Syphilitic Uveitis Research Articles

Ocular syphilis.

Review current literature relevant to syphilitic uveitis utilizing Medline search and online governmental resources relevant to the diagnosis and management of syphilis presenting with ocular manifestations. There is a trend for increasing frequency of primary and secondary syphilis in developed countries, especially in young men. Ocular manifestations of syphilis are rare, occurring in less than one in 1 million persons in the United Kingdom. Distinctive patterns of syphilitic uveitis include white, focal preretinal opacities, and acute posterior placoid uveitis. Enhanced imaging can facilitate clinical diagnosis. Definitive diagnosis remains serologic. The Centers for Disease Control currently recommends reverse sequence testing with initial treponemal antibodies, followed by a quantitative nontreponemal test, which, if negative, triggers a confirmatory treponemal pallidum agglutination test. Persons testing positive for syphilis should also be tested for HIV. Recommendations of the Centers for Disease Control for treatment are unchanged: all ocular syphilis should be treated according to neurosyphilis regimens and should receive cerebrospinal fluid testing. Increased case numbers of syphilitic uveitis have stimulated interest in this old disease. This locally destructive ocular inflammation with the potential for severe systemic complications is curable with treatment and should have the highest priority for prompt recognition and treatment.

Clinical Manifestations and Outcomes of Syphilis-associated Uveitis in Northern Spain

Purpose: To describe the clinical characteristics and to assess visual prognosis of patients with syphilis-associated uveitis in northern Spain.Methods: Retrospective review of clinical records in eight general uveitis referral centers.Results: Since the year 2000, 50 patients have been diagnosed: 31 men and 19 women; median age was 41 (19–76) years. A total of 34% were co-infected with HIV and 24% presented systemic manifestations of syphilis. Median initial visual acuity and vision at last visit in 93 affected eyes was 20/50 (20/20–20/2000) and 20/22 (20/20–20/2000), respectively (p < .0001). The most frequent manifestation was papillitis (33.3%). Fifty percent of eyes with macular edema on admission presented worsening of visual acuity at last visit, whereas frequency of worsening in eyes without edema was 7.1% (p = 0.009).Conclusions: In our series, patients with syphilitic uveitis were more usually middle-aged men and were frequently co-infected with HIV. Although most patients showed posterior segment involvement, visual prognosis was good.

THE ROLE OF METHOTREXATE IN RESOLVING OCULAR INFLAMMATION AFTER SPECIFIC THERAPY FOR PRESUMED LATENT SYPHILITIC UVEITIS AND PRESUMED TUBERCULOSIS-RELATED UVEITIS

This study was designed to investigate whether the antiinflammatory and antiproliferative activity of oral and intravitreal methotrexate (MTX) suppresses intraocular inflammation in patients with presumed latent syphilitic uveitis and presumed tuberculosis-related uveitis. Interventional prospective study including three cases with presumed latent syphilitic uveitis treated with intravenous penicillin and oral MTX, and two cases with presumed tuberculosis-related uveitis treated with standard antituberculosis therapy and intravitreal MTX injections. Treatment efficacy of all cases was assessed by best-corrected visual acuity, fundus fluorescein angiography, and optical coherence tomography. Four eyes of 3 patients with presumed latent syphilitic uveitis had improved best-corrected visual acuity, suppression of intraocular inflammation, and resolution of cystoid macular edema in 6 months with oral MTX therapy. No recurrence of intraocular inflammation was observed in 6 months to 18 months of follow-up period after cessation of MTX. Two eyes of two patients with presumed tuberculosis-related uveitis showed improved best-corrected visual acuity, suppression of intraocular inflammation, and resolution of cystoid macular edema after intravitreal injections of MTX. No recurrence of intraocular inflammation was observed in 6 months to 8 months of follow-up period after cessation of antituberculous therapy. For the first time in the treatment of presumed latent syphilitic uveitis and presumed tuberculosis-related uveitis, we believe that MTX might have an adjunctive role to suppress intraocular inflammation, reduce uveitic macular edema, and prevent the recurrences of the diseases.

