters 1 and 3, and the highest total DeSF score, whereas patients with MNS and MVNS showed enhanced levels of cluster 2. Receiver operating characteristic analysis revealed that DeSFS1 effectively discriminated PD, and DeSFS2 discriminated MNS/MVNS with high accuracy.

CONCLUSIONS

Patients with neurosyphilis at different stages have distinctive patterns of soluble factors in CSF, which are correlated with immune status and neuronal damage.

Influence of gender on clinical presentation, management practices and outcomes of ocular syphilis

Ocular syphilis is a re-emerging inflammatory eye disease with a clear gender imbalance, disproportionately affecting men. We investigated the impact of gender on the presentation, management practices and clinical outcomes of this condition. Data generated from a study of patients consecutively diagnosed with ocular syphilis who attended a subspecialist uveitis service at one of four hospitals in Brazil over a 30-month period were disaggregated for analysis by gender. Two-hundred and fourteen eyes (161 men and 53 women) of 127 patients (96 men and 31 women) were included. Posterior uveitis was the most common presentation in both men and women (80.1% vs. 66.7%, p > 0.05), but men were significantly more likely to have vitritis as a feature of their disease (49.4% versus 28.8%, p = 0.019). Three eyes of women had nodular anterior scleritis (p = 0.015). Men were more likely to undergo a lumbar puncture to assess for neurosyphilis (71.9% vs. 51.6%, p = 0.048), but men and women undergoing a lumbar puncture were equally likely to have a cerebrospinal fluid abnormality (36.2% vs. 25.0%, p = 0.393). All patients were treated with aqueous penicillin G or ceftriaxone, and there was a trend towards more men receiving adjunctive systemic corticosteroid treatment as part of their management (65.2% vs. 46.7%, p = 0.071). There were no significant differences in the age of presentation, bilaterality of disease, anatomical classification of uveitis, initial or final visual acuity, and rates of ocular complications between men and women. Our findings indicate that ocular syphilis has comparable outcomes in men and women, but that there are differences in the type of ocular inflammation and management practices between the genders.

Could ceftriaxone be a viable alternative to penicillin for the treatment of ocular syphilis?

This study was conducted to compare the effectiveness of ceftriaxone with that of aqueous crystalline penicillin G in treating ocular syphilis. We conducted a retrospective study from 2010 to 2021. Syphilis patients were administered either ceftriaxone (2 g intravenously daily for 14 days) or aqueous crystalline penicillin G [4 million units (MU) intravenously every 4 h for 14 days] as therapeutic interventions. Subsequently, we utilized these two groups to assess the serological results, cerebrospinal fluid analysis, and visual acuity at time intervals spanning 3 to 6 months post-treatment. A total of 205 patients were included, with 34 assigned to the ceftriaxone group and 171 to the penicillin group. The median age of patients was 56 years, with an interquartile range of 49-62 years, and 137 of them (66.8%) were male. Between 3 and 6 months after treatment, 13 patients (38.2%) in the ceftriaxone group and 82 patients (48.0%) in the penicillin group demonstrated effective treatment based on the clinical and laboratory parameters. The crude odds ratio (OR) was 0.672 (95% confidence interval [CI]: 0.316-1.428, P = 0.301), indicating no significant difference in effectiveness between the two groups. Thirty patients (17.5%) in the penicillin group and six patients (17.6%) in the ceftriaxone group did not experience successful outcomes. Notably, no serious adverse effects were reported in both the groups. There was no significant difference in the effectiveness of ceftriaxone and aqueous crystalline penicillin G in treating ocular syphilis. The administration of ceftriaxone without requiring hospitalization presents a convenient and safe alternative treatment option for ocular syphilis.

Clinical Insights: Antimicrobial Therapy for Infectious Uveitis

Infectious uveitis is a major global cause of vision impairment. Despite the eye's immune privilege, afforded by the blood-ocular barrier that restricts microbial entry, several pathogens such as bacteria, viruses, fungi, and parasites can still infiltrate and cause ocular infections and complications. Clinicians often encounter significant challenges in treating infectious uveitis due to limited or ineffective treatment options. Modern molecular techniques and imaging can aid in diagnosing and assessing intraocular infections. Various antimicrobial therapies exist, spanning topical and systemic treatments, but these are constrained by issues like drug concentration, penetration, effective duration, toxicity, and side effects. Treatment approaches also differ based on the infection's etiology. This review provides recent updates on antimicrobial therapies from a clinical perspective, covering topical, systemic, and regional treatments for infectious uveitis.

