Ocular syphilis presenting as unilateral chorioretinitis

Abstract

Syphilis is a multi systemic infection caused by Treponema pallidum. Ocular manifestations of Syphilis have a myriad of presentations and severity. A 31year old male patient was referred from ophthalmology department as a case of chorioretinitis for screening for syphilis. Patient had diminished vision and redness of right eye for 2 months duration. History of premarital exposure and extramarital contact was present. Ocular examination revealed – Rt eye: conjunctival congestion and Argyll Robertson pupil; Lt eye: normal. Fundoscopy of right eye showed yellowish white retinal lesions, macular edema and hyperaemia and left eye was normal .No genital lesion, scars or cutaneous lesion was present.VDRL was reactive in 1 dilution,TPHA was positive ; HIV test was negative ; CSF revealed VDRL – Negative and TPHA -Negative.Patient was treated with Injection procaine penicillin 1.2 Million units intramuscularly daily for 21 days. The patient responded well to treatment and there was improvement in his vision. Ocular Syphilis can occur at any stage of Syphilis and may be the only presenting sign. Syphilis serology was positive confirming the disease.This case highlights the importance of syphilis with ocular manifestation – there by proving that diagnosis of syphilis based on ocular finding is clinically challenging.

Keywords: Ocular syphilis, unilateral chorioretinitis, Treponema pallidum

How to cite this article:
Pai A. Ocular syphilis presenting as unilateral chorioretinitis. Ann Trop Med Public Health 2012;5:609-10

 

How to cite this URL:
Pai A. Ocular syphilis presenting as unilateral chorioretinitis. Ann Trop Med Public Health [serial online] 2012 [cited 2017 Nov 14];5:609-10. Available from: https://www.atmph.org/text.asp?2012/5/6/609/109312

 

Introduction

Syphilis is a multi-systemic infection caused by Treponema pallidum. Ocular manifestations of syphilis have a myriad of presentations and severity. Ocular syphilis can affect any structure of the eye and occur at any stage of the disease process, and it may also be the only presenting sign that leads to the eventual diagnosis of syphilis. Syphilitic ocular manifestations include interstitial keratitis, chorioretinitis, retinal vasculitis, vitritis, and papillitis, among which uveitis is the most commonly reported ocular presentation of syphilis. [1],[2] There are vary sparse reports of unilateral chorioretintis in a syphilis patient and hence we report this case.

Case Report

A 31-year-old male patient was referred from ophthalmology department as a case of chorioretinitis for screening for syphilis. Patient had diminished vision and redness of right eye for 2 months duration. History of premarital exposure was present 16 years back and extramarital contact was present 3 years back. No other positive history. Ocular examination revealed – Rt eye: conjunctival congestion and Argyll Robertson pupil; lt eye: normal. Fundoscopy of right eye showed yellowish white retinal lesions, macular edema and hyperaemia [Figure 1] and left eye was normal [Figure 2]. No genital lesion, scars or cutaneous lesion was present. VDRL was reactive in 1 dilution, TPHA was positive; HIV test was negative; CSF revealed VDRL – Negative and TPHA – Negative. His spouse and children were clinically and serologically negative for syphilis. Patient was treated with injection procaine penicillin 1.2 million units intramuscularly daily for 21 days. The patient responded well to treatment and there was improvement in his vision with resolving choroidal patch on fundoscopy [Figure 3].

Figure 1: Fundoscopy of right eye showing yellowish white retinal lesions

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Figure 2: Fundoscopy of left eye showing normal retina

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Figure 3: Fundoscopy of right eye showing Resolving choroidal patch after treatment

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Discussion

Syphilitic chorioretinitis is characterized by yellowish, ill-defined, placoid lesions that are confluent in the posterior pole or mid-periphery of the fundus. These lesions usually have a faded center and stippled hyperpigmentation of the retinal pigment epithelium (RPE) and they can coalesce to become large confluent lesions. [3] Chorioretintis is accompanied by variable amount of vitreous inflammation and may be associated with superficial haemorrhages, retinal vasculitis, disc oedema and serous detachment of the retinal pigment epithelium. A solitary unilateral, placoid, pale-yellow subretinal lesion is a less typical presentation of syphilitic chorioretinitis. [4]

Syphilis should be considered in all patients with uveitis and in particular those who are known to be HIV-positive or who engage in high-risk sexual activities. Serologic testing is required both to confirm the diagnosis and to monitor response to therapy. Patients with ocular syphilis should undergo CSF testing and regardless of findings, be treated as neurosyphilis. Although, abnormal CSF study results are not necessary to make a diagnosis of ocular syphilis, lumbar punctures are warranted in both HIV-infected and non-infected patients with ocular disease. Ocular syphilis can cause blindness if untreated and clinicians must be vigilant in making this diagnosis. The clinical course of syphilitic eye disease is variable and in some cases the chorioretintis could resolve spontaneously while others may result in widespread atrophy and loss of retinal function, even with treatment. [5] Syphilis has re-emerged as a growing public health problem. [6] Syphilis remains an important cause of ocular disease. Syphilis lingers on the differential diagnosis of all forms of ocular inflammation and should be considered when evaluating such patients.

Conclusion

Ocular syphilis can occur at any stage of syphilis and may be the only presenting sign. There were no other cutaneous, genital and systemic signs of syphilis in our patient. Syphilis serology was positive confirming the disease. This case highlights the importance of syphilis with ocular manifestation – there by proving that diagnosis of syphilis based on ocular finding is clinically challenging.

References

 

1. Aldave AJ, King JA, Cunningham ET. Jnr Ocular syphilis. Curr Opin Ophthalmol 2001;12:433-41.
2. French P. Syphilis. BMJ 2007;334:143-7.
3. Gass JD, Braunstein RA, Chenoweth RG. Acute syphilitic posterior placoid chorioretinitis. Ophthalmol 1990;97:1288-97.
4. Morgan S, Laufer H. Atypical syphilitic chorioretinitis and vasculitis.Retina 1984;4:225-31.
5. Kiss S, Damico FM, Young LH. Ocular manifestations and treatment of syphilis. Semin Ophthalmol 2005;20:161-7.
6. Kerani RP, Handsfield HH, Stenger MS, Shafii T, Zick E, Brewer D, et al. Rising rates of syphilis in the era of syphilis elimination. Sex Transm Dis 2007;34:154-61.

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1755-6783.109312

Figures

[Figure 1], [Figure 2], [Figure 3]

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