SHM Converge Scientific Abstract ePoster Gallery-Don't Go Blind: Ocular Syphilis in an Immunocompetent Patient

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A 30-year-old immunocompetent man developed progressive bilateral vision loss over 15 months, described as a “dark curtain” starting centrally. He was initially evaluated by ophthalmology, which found decreased visual acuity, but he delayed further care. About six months after symptom onset, his primary care physician initiated a neurologic workup that led to a diagnosis of tertiary syphilis, and he was treated with three intramuscular doses of benzathine penicillin G. Despite this, his central vision worsened, especially in the left eye, prompting hospital admission.<br /><br />On admission, he was afebrile with normal neurologic exam aside from severe visual impairment (20/400 bilaterally). HIV testing was negative, and RPR remained positive at 1:16. Lumbar puncture showed minimal abnormalities and a nonreactive CSF VDRL. MRI of the brain and orbits demonstrated bilateral optic nerve T2 signal changes without enhancement, supporting ocular involvement.<br /><br />The case highlights that ocular syphilis can occur at any stage of infection and should be treated like neurosyphilis, even when CSF testing is negative. If ocular findings are present without other neurologic deficits, CSF examination is not required before starting therapy. Recommended treatment is IV penicillin G for 10–14 days. The patient’s initial regimen—intramuscular benzathine penicillin—is appropriate for late latent or tertiary syphilis without neurologic disease, but it was insufficient for ocular syphilis.<br /><br />After receiving IV penicillin G every 4 hours for 14 days, he had mild visual improvement and his RPR later decreased. The report emphasizes that delayed or incomplete treatment can lead to poorer visual outcomes and recurrent disease. It also notes that CSF VDRL is insensitive, HIV testing should be performed in all ocular syphilis cases, and serial serum RPR is generally sufficient for follow-up.

Asset Subtitle

Robert G. Scott

Meta Tag

Author List Andres C. Urias Rivera, Doris Lin, Robert G. Scott

Category Clinical Vignettes

Distinguished Non-Finalist

Presenter Organization Baylor College of Medicine

Presenting Author Robert G. Scott

Track Adult

Keywords

ocular syphilis