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.

Causes of infectious pediatric uveitis: A review

Infectious pediatric uveitis is a rare disease that can cause severe ocular damage if not detected rapidly and treated properly. Additionally, early identification of an infection can protect the child from life-threatening systemic infection. Infectious uveitis can be congenital or acquired and may manifest as a primary ocular infection or as a reactivation. Nevertheless, publications on infectious paediatric uveitis are usually limited to a small number of patients or a case report. So far, most studies on uveitis in children have focused primarily on noninfectious uveitis, and a systematic study on infectious uveitis is lacking. In this review, we summarize the literature on infectious uveitis in pediatric populations and report on the epidemiology, pathophysiology, clinical signs, diagnostic tests, and treatment. We will describe the different possible pathogens causing uveitis in childhood by microbiological group (i.e. parasites, viruses, bacteria, and fungi). We aim to contribute to early diagnosis and management of infectious pediatric uveitis, which in turn might improve not only visual outcome, but also the general health outcome.

ACUTE SYPHILITIC NECROTIZING RETINITIS ASSOCIATED WITH PLACOID CHORIORETINITIS IN AN IMMUNOCOMPETENT PATIENT

PURPOSE

We report an atypical case of combined acute syphilitic necrotizing retinitis and a contiguous acute syphilitic posterior placoid chorioretinitis in an HIV-negative, immunocompetent patient.

METHOD

Observational case report.

RESULTS

A 56-year-old man presented with a one-week history of pain and blurred vision in the left eye. He also complained of left-sided hearing loss for several months. Ocular examination demonstrated a unilateral panuveitis with a yellowish placoid macular lesion involving the outer retina contiguous with an ovoid area of full-thickness retinitis extending temporally. Vitreal polymerase chain reaction analysis for HSV, CMV, VZV, and T. gondii were negative, but syphilis serology was reported as positive. An MRI of the head revealed bilateral enhancement along the facial nerves, more marked on the left side, consistent with syphilitic involvement. He was treated for neurosyphilis with a 14-day course of systemic procaine penicillin and oral probenecid. Oral prednisolone (1 mg/kg/day) was commenced 24 hours before initiating antibiotics to prevent Jarisch-Herxheimer reaction and treat his panuveitis.

CONCLUSION

To our knowledge, this is the first report of combined syphilitic necrotizing retinitis and acute syphilitic posterior placoid chorioretinitis occurring in continuity in the same eye. This case highlights the diversity of possible presentations of ocular syphilis, even in HIV-negative immunocompetent patients.

Syphilis for dermatologists: Current concepts

Dermatologists are familiar with the classic aspects of syphilis. Our objective in this update is to display novel features of sexually acquired syphilis, its pathophysiology, natural history, atypical clinical variants, skin of color, clinical pearls, and prospects. Textbook knowledge, congenital syphilis, epidemiology, and historical data are excluded.

Ocular syphilis masquerading as refractory retinal diseases

PURPOSE

To report two cases of syphilis masquerading as chronic refractory macular diseases.

CASE DESCRIPTIONS

Two patients had been diagnosed with neovascular age-related macular degeneration (neovascular AMD) and diabetic macular edema (DME), respectively. The disease worsened despite repeated intravitreal injections of anti-vascular endothelial growth factor (VEGF) and also surgical treatment (in suspected case of DME). Systemic evaluations were positive for syphilis. Intravenous penicillin was started, and the macular diseases improved. The lesions were well controlled afterward.

CONCLUSIONS

The current two cases demonstrated that ocular syphilis can masquerade as refractory chronic retinal diseases such as DME and neovascular AMD. Laboratory evaluations for syphilis may be needed, not only for uveitis but also for refractory retinal diseases. Indocyanine green angiography may be helpful to reveal occult syphilis.

Rising Incidence of Syphilitic Uveitis-Related Hospitalizations in the US

Importance

The number of syphilis cases continues to increase in the US every year since 2001 with a 74% increase observed since 2017. In addition, there remains a national shortage of injectable penicillin G. Despite the increase in reported cases, to the authors' knowledge, there has been no recent nationwide study investigating the trends in incidence of syphilitic uveitis.