Ocular Syphilis in Patients Infected With Human Immunodeficiency Virus

Uveitis secondary to syphilis in human immunodeficiency virus (HIV)-infected individuals is a well-documented but unusual phenomenon. We report the case of a 66-year-old man with HIV recently diagnosed with early latent syphilis coinfection who presented with an acute onset of ocular symptoms and whose condition was diagnosed as anterior uveitis. After administration of appropriate antibiotic therapy for syphilitic uveitis, his ocular symptoms resolved completely. We additionally provide a literature review on the presentation and management of syphilitic uveitis. This paper highlights the importance of considering syphilis in the differential of ocular symptoms, particularly in a patient with HIV, and also demonstrates that prompt evaluation and management are of paramount significance in an otherwise deleterious disease.

Gender and uveitis.

Sex differences in medicine include sex-specific diseases occurring only in one sex and sex-related diseases that are more common to one sex. Indeed differences in incidence, presentation, and course of disease between males and females are common. Eye disease is no exception. According to the WHO website, “In every region of the world and at all ages, females have a significantly higher risk of being visually impaired.” WHO estimates that globally there are approximately 314 million people with visual impairment and that women account for more than 64.5%. Even adjusted for age, the overall odds ratio of blind women to men is 1.43, representing a range from 1.39 in Africa to 1.63 in industrialized countries [1]. Gender-based differences refer to hormonal changes in menstrual cycles, pregnancy, menopause, disease susceptibility, and other anatomic or physiologic differences between women and men. Although the exact mechanisms are not fully understood, recent research demonstrates a link between sex hormones and microbial exposure in which microbiome can trigger testosterone-dependent protection from autoimmunity in the nonobese diabetic (NOD) mouse model [2, 3]. Sex hormones, X-chromosome-related effects, and epigenetic and environmental factors also affect activation and differentiation of different immune cells that play important roles in infectious and autoimmune diseases [4]. The differences of ocular diseases between the sexes are nowhere more apparent than in the field of ocular inflammation. Females as a gender group have heightened immune responses not only to foreign antigens but also to self-antigens. Thus there is a greater preponderance of autoimmune disorders including noninfectious uveitis in women than in men. Recently, the Pacific Ocular Inflammation Study reported that, of 217 061 eligible patients, 872 were identified using International Classification of Diseases, Ninth Revision codes, and 224 cases of uveitis were confirmed. The overall uveitis incidence rate was 24.9 cases per 100000 person-years. The annual prevalence rates for 2006 and 2007 were 57.5 and 58.0 per 100000 persons, respectively. No difference in incidence rate was found by sex (P = 0.63), but female patients had a higher prevalence (P = 0.008) [5]. This special issue attempts to identify gender- and sex-based differences in various uveitides: infectious and noninfectious autoimmune uveitis, for example, multiple sclerosis in young and middle-aged women, juvenile idiopathic arthritis in girls, and syphilitic uveitis in HIV infected patients in males. Clinical manifestations and courses may appear differently between female and male patients in certain uveitides. Gender-based differences in uveitis should be also considered in care and treatment of the diseases, as well as the underlying genetic background and physical and social environment. Chi-Chao Chan Debra A. Goldstein Janet L. Davis H. Nida Sen

Clinical Manifestations of Syphilitic Uveitis in the Korean Population

Clinical Manifestations of Syphilitic Uveitis in the Korean Population

Can we consider syphilitic uveitis as neurosyphilis? A retrospective analysis of lumbar puncture results in a cohort of syphilitic uveitis patients

AbstractPurpose To investigate the cerebral spinal fluid (CSF) composition of patients with syphilitic uveitis (SU) and classify SU as neurosyphilis or not.Methods Retrospective study of SU patients from 2 Belgian university centers from 2003 to 2012. The diagnosis of SU was based on a positive syphilitic serology (FTA‐Abs and RPR) and a treatment response. Charts were reviewed for uveitis anatomical location, HIV status, serum RPR and CSF findings. Diagnosis criteria for neurosyphilis were: positive CSF‐RPR and/or CSF‐white blood cells (WBC) ≥ 5/μl for HIV‐, and positive CSF‐RPR and/or CSF‐WBC ≥ 20/μl for HIV+.Results 20 patients were included. 5 were HIV+. There were 3 papillitis, 10 posterior uveitis and 7 panuveitis. Cells were found in CSF in all patients (mean 40/μl) and were predominantly lymphocytes. Mean CSF‐proteins, lactate and glucose were 0.57g/l, 17mg/dl and 62mg/dl respectively. No differences were found between HIV+ and – patients. CSF‐RPR was + in 2/5 (40%) of HIV+ and in 11/15 (73%) of HIV‐ with no statistical difference.Conclusion In our series, all patients had a CSF cellular reaction, mostly lymphocytic. This strongly suggests that the blood brain barrier is disrupted during syphilitic uveitis. However, a positive RPR was not observed in all CSF. Despite this discrepancy, following our criteria, 100% of our patients could be classified as neurosyphilis.

