Case Presentation: A 72 year-old male with a diffuse rash and vision changes presented to the ophthalmologist for two weeks of photophobia, binocular horizontal double vision and eye irritation. Ocular exam was significant for visual acuity of 20/60 in the right eye and 20/125 in the left eye, a change from baseline of 20/20 a year prior. Slit lap exam was significant for 1+ anterior chamber cells, diffuse fine keratic precipitates, posterior synechiae, and 3+ vitreous haze of both eyes. He was sent to the ED for further workup given that the rash coincided with his ocular symptoms. The rash initially presented on his back and upper extremities, and later spread to the front of his torso and lower extremities. He endorsed multiple male and female sexual partners, although with consistent condom use and no history of sexually transmitted infections.
Physical exam was significant for diffuse erythematous macules and papules coalescing into plaques with overlying scales involving the back, abdomen, upper and lower extremities without oral, penile, facial, palmar or sole involvement. Given his initial presentation and sexual history, he was started on IV penicillin for empiric treatment of ocular syphilis. Serology revealed a positive RPR (1:64) and positive T. pallidum Ab IgG FTA-ABS. No concomitant STIs noted. Dermatopathology was significant for spirochetes seen in the epidermis. Follow-up ocular exam after seven days of IV penicillin revealed improved visual acuity in both eyes. Slit lamp exam revealed no anterior chamber inflammation or keratic precipitates of both eyes.
Discussion: We present an interesting case of secondary syphilis with concomitant ocular syphilis. Syphilis rates have been on the rise, most notably in the MSM community. In 2017, the rate of primary and secondary syphilis in men vs women was 16.9 vs 2.3 cases per 100,000 respectively. In patients older than 65, the rate was 1.5 per 100,000; therefore placing syphilis lower on a differential for patients in this age group. Studies have shown that rates of ocular syphilis are higher in HIV-infected patients. In a recent CDC study, 0.2% of patients with syphilis in New York City were found to have ocular syphilis. It can present at any stage of syphilis with photophobia or vision loss. Reports of anterior uveitis are limited, and the most common manifestation of ocular syphilis is posterior uveitis and panuveitis.
Conclusions: Ocular syphilis is a rare, but increasingly more prevalent manifestation of syphilis that requires early detection to prevent permanent vision loss. Social history, regardless of age, is key in every history and physical.
To cite this abstract:Nagirimadugu, A; Pillay, K; Chandra, G. OCULAR SYPHILIS: SEEN AT ANY AGE AND EVERY STAGE. Abstract published at Hospital Medicine 2019, March 24-27, National Harbor, Md. Abstract 877. https://www.shmabstracts.com/abstract/ocular-syphilis-seen-at-any-age-and-every-stage/. Accessed July 23, 2019.