Objective

To evaluate the national and regional incidence of syphilitic uveitis-related hospitalizations in the US.

Design, Setting, and Participants

This was a retrospective, cross-sectional study. The Nationwide Inpatient Sample was queried to identify all inpatient admissions with a diagnosis of syphilitic uveitis in the US between the years 2010 and 2019. Analyses were performed to determine baseline sociodemographic characteristics and identify national and regional trends in incidence. All patients hospitalized with a diagnosis of syphilis, uveitis, and/or syphilitic uveitis were eligible for inclusion. Statistical analysis of study data took place in June 2023.

Exposure

Diagnosis of syphilis, uveitis, and/or syphilitic uveitis on inpatient admissions during the years 2010 to 2019 in the Nationwide Inpatient Sample.

Main Outcome Measures

The primary outcome was to determine trends in the national and regional incidence of syphilitic uveitis-related hospitalizations in the US. Secondary outcome measures included sociodemographic characteristics of patients with syphilitic uveitis, incidence stratified by sex and race and ethnicity, and median charge per syphilitic uveitis hospital admission.

Results

From the Nationwide Inpatient Sample, inpatient data from 444 674 patients (median [IQR] age, 53 [37-67] years; 54.8% male) were analyzed. There were an estimated 5581 syphilitic uveitis-related hospitalizations during the 10-year study period. The median (IQR) age of individuals with syphilitic uveitis was 45 (35-55) years, and 4395 patients (78.9%) were male. Syphilitic uveitis disproportionately affected African American individuals (1787 patients [32%], although they compose 13.6% of the population) and those belonging to the lowest median household income quartile (2163 [38.8%]). The national incidence was 0.15 per 100 000 population and showed an increasing trend over the years, with the lowest incidence in 2011 (0.08 per 100 000 population) and the highest incidence in 2019 (0.23 per 100 000 population; P = .04). Regional analysis showed an increase in incidence across all 4 US geographical regions. A total of 1293 patients (23.2%) had comorbid AIDS.

Conclusion and Relevance

Although this cross-sectional study only captured inpatient diagnosis, an increasing incidence of syphilitic uveitis-related hospitalizations was observed in the US between 2010 and 2019. Given the concomitant national shortage of injectable penicillin G, results suggest that clinicians should maintain a high index of suspicion for syphilis when evaluating patients with intraocular inflammation.

Sexually transmitted infections and HIV in ophthalmology

The ocular and periocular manifestations of sexually transmitted infections are heterogeneous in etiology, manifestations, and complications. Etiologic agents include bacteria, viruses, parasites, and protozoa, which are most frequently transmitted via direct ocular contact with an active lesion or infected bodily fluid, autoinoculation, or dissemination from a distant site. Vertical transmission most commonly occurs perinatally during vaginal delivery. The complications of ophthalmia neonatorum can be severe, with the potential for permanent blindness or life-threatening systemic involvement if untreated. Clinical features, diagnostic modalities, and therapeutic regimens vary based on etiology and are summarized in this review. Prompt diagnosis is imperative, given the severe sequelae that may result from ocular involvement in these infections, including permanent vision loss. A multidisciplinary approach, involving both ophthalmology and dermatology, to diagnosis and management is essential to mitigate the risk of morbidity associated with sexually transmitted infections resulting in eye disease.

Through the Eyes: A Case of Ocular Syphilis

Syphilis is a bacterial disease caused by Treponema pallidum and is sexually transmitted via vaginal, anogenital, or orogenital contact. Vertical transmission between mother and unborn child is also possible, but transmission via skin-to-skin or blood contact is rare. The objective of this case is to highlight this rare ocular manifestation of syphilis as it manifests as a multisystemic disease affecting many organ systems. This is a case of a 46-year-old male with vision loss who was referred to the emergency department by an ophthalmologist. Two days before the presentation at the emergency department, the ophthalmologist observed the presence of optic disc edema in the left eye. At the emergency department, he complained of bright light spots in the left eye and complete darkness in the central aspect of the eyes. He reported having a non-pruritic erythematous rash on the anterior abdomen that began one week before his presentation at the emergency department. The patient also reported having multiple sexual partners. Physical examination findings showed a visual field defect in the left eye, normal bilateral eye movement, and a non-tender skin reticulation over the anterior abdominal wall. Lab results showed complete blood count (CBC) and comprehensive metabolic panel (CMP) within normal limits, fluorescent treponemal antibody (FTA) antibody reactive, human immunodeficiency virus (HIV) test and hepatitis panel negative, rapid plasma reagin (RPR) titer 1:64, and imaging results negative for any significant abnormalities. The infectious disease specialists were consulted, and the recommended IV penicillin of four million units every four hours was given. The patient reported an improvement in his blurry vision over three days. By six months, his vision was back to baseline. This case report is significant due to the rare occurrence of ocular complications as an initial presentation of syphilis. Considering the rising cases of syphilis in the United States, it is important to highlight the possibility of this uncommon clinical presentation of syphilis.

