Secondary Syphilis Presenting as Bilateral Simultaneous Papillitis in an Immunocompetent Individual

Abstract

Ocular syphilis is a common presentation for patients with secondary or tertiary syphilis and usually includes posterior uveitis or panuveitis, though a myriad of symptoms have been associated. We report the case of a 58-year-old Caucasian male who presented with fast-progressing vision loss and a new onset of floaters in both eyes. An initial fundus exam revealed only bilateral optic disc edema, and neurological evaluation was negative. Subsequent ophthalmology evaluation in the clinic revealed a ragged retinal pigmented epithelium on optical coherence tomography (OCT) and posterior placoid chorioretinitis, raising suspicion of syphilis. Intravenous penicillin therapy was immediately initiated based on high clinical suspicion of ocular syphilis while awaiting lab confirmation, which was later confirmed as a new syphilis infection. He was subsequently given oral prednisone 48 hours into penicillin therapy for a significant posterior inflammatory response in both his eyes. His visual recovery was drastic due to the timely use of oral steroids. Classical findings such as ragged retinal pigmented epithelium on OCT and posterior placoid chorioretinitis demonstrate strong clinical suspicion of ocular syphilis. Oral prednisone when used timely with penicillin therapy in special situations such as bilateral severe posterior uveitis, panuveitis, or optic neuritis may aid in a faster and smoother visual recovery. A high index of clinical suspicion of ocular syphilis should be maintained in patients with human immunodeficiency virus (HIV) infection presenting with uveitis, posterior placoid morphology, or optic disc edema. Oral prednisone may be an effective adjuvant treatment for immunocompetent patients who mount a strong inflammatory response to ocular syphilis infection.

Keywords: human immunodeficiency virus; immunocompetent; ocular syphilis; papillitis; prednisone.

Figure 1. Montage fundus photos showing a round, deep, creamy lesion at the posterior pole of the right eye suggesting ASPPC (arrow), bilateral papillitis (arrowheads), and bilateral venous dilation (asterisks).

(a) Before treatment (OD); (b) before treatment (OS); (c) after treatment (OD); (d) after treatment (OS). ASPPC: acute syphilitic posterior placoid chorioretinitis.

Figure 2. OCT images one week after initial presentation which show granular ragged appearing retinal pigmented epithelium with disruption of the ellipsoid zone (arrow).

(a) Before treatment (OD); (b) before treatment (OS); (c) after treatment (OD); (d) after treatment (OS). OCT: optical coherence tomography.

Figure 3. FA and ICG images from one week after initial presentation but before treatment which demonstrate bilateral papillitis (arrow) and posterior placoid morphology which appears as a hyper-fluorescent lesion at the posterior pole (*).

(a) Before treatment and early (OD); (b) before treatment and early (OS); (c) before treatment and late (OD); (d) before treatment and late (OS). FA: fluorescein angiography, ICG: indocyanine green.