Presentations

Abstract

Introduction:

Syphilis, or Treponema pallidum, is often referred to as "the great imitator" for its ability to manifest and present in a multitude of ways, and often look remarkably similar to a variety of other conditions. This can often lead to difficulty and delays in diagnosis and therefore delays in treatment, increasing the likelihood of the spread of the disease.

Neurosyphilis, or symptoms caused by damage to the brain, nervous system, or eyes, can occur at any stage of the disease course and is especially difficult to diagnose. Our primary methods of diagnosing neurosyphilis, VDRL in the CSF and RPR titers, are not very sensitive or specific and do not necessarily rule out the condition if the tests return negative.

Herein, we review the case of a 21-year-old woman, who presented with ocular pain, vision changes, and scleral injection and was ultimately diagnosed with ocular syphilis.

Case Presentation: A 21-year-old female with no previous medical history presented to the emergency department with a complaint of right eye erythema, binocular blurry vision, headache, photophobia, nausea and vomiting that began the day before.

The patient was referred to the ED by her ophthalmologist after she presented with a 1-month history of ocular pain with acute worsening over the previous day and a decrease in visual acuity. Her ophthalmologist's impression was an acute anterior uveitis of the right eye, and he proceeded with a broad infectious and autoimmune workup. All tests were normal except RPR returned positive with a ratio of 1:64. The patient was referred to the ED for concern of ocular syphilis and potential meningitis.

In the ED, the patient was tachycardic but physical exam showed no signs of meningismus. CBC returned without leukocytosis or anemia. The patient underwent lumbar puncture (LP) and was tested for multiple STIs, and chlamydia and trichomonas returned positive. The patient's lumbar puncture showed only isolated elevated RBCs, and VDRL CSF was non- reactive. HIV testing was negative.

ID was consulted, and began the patient on 4mU IV penicillin every 4 hours. ID agreed that the patient's LP was not consistent with neurosyphilis due to minimal pleocytosis and normal protein, as well as a negative CSF VDRL. The patient was also treated Doxycycline 100 mg po BID and Metronidazole 500mg po BID for 7 days each to target her chlamydia and trichomonas.

During the patient's hospital stay, the scleral injection improved; eye pain, headaches, neck stiffness, and vision changes resolved. The patient was discharged with IV Penicillin to complete a 14 days course through a PICC line

Discussion:

The incidence of syphilis has been increasing in recent years in the U.S., making early detection and treatment all the more important. Reports suggest that rates of ocular syphilis are also rising in the US.

Ocular syphilis can involve almost any eye structure but posterior uveitis and panuveitis are most common as seen in our patient. Ocular syphilis is often but not always accompanied by syphilitic meningitis.

With syphilis, there is always more than meets the eye!