Demystifying Ocular Syphilis - A Major Review

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.

A Case of Syphilis with a Rare Finding: Subretinal Hypopyon

PURPOSE

To report clinical features and follow-up of a case with subretinal hypopyon due to syphilis infection.

CASE PRESENTATION

We present a case of syphilis admitted with optic neuritis and treated with intravenous pulse steroids without antibiotics. The patient was referred to the uvea clinic in the follow-up because of decreased vision and the onset of multiple retinitis foci. We determined subretinal hypopyon in the left eye and a positive TPHA test. A significant regression was observed in retinitis and hypopyon with antibiotic therapy.

CONCLUSION

Before starting a steroid treatment, infective etiologies should be considered in patients with optic neuritis. Treating with a high dosage of steroids without antibiotics in syphilis would worsen the clinical features and prognosis.

Pathogenesis of Bacterial Uveitis

PURPOSE

To describe the pathogenesis and the general immune mechanisms of the most frequent causes of bacterial uveitis.

METHODOLOGY

Narrative review.

RESULTS

Both extra- and intracellular bacteria can induce uveitis, whereas intracellular bacteria are generally transported into the inner eye via cells of the innate immune system, mainly macrophages. Systemic adaptive immunity is usually induced before the bacteria are localized to the inner eye, and once T and B cells have detected the pathogens behind the blood-eye barriers they elicit an acute and/or chronic inflammatory response deteriorating visual acuity that can severely affect the non-regenerating, intraocular tissues.

CONCLUSIONS

An understanding of pathogenic mechanisms, and its correlation with clinical and imaging features, can facilitate early recognition of microbial factors and institution of appropriate therapy.

Case Report: Multimode Imaging of Chronic Syphilitic Chorioretinitis

SIGNIFICANCE

The clinical manifestations of ocular syphilis may mimic those of other diseases, which may result in a missed diagnosis and delayed treatment.

PURPOSE

We describe multimodal imaging findings and treatment outcomes of a patient with chronic syphilitic chorioretinitis.

CASE REPORT

A 40-year-old male patient complained of progressive decreased visual acuity of his left eye for more than 1 year. The best-corrected visual acuity was 20/20 in the right eye and 3/50 in the left eye. Relative afferent pupillary defect and 1+ vitreous cells were detected in the left eye. The authors performed fundus examination, fluorescence angiography, ultrawide-field fundus autofluorescence, structure optical coherence tomography, wide-field montage optical coherence tomography angiography, and visual field. Laboratory tests including a toluidine red unheated serum test (1:32) and the Treponema pallidum antibody (9.01S/CO) showed positive results. Chronic syphilitic chorioretinitis was diagnosed in both eyes. The patient was admitted for administration of intravenous penicillin G for 14 days, followed by intramuscular benzathine penicillin G weekly for three doses. Six months after treatment, the toluidine red unheated serum test ratio had decreased to 1:2 (positive). The best-corrected visual acuity was 20/20 in the right eye and 6/20 in the left eye. The reexamination results showed that the ocular structure and capillaris flow partially recovered.

CONCLUSIONS

Chronic syphilitic chorioretinitis profoundly affects the structure of the retina and choroid; however, eyes may partially recover after an effective treatment. Ultrawide-field imaging technology has several advantages, such as broader imaging field and more details provided, in determining syphilis-induced ocular disorders.

