Ocular Uveitis as the Initial presentation of Acquired Syphilis

Introduction: Syphilis is a sexually transmitted, chronic, systemic infection caused by the spirochete Treponema pallidum. If left untreated, the disease progresses though 4 stages, with the potential to cause significant morbidity to any major organ of the body. Common syphilitic ocular manifestations, including anterior, intermediate and posterior uveitis, chorioretinitis, retinitis, retinal vasculitis, interstitial keratitis and cranial nerve and optic neuropathy can occur at any stage of the disease. The ocular manifestations are highly variable, so syphilis is known as “The Great Masquerader”. Involvement of the eye may be the presenting manifestation of syphilis and is often associated with delayed diagnosis and treatment, which may result in irreversible visual loss and structural changes. Case Report: We report a case of a 51 year old African American female with medical history of hyperthyroidism who presented in emergency department complaining of right eye pain, redness, tearing, photophobia and blurring of vision for one week. Physical examination was notable only for bilateral non tender axillary lymphadenoapthy. Eye exam showed bilateral conjunctivitis with pupils reactive to light and accommodation. Visual acuity was 20/50 in the right eye and 20/50 in the left eye. Slit-lamp examination revealed keratic precipitates in her cornea bilaterally a hallmark of Iritis. Ophthalmoscopy showed Cystoid macular edema. The anterior chamber showed 1+ cell in the right eye, 2+ cell in Vitreous bilaterally and normal retina. Tonometry showed normal intraocular pressure. Patient was admitted for further evaluation and treatment of ocular Uveitis. Since our patient’s history and physical exam were unremarkable in the presence of bilateral uveitis extensive laboratory work-up was sent including complete blood count, Erythrocyte sedimentation rate, Antinuclear antibody, Rapid plasma regain, Venereal disease research laboratory, HIV, chest x-ray, ACE level. All work-up was negative with exception of TPPA reactive, MHATP reactive and IgG syphilis positive. Subsequently lumbar puncture was done with findings of lymphocytic pleyocytosis with a WBC count of 15 cells/μL and VDRL negative. Patient was diagnosed with Uveitis due to Ocular syphilis and Neurosyphilis and was started on treatment with aqueous penicillin G 4 million units 4 hourly along with topical Prednisolone and cyclopentolate eye drops. She responded well to given treatment and reported significant improvement in her symptoms and signs.