Neurosyphilis Presenting as an Atypical Case of Posterior Placoid Chorioretinitis in a Young, HIV-Negative Male

Abstract

Ocular syphilis can occur at any time after initial infection and most commonly presents as posterior uveitis or panuveitis, although many other ocular findings have been documented. We present the case of a young, otherwise healthy Caucasian HIV-negative male who presented with acute onset of photopsias, floaters, and a rapidly progressive unilateral scotoma who was originally diagnosed with acute zonal occult outer retinopathy (AZOOR) and started on a high dose prednisone taper. Although his clinical symptoms improved on corticosteroids, he was later switched to Penicillin G treatment when his blood and cerebrospinal fluid (CSF) testing demonstrated syphilis as his underlying diagnosis. Given his ocular findings on the exam and reactive syphilitic testing, he was ultimately diagnosed with acute syphilitic posterior placoid chorioretinitis (ASPPC). Our patient's clinical improvement after a high-dose prednisone trial offers further evidence of an autoimmune component to the pathophysiology of ASPPC.

Keywords: chorioretinitis; immunology; ocular syphilis; penicillin g; syphilis.

Figure 1. Fundus photo images of the right eye. (A) Cream-yellow lesion present adjacent to the macula (arrow). (B) Resolution of the yellow lesion following penicillin therapy.

Figure 2. Optical coherence tomography (OCT) of the right eye. (A) Nodular thickening of the outer retinal pigment epithelium with disruption of the inner and outer segment photoreceptor junction (arrows). (B) Reestablishment of photoreceptor junction following penicillin therapy.

Figure 3. Autofluorescence imaging of the right eye. (A) Superotemporal placoid area of hyperautofluorescence (arrow). (B) Superotemporal placoid area of hyperautofluorescence following two weeks of steroid therapy (arrow). (C) Resolution of the lesion following penicillin therapy.

Figure 4. Late phase fluorescein angiography (FA) of right eye demonstrating right superotemporal hyperfluorescent staining with characteristic “leopard spotting” pattern (arrow).