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Sometimes the Eyes Say More Than the Mouth

Ocular fundus image of the left eye shows mild optic disc swelling, multifocal retinochoroidal exudates, retinal phlebitis, and mild vitreous opacity.

Ocular fundus image of the left eye shows mild optic disc swelling, multifocal retinochoroidal exudates, retinal phlebitis, and mild vitreous opacity.

A 48-year-old man with a history of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS)-associated cryptococcal meningitis was referred to our hospital with blurred vision in his left eye for several months. He was diagnosed with bilateral chronic posterior uveitis (Figure). After ruling out secondary uveitis, such as sarcoidosis, Behçet disease, Vogt-Koyanagi-Harada disease, herpesvirus infection, and tuberculosis, uveitis was highly suspected to be attributable to syphilis, namely ocular syphilis, considering AIDS as his underlying disease and previous unprotected sexual contact with males and females. Positive results from a rapid plasma reagin test (RPR) (1:32) and Treponema pallidum agglutination assay were confirmed. The patient was treated with intravenous penicillin G for 14 days and ophthalmic symptoms improved; complete resolution of ocular inflammation was observed at 7 months post treatment. At 9 months post treatment, decreased reactivity on RPR was confirmed on an outpatient basis.

Ocular syphilis, such as uveitis, retinitis, and optic neuritis, is caused by T. pallidum infection and can result in a variety of ocular signs and symptoms, including redness, blurry vision, and vision loss.1

Although ocular syphilis is usually an infrequent manifestation of syphilis infection, clusters of ocular syphilis were recently reported in the US.1 Most suspected cases of ocular syphilis were in males and 50% were in HIV-infected persons, which is consistent with the epidemiology of syphilis in the US.1

A cerebrospinal fluid examination is recommended for patients with ocular syphilis to rule out neurosyphilis, because the concurrent infection rate is high; neurosyphilis was ruled out in our case.2

A detailed medical interview about sexual contact and serological testing for syphilis infection should be performed in patients with uveitis of unknown etiology, because ocular symptoms can be the initial manifestation of syphilitic disease; visual prognosis is usually excellent with treatment.23

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- Tatsuya Fujikawa, MD, PhD, Yuka Sogabe, MD

This article originally appeared in the December 2017 issue of The American Journal of Medicine.

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