Clinical features of 32 cases of syphilitic uveitis

Objectives To investigate the clinical characteristics and prognosis of syphilitic uveitis.Methods Clinical charts of 32 syphilitic uveitis patients were retrospectively analyzed.The diagnosis was confirmed by clinical and laboratory tests.There were 32 patients (50 eyes),18 males and 14 females; the ages were from 21 to 62 years ole,with a mean age of 42 years old.Eighteen patients were bilateral.All patients had complete ocular examinations including visual acuity,intraocular pressure,slit lamp biomicroscopy,ophthalmoscopy,fundus fluorescein angiography (FFA),indocyanine green angiography (ICGA).Results Inflammatory cells in the anterior chamber and corneal endothelium were present in 42eyes.Thirty eyes showed congestion and swelling of optic discs.Yellow-white lesions in the posterior pole were present in 18 eyes.No change in 6 eyes.FFA showed staining or hyperfluorescence of optic disc in 32eyes,venous leakage in 34 eyes,and cystoid macular edema in 15 eyes.ICGA showed squamous or disseminative hypofluorescence damages in 26 eyes.All patients were treated with penicillin and glucocorticoids,36 eyes had improved vision and fundus damage had abated.Conclusions Most syphilitic uveitis was panuveitis with retinal vasculitis.The prognosis is good with early diagnosis and timely treatment of this disease. Key words: Syphilis/complications; Uveitis/etiology; Disease attributes

THU0365 Syphilitic uveitis: A multicenter study of 50 cases

BackgroundIncreased incidence of syphilis has been observed in developed countries in the last decade. In some cases uveitis indistinguishable from that related to non-infectious autoimmune uveitis may be the presenting...

Successful treatment of syphilitic uveitis in HIV-positive patients

We report successful treatment of syphilitic uveitis in a case series of three Human immunodeficiency virus (HIV)-positive patients at Malaysia’s Selayang Hospital eye clinic. All three patients with syphilitic uveitis were male, aged from 23 to 35 years old, with a history of high-risk behaviors. Of the patients, two presented with blurring of vision and only one patient presented with floaters in the affected eye. Ocular examination revealed intermediate uveitis (case 1 and case 3) and panuveitis (case 2). Each patient showed a high Venereal Disease Research Laboratory (VDRL) titer at presentation and they were also newly diagnosed as HIV positive with variable CD4 counts. All three patients responded well to a neurosyphilis regimen of intravenous penicillin G. At 3 months posttreatment, there was reduction in VDRL titer with improvement of vision in the affected eye. Diagnosis of syphilis needs to be ruled out in all cases of uveitis. All syphilitic uveitis cases should have HIV screening and vice versa, as syphilis is one of the most common infectious diseases associated with HIV-positive patients. Early detection and treatment are important for a good visual outcome.

Uveitis heralding previously unknown luetic and HIV infection. Syphilitic uveitis in an Italian referral center.

This study was conducted to determine the incidence of luetic uveitis in the last seven years at our uveitis center and to describe the characteristics and the role of uveitis in the diagnosis of syphilitic infection with or without unknown HIV infection. We retrospectively reviewed syphilitic uveitis in patients observed at our center between 2004 and 2010. The diagnosis was based on the serological evidence for syphilis, uveitis, exclusion of other etiologies. All patients had HIV testing. We describe 14 new cases of luetic uveitis: 6 co-infected with previously unknown HIV-infection had panuveitis, while the most common presentation in HIV-negative patients was posterior uveitis. Syphilis has been recognized as reemerging disease. The ocular inflammation can be the first symptom of syphilis. This study underlines the importance of a prompt and correct diagnosis of this ocular disease.

