Journal List > J Korean Ophthalmol Soc > v.55(8) > 1009760

Han, Lee, Kwon, Song, Kim, and Chung: A Case of Syphilitic Scleritis Initially Misdiagnosed as Noninfectious Nodular or Fungal Scleritis

Abstract

Purpose

To report a case of syphilitic scleritis initially misdiagnosed as noninfectious nodular or fungal scleritis.

Case summary

A 63-year-old female, who had severe headaches and ocular pain in her left eye despite treatment with topical and oral NSAIDs for the past 4 months, was transferred from a local clinic. The patient had a history of pterygium excision in the same eye 4 years prior. Upon presentation, she had a scleromalacia with calcified plaque at the nasal conjunctiva. An erythematous nodular elevated lesion was observed in the superonasal sclera. Microbiological smear and cultures were performed to exclude infectious scleritis. Under the suspicion of noninfectious nodular scleritis, the patient was prescribed topical oral steroid and oral NSAIDs. Candida parapsilosis was identified by the microbiological culture. Under the suspicion of fungal scleritis, oral fluconazole and topical amphotericin B were administered, but the lesions did not improve. On the 23rd day of treatment, we discovered the patient had a history of syphilis. The serology test was negative for RPR and FTA-ABS IgM but positive for FTA-ABS IgG. Under the suspicion of syphilitic scleritis, oral doxycycline (200 mg bid) was administered and benzathine penicillin M (2.4 million units) was injected intramuscularly 3 times at 1-week intervals. After the doxycycline and benzathine penicillin therapy, the pain and nodular erythematous lesions were completely resolved.

Conclusions

As shown in this case, syphilitic scleritis should be considered when the patient is resistant to other conventional treatments and shows positive serological tests for syphilis. This is important because syphilitic scleritis is usually aggravated by steroid treatment but can be cured by proper anti-syphilitic chemotherapy.

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Figure 1.
Elevated erythematous nodular scleral lesion (white arrow), conjunctival injection, and nasal calcified plaque (black arrow) were noted at initial visit (A: superonasal view of involved eye; B: same area with A under blue light with fluorescent dye staining).
jkos-55-1233f1.tif
Figure 2.
Thirteen days after the first doses of benzathin penicillin M injection, scleral inflammation and conjunctival injection completely resolved and the nodule disappeared (A: superonasal; B: inferonasal bulbar area of involved eye).
jkos-55-1233f2.tif
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