Presentation of Ocular Syphilis in a HIV-Positive Patient with False-Negative Serologic Screening

Abstract

Purpose: The ocular sequelae of syphilis are devastating and may cause blindness. The ambiguous nature of its ocular manifestations makes syphilis difficult to detect. Though uncommon, the rise of syphilis in the United States requires a renewed understanding of its ophthalmic presentation to prevent devastating outcomes. We present this case to raise awareness for the increasing prevalence of ocular syphilis and appropriate serologic testing.

Observations: We describe a 65-year-old HIV-positive male with worsening retinitis, uveitis, and rapid visual loss. Initial lab results showed a nonreactive rapid plasma reagin (RPR) for syphilis. However, subsequent Treponema pallidum antibody testing was positive 48 hours after initial false-negative serologic screening. The patient had a rapid and successful recovery following treatment with penicillin.

Conclusions and importance: The incidence of syphilis is on the rise once again, and patients living with HIV are at increased risk. Ocular syphilis should be considered in susceptible populations in the clinical setting of retinitis, uveitis, and worsening visual loss with unknown cause. In addition, retesting for syphilis will decrease the prevalence of false-negative results, especially in patients with high clinical suspicion.

Figure 1

Baseline imaging results. (a) Optical coherence tomography upon initial presentation was unremarkable. (b) Fluorescein angiography at the first visit revealed focal hyperfluorescence inferior to the optic nerve in the right eye (top) and vasculitis of the inferotemporal vessels in the left eye (bottom). (c) Fundus photos upon initial presentation. Normal retinal vessels in the right eye. Peripheral retinitis with white yellow necrotic retina and slight disc edema in the left eye.

Figure 2

Imaging results 21 days after initial presentation. (a) Optical coherence tomography of the right eye (top) showed vitreous debris with no evidence of subretinal fluid. The view of the left eye (bottom) was limited due to heavy vitreous debris. (b) Fluorescein angiography following visual decline. There are marked retinitis and vitreous debris in the right eye (top) and limited views due to heavy vitreous debris in the left eye (bottom). (c) Fundus photos revealed vitreous debris with 1+ vitritis and peripheral retinitis in the right eye. Heavy vitreous debris with 4+ vitritis causing limited views in the left eye.

Figure 3

Syphilis screening algorithms. Traditional serologic screening (a) compared to reverse sequence serologic screening (b). Screening algorithms adopted from CDC recommendations [3, 4]. RPR, rapid plasma reagin; TP-PA, Treponema pallidum particle agglutination; EIA, enzyme immunoassay; CIA, chemiluminescence immunoassay.