A 40 y.o. male presents with loss of vision in the L outer lower quadrant of the L eye

This is what you see when you look at the fundus

What is wrong?

Our patient had neurosyphilis with chorioretinitis and vitritis.  Syphilis in the eye can present with uveitis, retinal vasculitis  or interstitial keratitis. In short, any structure in the eye can be affected.

IN REVIEW

Syphilis is caused by the bacterium Treponema pallidum and can present in primary, secondary , latent and tertiary stages. Primary presents with a single chancre.  Secondary syphilis is the classic palms and soles rash.  In tertiary syphilis gummas may be present and neurologic and cardiac symptoms occur.

Two kinds of tests are available for syphilis: treponemal and non treponemal.  The VDRL and RPR  are non treponemal tests  and are used for screening and following treatment since they become non reactive with treatment. In contrast a treponemal test (FTA-abs) , detects antibodies to antigens on the treponemes and remains positive after treatment.   

The spirochetes can be seen on dark field microscopy

A SECOND PATIENT PRESENTED WITH FACIAL DROOP

A 44 y.o. male presented with facial droop and slurred speech.  10/7 he presented with HA, 10/8 he developed facial droop.  10/9 he developed hearing loss and had a negative MRI. He developed fatigue and malaise with persistent HA and leg pain. RPR was  1:256 and CSF VDRL was positive at 1:8.  This patient also had neurosyphilis and was treated with IV PCN q 4 hours for two weeks He developed a Jarisch-Herxheimer reaction which was treated symptomatically. He was also thought to have syphilitic hepatitis with isolated alk phos.

the soles of his feet showed a classic secondary syphilis rash

Syphilis rates had been declining  since 1990 but in the last ten years cases have increased. Because of the multitude of ways it can present (in our two cases vision loss, hearing loss or facial droop), consider it when patients present with  neurologic or ophthalmologic findings.

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Singh A. Ocular and neurosyphilis: epidemiology and approarch to management. Curr Opin Infect Dis. 2020 Feb;33(1):66-72.

Pessoa L, Galvao V. Clinical aspects of congenitalsyphilis with Hutchison’s triad. BMJ Case Rep 2011 Dec 21;2011