Vision-related quality of life in patients treated for ocular syphilis

Multiple studies have showed negative impact of non-infectious uveitis on quality of life (QoL). Less is understood regarding life experiences in patients with infectious uveitis. We investigated vision-related QoL in individuals who had recovered from ocular syphilis. 32 adults treated for ocular syphilis at a uveitis service in Brazil completed the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25), and a comprehensive ophthalmic examination was performed. Medical records were reviewed to confirm resolution of ocular inflammation for 3 months pre-enrolment, and collect clinical data. The NEI VFQ-25 composite score was low overall (75.5 ± 19.8, mean ± standard deviation), and subscale scores varied from relative lows of 59.1 ± 39.6 (driving) and 60.9 ± 24.5 (mental health), to relative highs of 84.8 ± 21.8 (ocular) and 89.1 ± 21.0 (color vision). Adults aged over 40 years and those with a final visual acuity of 20/50 or worse had significantly lower mean composite and subscale scores. Other clinical characteristics-including gender, HIV co-infection, and type of uveitis-did not significantly influence scores. Our findings, taken in context with previous observations that prompt recognition achieves better vision outcomes, suggest early treatment may improve QoL after recovery from ocular syphilis.

Inflammatory eye disease for rheumatologists

PURPOSE OF REVIEW

This review provides a framework for understanding inflammatory eye disease diagnosis, differential diagnosis, and management for rheumatologists. Uveitis, scleritis, episcleritis, peripheral ulcerative keratitis, and orbital inflammation are all discussed. The goal is to facilitate the development of approaches to inflammatory eye diseases that will help rheumatologists co-manage these patients with eye care providers specializing in ocular inflammation.

RECENT FINDINGS

In recent years, studies have aimed to advance biologic treatments and define standard-of-care therapy. Inflammatory eye diseases are highly heterogeneous and often rare, which poses significant challenges to their research and the interpretation of existing data. To date, glucocorticoids, mycophenolate, methotrexate, and TNF inhibitors remain the mainstay of treatment options for many of these diseases.

SUMMARY

Patients with inflammatory eye diseases require multidisciplinary care for best outcomes, frequently including rheumatologists. Understanding the differentials, diagnostics, and treatment are essential to preserving vision in these patients. The diverse nature of the disease processes within this field requires focusing on specific disease phenotypes and endotypes in research and clinical practice.

Syphilis

Syphilis is a curable systemic infectious disease with a clear increase in incidence in recent years. The disease presents with a broad clinical spectrum and challenges clinicians due to the long incubation period and the sometimes complex interpretation of serological test results. Penicillin G remains the treatment of choice in all stages of syphilis.

Infrared analysis in the aqueous humor of patients with uveitis: Preliminary results

Inflammatory processes affecting the uvea result in a temporary o permanent blurred vision and represent an important cause of visual impairment worldwide. It is often hard to make a precise diagnosis which is dependent on the clinical expertise, diagnostic tests, laboratory investigations in blood and sometimes in the aqueous humor (AH). With the aim of obtaining proof of principle Fourier Transformed Infrared (FT-IR) absorbance spectroscopy was applied to study the molecular composition of 72 AH samples collected in 26 patients with uveitis and in 44 controls. The unsupervised exploration of the internal structure of the dataset by principal component analysis reduced hundreds IR variables to those most representative allowing to obtain the predictive model that distinguished the AH spectra of patients with uveitis from controls. The same result was obtained by unsupervised agglomerative cluster analysis. After labeling the spectra with some clinical information it was observed that most severe uveitis with active processes were grouped separately from chronic and relapsing uveitis and controls. The consistence of prediction models is discussed in the light of supporting etiological diagnosis by machine learning processes. In conclusion, proof of principle has been obtained that the IR spectral pattern of AH may reflect particular uveal diseases.

