Zeitschrift für HIV und Retroviren Offener Zugang


Ocular symptoms as atypical presentation of re-emerging pathogen

Brian McCann

We present an unusual case of a patient presenting with blurry vision, and rapid visual loss over two days as their main symptom. Examination demonstrated a maculopapular rash, which the patient had previously dismissed. Opthalmology examination showed significantly reduced visual acuity in left eye 1.06 logMAR, and features consistent with uveitis. A broad differential diagnosis was considered. Investigations showed Treponema pallidum IgM positive,VDRL/ RPR positive, titre 1:32. HIV negative. Lumbar puncture was performed with CSF PCR treponema pallidum positive VDRL 1:80. Treated with IV benzathine penicillin 2.4g six times a day, for fourteen days, in addition to high dose steroids. Rapid improvement in visual acuity and end of treatment, and resolution of rash. Partner also successfully treated.

Syphilis is a disease caused by the spirochete treponema pallidum, which is transmitted sexually, and from mother to child. This organism has the ability to affect any body system, which explains why it presents a diagnostic headache for clinicians, as it can present itself in a multitude of ways.  The incidence of syphilis cases is at its highest since WW2. Syphilis contributes to approximately 2% of uveitis cases, and forms an important part of a differential diagnosis. There are infrequent case reports in the literature presenting this way. Investigation and interpretation of lab results can be difficult, and these must always be interpreted in context of clinical picture. This case highlights the importance of taking a sexual history as part of a routine systemic enquiry, as this can direct us towards possible diagnoses, and guide investigation. The rising incidence highlights a need for clinicians to be vigilant of this infection, as it is highly difficult to diagnose. But importantly, it is also highly curable.