Secondary syphilis with progressive ocular involvement in an immunocompetent patient

ARTICLE

Auteur(s) : Caterina Foti¹, Luigi Carnimeo¹, Susanna Delvecchio¹, Silvana Guerriero², Nicoletta Cassano¹, Gino A Vena¹

¹Department of Internal Medicine, Immunology and Infectious Diseases, Dermatology Clinic, University of Bari, Policlinico, Piazza Giulio Cesare, 11, I-70124 Bari, Italy
²Unit of Opthalmology, Department of Ophthalmology and Otorhinolaryngology, University of Bari, Italy

Syphilitic ocular manifestations are polymorphous and may occur during the secondary or tertiary stages of the disease [1-3]. We report the case of an immunocompetent 60-year-old woman who developed progressive ocular involvement due to secondary syphilis. The patient was referred to our outpatient clinic in September 2007 because of a papular rash involving the palms and soles which had become evident a few weeks earlier. The patient’s health was described as good until July 2007, when she was admitted to an ophthalmology unit after the development of sudden visual loss in the left eye associated with retro-orbital pain and diminished colour perception. A marked decrease in visual acuity to 0.1 in the affected eye was detected, and visual field examination revealed a central scotoma. The fundus appeared normal. Brain magnetic resonance imaging and computed tomography did not reveal any pathological changes. Visual evoked potentials showed a delayed P100 latency and a marked decrease in amplitude in the left eye. Routine laboratory examinations and immunological and microbiological assessments, including serology for HIV, Brucella, Leptospira, and assays for the detection of fungal antigens in the serum, gave negative results. An optic retrobulbar neuritis was then diagnosed and methylprednisolone was given intravenously, 500 mg daily, for five consecutive days. On discharge, visual acuity in the left eye had improved to 0.3 and oral prednisone 0,5 mg/kg/day was prescribed. Four weeks later, despite corticosteroid therapy, the patient experienced a bilateral reduction of vision. Visual acuity was 0.6 in the right eye and 0.1 in the left eye; keratic precipitates and vitreous floating opacities were present, as well as findings consistent with chorioretinitis in both eyes. Moreover, the right optic nerve was hyperaemic with signs of vasculitis and retinal haemorrhages. On fluorescein angiography, hypofluorescent and hyperfluorescent areas were irregularly distributed in both eyes. Physical examination disclosed palmoplantar papulosquamosus lesions, and a maculopapular exanthema, associated with micropolyadenopathy and only mild constitutional symptoms. Exanthema appeared in June and was attributed to an undetermined allergy at that time. The patient reported a single sexual partner (the husband) during her lifetime. Serologic tests for syphilis were finally performed. The Venereal Disease Research Laboratory (VDRL) test titer was 1:128, the Treponema pallidum haemoagglutination assay (TPHA) was 1:2,560, and the fluorescent treponemal antibody absorption (FTA-ABS) test was also positive (IgG +4 and IgM +3). The patient refused to undergo lumbar puncture. She was treated with intravenous penicillin 4 MU every four hours for ten days, followed by three intramuscular benzathine penicillin 2.4 MU (weekly). Oral prednisone was discontinued after the first week of penicillin treatment. At follow-up after three months, ophthalmological findings improved, with a visual acuity of 0.7 in both eyes, and VDRL titer was 1:32.

A re-emergence of syphilis has been reported in Europe during recent years [4]. The case described underlines that the eye may be one of numerous sites of syphilitic inflammation and damage. Ocular syphilis in any form should be treated like neurosyphilis [3]. Secondary syphilis caused a progressive deterioration of ocular findings in our patient, who developed an optic neuritis and subsequently signs suggestive of panuveitis with severe chorioretinitis. These conditions can result in permanent loss of vision if not adequately treated. Therefore, an accurate diagnosis and an early treatment are fundamental to preserve visual acuity and ocular function. Syphilis was not recognized as the cause of the initial presentation of ocular disease in our patient, so inappropriate treatment with systemic corticosteroids was administered. Corticosteroid monotherapy might induce a treponemal load increase, augmenting the risk of syphilis-related complications [5]. In conclusion, ocular involvement should be carefully evaluated in patients with syphilis, and, at the same time, this infection should be considered as a potential cause of ocular inflammation.

Acknowledgements

Références

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5 Solebo AL, Westcott M. Corticosteroids in ocular syphilis. Ophthalmology 2007; 114: 1593.