Clinical Features and Possible Origin of Preretinal Deposits in Different Ocular Diseases and Events: A Narrative Review

Preretinal deposits (PDs) are a rare condition among fundus diseases. We found that preretinal deposits have some features in common that can provide clinical information. This review affords an overview of PDs in different but related ocular diseases and events, and summarizes the clinical features and possible origin of PDs in related conditions, providing diagnostic clues for ophthalmologists when facing PDs. A literature search was performed using three major electronic databases (PubMed, EMBASE, and Google Scholar) to identify potentially relevant articles published on or before June 4, 2022. Most of the cases in the enrolled articles had optical coherence tomography (OCT) images to confirm the preretinal location of the deposits. Thirty-two publications reported PD-related conditions, including ocular toxoplasmosis (OT), syphilitic uveitis, vitreoretinal lymphoma, human T-cell lymphotropic virus type 1 (HTLV-I) associated uveitis or HTLV-I carriers, acute retinal necrosis, endogenous fungal endophthalmitis, idiopathic uveitis, and exogenous materials. Based on our review, OT is the most frequent infectious disease to exhibit PDs, and silicone oil tamponade is the most common exogenous cause of preretinal deposits. PDs in inflammatory diseases are highly suggestive of active infectious disease and are preferentially accompanied by a retinitis area. However, PDs will largely resolve after etiological treatment in either inflammatory or exogenous conditions.

Stepwise approach for fundus imaging in the diagnosis and management of posterior uveitis

An array of retinochoroid imaging modalities aid in comprehensive evaluation of the immunopathological changes in the retina and choroid, forming the core component for the diagnosis and management of inflammatory disorders such as uveitis. The recent technological breakthroughs have led to the development of imaging platforms that can evaluate the layers of retina and choroid and the structural and functional alteration in these tissues. Ophthalmologists heavily rely on imaging modalities such as dye-based angiographies (fluorescein angiography and indocyanine green angiography), optical coherence tomography, fundus autofluorescence, as well as dye-less angiography such as optical coherence tomography angiograph,y for establishing a precise diagnosis and understanding the pathophysiology of the diseases. Furthermore, these tools are now being deployed with a 'multimodal' approach for swift and accurate diagnosis. In this comprehensive review, we outline the imaging platforms used for evaluation of posterior uveitis and discuss the organized, algorithmic approach for the assessment of the disorders. Additionally, we provide an insight into disease-specific characteristic pathological changes and the established strategies to rule out disorders with overlapping features on imaging.

An Updated Review of Recent Advances in Neurosyphilis

Neurosyphilis is caused by Treponema pallidum invading the central nervous system, of which the incidence is increasing worldwide. Due to its variable clinical manifestations, diagnosis of neurosyphilis remains challenging, especially the asymptomatic form. This review focuses on recent advances in neurosyphilis, including epidemiology, clinical manifestations, laboratory findings, comorbidities, diagnosis, treatment, prognosis, and basic research. The expansion of men who have sex with men and the infection of human immunodeficiency virus mainly accounted for the increasing incidence of neurosyphilis. The rate of some historically described forms of neurosyphilis in the pre-antibiotic era declined significantly; atypical features are more prevalent. Neurosyphilis, regarded as a great mimicker for neuro-ophthalmic, audio-vestibular, and psychiatric disorders, often presents concomitantly with other diseases, including metabolic disorders. Studies on long non-coding RNAs, miRNAs, chemokines, and metabolites in peripheral blood and cerebrospinal fluid may facilitate exploring the pathogenesis and identifying novel biomarkers of neurosyphilis. The drug resistance of Treponema pallidum to penicillin has not been reported; ceftriaxone was proposed to be more effective than penicillin, whereas few randomized controlled trials supported this view. This study may pave the way for further research, especially the diagnosis and treatment of neurosyphilis.

A Case of Ocular Syphilis in an HIV-Positive Patient With Penicillin Allergy

Ocular syphilis has a wide range of presentations; however, the most common findings are ophthalmalgia, blurry vision, and erythematous conjunctiva. This report presents a case of ocular syphilis in a human immunodeficiency virus-positive patient with an allergy to penicillin. On presentation, the patient was diagnosed using a fluorescent treponemal antibody absorption test, in addition to rapid plasma reagin. In this case, the patient received alternative treatment with doxycycline prior to penicillin desensitization, with marked improvement of his symptoms.

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.

