Clinical Manifestations of Ocular Syphilis Combined with Neurosyphilis

Yong Wun Cho; Che Ron Kim; Yong Seop Han; In Young Chung; Jong Moon Park

doi:10.3341/jkos.2014.55.4.602

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Cho, Kim, Han, Chung, and Park: Clinical Manifestations of Ocular Syphilis Combined with Neurosyphilis

Original Article

J Korean Ophthalmol Soc 2014;55(4):602-607.

Published online: 7 September 2014

DOI: https://doi.org/10.3341/jkos.2014.55.4.602

Clinical Manifestations of Ocular Syphilis Combined with Neurosyphilis

Yong Wun Cho, MD¹, Che Ron Kim, MD¹, Yong Seop Han, MD, PhD^1,², In Young Chung, MD, PhD^1,², Jong Moon Park, MD, PhD^1,²

¹Department of Ophthalmology, Gyeongsang National University School of Medicine, Jinju, Korea

²Gyeongsang Institute of Health Science, Gyeongsang National University, Jinju, Korea

Address reprint requests to Jong Moon Park, MD, PhD Department of Ophthalmology, Gyeongsang National University Hospital, #79 Gangnam-ro, Jinju 660-702, Korea, Tel: 82-55-750-8167, Fax: 82-55-758-4158 E-mail: parkjm@gnu.ac.kr

Received 8 June 20139 October 2013 Accepted 20 February 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To report the manifestation of ocular syphilis combined with neurosyphilis in patients who present with uveitis clinically and are diagnosed initially by an ophthalmologist.

Methods

This study is a retrospective, clinical investigation of seven male patients with ocular syphilis from a single tertiary center between 2009 and 2012.

Results

The average age of the patients at onset was 44.4 years (range, 33-71 years). Posterior segment involvement was found in all patients. Two patients had papillitis. In serologic testing, all patients had positive responses to Venereal Disease Research Laboratory (VDRL), fluorescent treponemal antibody-absorption test (FTA-ABS) and Treponema pallidum hemag-glutination (TPHA). In fluorescein angiography (FAG), retinal vascular and disc leakage was the most common finding. Cerebrospinal fluid (CSF) analysis was performed for six patients and demonstrated positive CSF FTA-ABS and CSF TPHA tests in all patients. CSF VDRL was reactive in 2 patients (33.3%).

Conclusions

All patients with ocular syphilis were diagnosed with neurosyphilis based on the analysis of CSF with FTA-ABS and TPHA. Ophthalmologists play an important role in the early diagnosis and treatment of syphilis.

Keywords: CSF analysis, Neurosyphilis, Ocular syphilis

References

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Figure 1.

Photographs of Patient 2. (A) A right eye fundus photograph, at the first visit, shows normal retinal appearance. (B) A left eye fundus photograph, at the fist visit, shows subfoveal exudation and macular edema. (C) A right eye fluorescein angiograph at the mid-phase shows peirvascular and multiple RPE leakage at the super-otemporal quaderant. (D) A left eye fluorescein angiograph at the mid-phase shows macular pooling of dye and peripheral PRE active leakage. (E) A right eye fundus photograph, at the last visit, shows normal retinal appearance. (F) A left eye fundus photograph, at the last visit, shows subfoveal exudation and macular edema resolved.

Table 1.

Demographics, clinical findings of ocular syphilis

Patient	Age/ Sex	Presenting VA (OD; OS)	Anterior segment	Posterior segment	FAG	Response (as of last follow-up)	Follow-up (from start of Tx)	Final VA (OD; OS)
1	40/M	10/20020/20	Iridocyclitis, KP, OD	Vitreous opacity, snow ball, salt pepper like	OD) Diffuse leakage, Disc leakage (optic neuritis),	Diffuse retinal Degeneration	3 years	20/2020/20
1				app., Hyperemic disc, OD	late phase macular diffuse edema
2	42/M	20/32	Clear, OU	Vitreous opacity, ME,	OD) Multifocal leaking in	Resolution	1 year	20/20
2		20/200		OS: Subfoveal exudation, exudative elevation, OS	RPE, macular edema, disc leakage OS) Macular pooling of dye, peripheral PRE active leakage	vitreous opacity, Decreased macular exudation, OS		20/20
3	71/M	20/10020/20	Clear, OU	ERM, OD; PED, OS: RPE degeneration, OU	OU) window defect OD) Epiretinal membrane, vascular leakage	ERM, OD: PED, OS	1 year	20/4020/20
4	40/M	20/40	Clear, OU	Temporal branch	OD) vascular leakage	Temporal branch	9 months	20/32
		20/50		perivascular sheathing, venous bleeding, retinal Hx., RPE degeneration, snow ball, OU : Peripheral vascular	OS) vascular leakage, branch vein occlusion	perivascular sheathing, retinal hemorrhage, OS		20/32
				occlusion (retinal vasculitis), OD
5	33/M	20/12520/20	Clear, OU	Disc swelling, disc hyperemia marginal blurring, OU;	OU) disc leakage, venous tortuosity, OD) vascular leakage	Disc swelling, disc hyperemia marginal blurring,	1 year	20/4020/20
5				exudation macular, vasculitis, OS (Post optic neuritis steroid Medication state, OS)	OS) vascular leakage, macular edema	OD
6	36/M	20/20020/20	Clear, OU	Vitritis, vasculitis, macular hypopigmentation, OD	OD) vascular leakage, disc leakage	Resolution vitritis and vasculitis, OD	4 months	20/3220/20
7	49/M	20/20020/40	Clear, OU	RPE degeneration, macular degeneration, OD	OD) vascular leakage OS) vascular leakage, disc leakage	Remain	4 months	20/3220/20

FAG = fluorescein angiography; Tx = treatment; KP = keratic precipitate; ERM = epiretinal membrane; PED = pigment epithelium detachment; RPE = retinal pigment epithelium.

Table 2.

Cerebrospinal fluid (CSF) findings

Patients	Age/Sex	WBC count (0-5 cells/mm³)	Glucose (>50 mg/dL)	Protein (20-40 mg/dL)	CSF
Patients	Age/Sex	WBC count (0-5 cells/mm³)	Glucose (>50 mg/dL)	Protein (20-40 mg/dL)	FTA-ABS	TPHA	VDRL
1	40/M	32	61	46	Reactive	Reactive	Reactive
2	42/M	7	88	39	Reactive	Reactive	Non-Reactive
3	71/M	UC	UC	UC	UC	UC	UC
4	40/M	23	55	32	Reactive	Reactive	Non-Reactive
5	33/M	7	57	39	Reactive	Reactive	Non-Reactive
6	36/M	7	62	53	Reactive	Reactive	Non-Reactive
7	49/M	4	127	81	Reactive	Reactive	Reactive

WBC = white blood cell; FTA-ABS = fluorescent treponemal antibody absorption test; TPHA = treponema pallidum hem-agglutination test; VDRL = venereal disease research laboratory test; UC = unchecked.

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