Diagnostic riddle– case report of ocular syphilis

TL;DR

A 29-year-old man with unusual eye symptoms was later diagnosed with ocular syphilis and HIV, highlighting the need to consider STIs in atypical eye cases.

Contribution

This case report emphasizes the importance of considering syphilis in the differential diagnosis of non-responsive ocular symptoms.

Findings

The patient initially showed symptoms resembling herpetic infection but was later diagnosed with syphilis and HIV.

Penicillin and antiretroviral treatment led to significant improvement in the patient's ocular condition.

Six months after treatment, the patient's visual acuity returned to normal in both eyes.

Abstract

Syphilis is one of sexually transmitted infections (STIs). The incidence of Treponema pallidum infection has increased in the last 20 years. This rise is also evident in ophthalmological practice, with cases of ocular syphilis becoming more frequent.

We present a case of a 29-year-old patient with blurred vision in his left eye. Patient showed no general symptoms, nor previous history of eye disorders. On ophthalmological examination, the best-corrected visual acuity (BCVA) was 20/20 in the right eye (OD) and 20/80 in the left eye (OS). The left eye presented high intraocular pressure (IOP) of 31 mmHg and symptoms of anterior uveitis with a linear branching corneal erosion. A B-scan ultrasound of the left eye revealed no vitritis. The preliminary diagnosis of herpetic infection was made, and antiviral therapy was introduced. Despite the initial improvement, symptoms of active anterior uveitis were found on follow-up visits. After approximately 4 weeks of ambulatory treatment, the patient was admitted to the hospital because of roseolae and lumps of the left iris, which appeared accompanied by a rash on patients’ lower limbs. Laboratory tests confirmed syphilis and human immunodeficiency virus (HIV) coinfection. During hospitalization intravenous treatment with penicillin and antiretroviral drugs was introduced. Therapy with penicillin was continued to 21 days with improvement in examination. On a follow-up visit after 6 months BCVA in both eyes was 20/20.

It is crucial to consider testing for STIs, especially Treponema pallidum infection, in the diagnostic process of patients with nontypical or nonresponsive to treatment ocular symptoms.

Figures