Clinical manifestations and outcomes of ocular syphilis in Asian Indian population: Analysis of cases presenting to a tertiary referral center

Abstract

Purpose: To describe disease manifestations and outcomes of ocular syphilis in Asian Indian population.

Methods: Retrospective analysis of patients diagnosed with ocular syphilis at a tertiary referral center in India. Demographics, history, extraocular and ocular manifestations, ocular and systemic investigations, treatment and visual acuity outcomes were noted. All patients were diagnosed after necessary laboratory investigations including HIV ELISA (Human immunodeficiency virus, enzyme-linked immunosorbent assay), VDRL (venereal disease research laboratory), and TPHA (treponema pallidum hemagglutination).

Results: Totally, 20 patients with mean age at presentation 38.25 ± 9.76 were analyzed. 9/20 patients had bilateral involvement. 8/20 had concurrent HIV at presentation with an average CD4 counts of 592.25 ± 411.34 cells/microliter. The mean duration of symptoms at time of presentation was 15.45 ± 35.15 weeks. VDRL test was reactive in 45% (9/20) patients whereas, all patients had a reactive TPHA test. Clinical manifestations included outer retinal placoid chorioretinitis lesions (8/20, 40%), followed by retinitis mimicking acute retinal necrosis as the second most common phenotype (4/20, 20%). Other presenting manifestations noted were panuveitis, miliary retinitis lesions, retinal vasculitis, intermediate uveitis, and anterior uveitis. The clinical phenotypes in immunocompromised included panuveitis, acute retinal necrosis and isolated anterior uveitis. Mean follow up duration was 6.32 ± 6.15 months. An improvement in mean best corrected visual acuity (BCVA) of (0.63 LogMAR, approximately 6 Snellen lines, P < 0.02) was noted at last follow-up.

Conclusion: Phenotypic manifestations of ocular syphilis are varied. Non-treponemal tests like VDRL may be unreliable when compared with treponemal tests in diagnosing ocular syphilis. Syphilitic uveitis is considered equivalent to neurosyphilis and is treated similar to neurosyphilis.

Keywords: HIV; luetic; ocular syphilis; panuveitis and granulomatous; syphilis.

Figure 1

Fundus photograph of the left eye showing outer retinal placoid lesion (a), with the autofluorescence showing speckled hyperautofluorescent dots corresponding to the lesion and within, interspersed with pin point hypoautofluorescent dots (b). Optical coherence tomography (OCT) line scan through the lesion shows areas of irregularity or loss of ellipsoid zone, neurosensory detachment with hyperreflective dots, areas of thinned and thickened retinal pigment epithelium (RPE), inflammatory subretinal and subRPE deposits/lesions (c). (d) Left eye after treatment showing resolution

Figure 2

(a) Fundus photograph of the left eye showing a posterior outer retinal placoid retinitis lesion with perivascular sheathing in the inferotemporal quadrant, (b). Mid phase FA showing hyper fluorescence with interspersed small areas of hypo fluorescence (leopard spotting) and an area of marked hypo fluorescence along the active retinitis edge (yellow star), (c). Inferotemporal periphery showing the area of retinitis with hypo fluorescence and mild staining of vessel walls and (d). Late phase showing disc hyperfluorescence and increased hyper fluorescence corresponding to active retinitis edge

Figure 3

An Optos widefield image of the right eye showing multiple full thickness retinitis lesions extending along the vessels. Multiple areas of perivascular sheathing may also be noted. Inferior part of the picture shows multiple small full thickness retinitis lesions or scars

Figure 4

A fundus photograph of the left eye showing miliary retinal lesions (yellow arrow), with presence of retinal perivascular sheathing (a, chevron), OCT vertical line scan through the miliary lesions reveals hyperreflectivity through the full thickness of the retina (b, yellow oval)