Title : Blind spot: A case of ocular syphilis in a patient with HIV
Abstract:
Ocular syphilis is a rare and potentially blinding complication of localized Treponema pallidum infection. Unlike the typical progression of syphilis through the primary, secondary, latent and tertiary stages with distinct, accompanying symptoms, ocular syphilis can occur at unpredictable intervals during the course of T. pallidum infection with vague symptoms that often mimic other diseases. Therefore, high clinical suspicion is necessary for accurate diagnosis— especially in the absence of common manifestations such as palmar rash, genital lesions, and vision changes.
Furthermore, the synergistic interaction of HIV and Syphilis not only increases the likelihood of coinfection but also increase the risk of neurosyphilis in HIV patients. The case aims to highlight the clinical manifestations of ocular syphilis in an HIV patient and underscore the importance of considering this diagnosis in high-risk populations with unexplained ocular symptoms.
This is a case of a 37 YO male, with a history of HIV and suppressed viral load, who presented with a one-week duration of pressure-like pain, swelling, conjunctivitis and purulent discharge of the right eye with accompanying right-sided pressure-like headache. Patient stated that one month prior, eye examination revealed increased pressure of the right eye without vision changes or additional symptoms. Patient reported HIV medication compliance and review of medical records confirmed suppressed viral load but, with an increased viral load and decreased CD4 count compared to 3 months prior. Patient denied sexual activity during the past year. HEENT and Neurologic examinations were positive for bilateral conjunctivitis with crusted discharge but otherwise unremarkable. Lab results were significant for inflammatory markers (elevated platelets, C reactive protein and erythrocyte sedimentation rate). Head CT was negative for abnormalities. Initial trial of Valacyclovir and Polymyxin B sulf-trimethoprim failed to resolve symptoms. Patient then presented with worsening of initial symptoms in addition to bilateral otalgia, tinnitus and facial maculopapular rash. Further testing demonstrated a positive RPR, and patient was referred to the hospital where additional testing demonstrated positive treponemal Ab with titer of 1:128. CSF analysis showed elevated protein and white blood cell count– lymphocyte predominant– but negative CSF VDRL. Based on these findings, treatment with penicillin G was commenced with resolution of symptoms following treatment.
Due to the rise in syphilis cases globally and potential complications of undiagnosed disease, healthcare providers must maintain a high index of suspicion for ocular syphilis, particularly in patients with risk factors such as HIV infection or multiple sexual partners. Early detection and intervention is necessary to prevent severe complications and improve patient outcomes.