Clinical features and incidence of visual improvement following systemic antibiotic treatment in patients with syphilitic uveitis

To describe the clinical features, longitudinal pattern, and incidence rate of improvement of visual acuity (VA) following antibiotic therapy in patients with syphilitic uveitis. A total of 36 patients were included in this retrospective study from 2009 to 2020. The longitudinal patterns of mean VA values during follow-up were analyzed using a linear mixed model. Most patients were men with HIV coinfection (81%) and presented with panuveitis (49%). The mean VA at baseline improved from 0.97 to 0.39 logMAR at 6 months and remained stable thereafter. The cumulative incidence of VA ≥ 20/25 achieved by 2 years was 70%. Receiving antibiotic therapy within four weeks of the onset of ocular symptoms (adjusted hazard ratio [aHR] 3.4, P = 0.012), absence of HIV coinfection (aHR 8.2, P < 0.001), absence of neurosyphilis (aHR 6.5, P = 0.037), better presenting VA (aHR 5.0, P = 0.003), and intermediate uveitis as opposed to panuveitis (aHR 11.5, P = 0.013) were predictive of achieving VA ≥ 20/25. Men with HIV coinfection represented the majority of our patients. Visual outcomes, in response to antibiotics, were favorable. Delayed treatment, poor presenting VA, presence of HIV coinfection, and concomitant neurosyphilis decreased the likelihood of VA restoration.

Mechanisms, Pathophysiology and Current Immunomodulatory/Immunosuppressive Therapy of Non-Infectious and/or Immune-Mediated Choroiditis

Non-infectious choroiditis comprises immune-mediated diseases resulting from diverse pathophysiological mechanisms. These conditions are sub-divided into two main groups, (1) diseases of the choriocapillaris and (2) diseases of the choroidal stroma. The purpose of this study is to expose the pathophysiology of the most common diseases of both these groups and recommend the optimal immunomodulatory/immunosuppressive therapy of each analyzed condition based on literature data and data from our own centers. Material and Methods: Narrative review. In the group of choriocapillaritis entities or primary inflammatory choriocapillaropathies (PICCPs) including multiple evanescent white dot syndrome (MEWDS), acute posterior multifocal placoid pigment epitheliopathy (APMPPE), idiopathic multifocal choroiditis (MFC) and serpiginous choroiditis (SC), as well as secondary choriocapillaritides including acute syphilitic posterior multifocal placoid chorioretinitis (ASPMPC) and tuberculosis-related SC (TB-SC), were analyzed. In the group of stromal choroidites, HLA-A29 birdshot retinochoroiditis (BRC) and Vogt-Koyanagi-Harada (VKH) disease were included. For each entity a literature search, in the PubMed database, on treatment was performed and analyzed and the therapeutic attitudes of our own centers were presented. Management of immune-mediated choroiditis implies vigorous immunosuppressive therapy given in a prompt and prolonged fashion in most of these entities.

Pediatric uveitis: Role of the pediatrician

The challenges of childhood uveitis lie in the varied spectrum of its clinical presentation, the often asymptomatic nature of disease, and the evolving nature of the phenotype alongside normal physiological development. These issues can lead to delayed diagnosis which can cause significant morbidity and severe visual impairment. The most common ocular complications include cataracts, band keratopathy, glaucoma, and macular oedema, and the various associated systemic disorders can also result in extra-ophthalmic morbidity. Pediatricians have an important role to play. Their awareness of the various presentations and etiologies of uveitis in children afford the opportunity of prompt diagnosis before complications arise. Juvenile Idiopathic Arthritis (JIA) is one of the most common associated disorders seen in childhood uveitis, but there is a need to recognize other causes. In this review, different causes of uveitis are explored, including infections, autoimmune and autoinflammatory disease. As treatment is often informed by etiology, pediatricians can ensure early ophthalmological referral for children with inflammatory disease at risk of uveitis and can support management decisions for children with uveitis and possible underling multi-system inflammatory disease, thus reducing the risk of the development of irreversible sequelae.

A 2021 Update on Syphilis: Taking Stock from Pathogenesis to Vaccines

In 2021 the scientific community's efforts have been focused on solving the back-breaking challenge of the COVID-19 pandemic, but sexually transmitted infections (STI) are still one of the most common global health problems. Syphilis is a systemic disease caused by the spirochaete Treponema pallidum (TP) and is one of the oldest known diseases. Its incidence has increased in the last few years and syphilis still remains a contemporary plague that continues to afflict millions of people worldwide. Despite research improvements, syphilis pathogenesis is not completely clear; clinical presentation is very heterogeneous and the diagnosis can sometimes be difficult. Furthermore, few therapeutic options are available, and a vaccine has not been found yet. In this review, we describe the most recent evidence concerning the clinical manifestation, diagnosis, treatment and vaccine prospectives for this disease.