Current status of HIV infection and ocular disease

In the present era of highly active antiretroviral therapy (HAART), the challenges that HIV/AIDS patients face with regard to ocular complications has changed immensely; nonetheless, significant ocular morbidity persists. We present an update on these challenges, focusing particularly on the relevant literature from the past 12-18 months. Although its incidence has decreased substantially in the HAART era, cytomegalovirus (CMV) retinitis remains an important cause of ocular morbidity and predictor of mortality. Presently, patients with less than 50 CD4 T-cells/μL have an approximately equal risk of developing this potentially blinding ocular complication compared with the pre-HAART era. Less is understood about the current epidemiological considerations of ocular syphilis and HIV; however, patients with HIV may have increased likelihood of posterior syphilitic uveitis. Regarding the neuroretinal disorder associated with HIV, new ophthalmic imaging modalities are helping to uncover potentially associated structural alterations. Future challenges in the fight against HIV/AIDS-related eye disease will involve identifying additional factors conferring increased risk of CMV retinitis, understanding the scope of ocular syphilis and other eye infections in HIV patients, and furthering our understanding of the structural changes in neuroretinal disorder as an indicator of other end-organ damage.

OCULAR MANIFESTATIONS OF SYPHILITIC UVEITIS IN CHINESE PATIENTS

To present the manifestations of syphilitic uveitis in Chinese patients. This is a retrospective case series of 35 eyes of 19 patients with syphilitic uveitis. The data of these patients including complaints, ocular and systemic manifestations, human immunodeficiency virus status, results of auxiliary examinations, treatment, and follow-up were reviewed. Nineteen consecutive Chinese patients were diagnosed with syphilitic uveitis by serologic tests. Four patients had circulating human immunodeficiency virus antibodies. Ocular involvement was found in 35 eyes. Posterior segment involvement was found in 30 eyes of 17 patients (85.7%), whereas anterior segment involvement was found in 14 eyes of 8 patients (40.0%). Thirty eyes of 17 patients (85.7%) presented with vitreous opacities and 28 eyes of 16 patients (80.0%) with retinitis. Papillitis and retinal vasculitis were found in 10 eyes of 6 patients (28.6%) and 7 eyes of 4 patients (20.0%), respectively. Multiple precipitates on the retina and posterior vitreous membrane were observed in six eyes of three patients. A large iris granuloma was observed in one eye. Posterior uveitis was the most common ocular finding in these investigated Chinese patients with syphilis. Coinfection of syphilis and human immunodeficiency virus was less common in these patients. Syphilis should be considered in the differential diagnosis of patients presenting with large iris granulomas.

Secondary choriocapillaritis in infectious choroiretinitis

AbstractPurpose Primary choriocapillaritis is the mechanism at the origin of diseases such as MEWDS, APMPPE, multifocal choroiditis and serpiginous choroiditis. In case of severe chorioretinal inflammation as in infectious posterior uveitis, indocyanine green angiography (ICGA) shows much more widespread involvement than seen by funduscopy or fluorescein angiography (FA) in form of hypofluorescent areas. The aim of this work was to analyse this occult choroidal involvement.Methods Charts of patients with toxoplasmic retinochoroiditis (TRC), syphilitic and tuberculous posterior uveitis seen in the Centre for Opththalmic Specialised Care (COS) in Lausanne, Switzerland from 1995 to 2011 were reviewed and patients with occult choroidal ICGA lesions were analysed.Results Occult ICGA lesions were characterized by a ring of hypofluorescence around the focus as well as small hypofluorescent satellite lesions in TRC and tuberculous posterior uveitis. In syphilitic posterior uveitis the ICGA hypofluorescence was characterized by more extensive areas that could contrast with minimal FA and fundus findings. For all three entities these hypofluorescent areas responded well to treatment, completely regressing in syphilitic posterior uveitis and regressing to a size equivalent to the foci seen on funduscopy and FA.Conclusion The aspect and the quick response to therapy of occult hypofluorescent areas on ICGA seen in severely inflamed infectious posterior uveitis most probably correspond to inflammatory choriocapillaris hypo or non‐perfusion and its extent needs to be assessed by performing a global appraisal of these cases including ICGA.

Syphilitic uveitis: Vilnius region perspetive: 6 case reports

AbstractPurpose To examine the clinical manifestations of syphilitic uveitis in Vilnius region population over four years and review trends in incidenceMethods A retrospective case series of 6 patients (8 eyes) with syphilitic uveitis who were managed in Vilnius region between 2009 and 2012Results Between 2009 and 2012 were 6 patients (mean age 42,67 years, range 28 ‐ 66) all of them with positive Treponema Pallidum Chemiluminescent Immunoassay (CLIA) and negative Human Immunodeficiency Virus (HIV) serology. Venereal Disease Research Labarotory (VDRL) and/or Treponema Pallidum Heamaglutination Assay (TPHA) and/or non – reactive Rapid Plasma Reagin (RPR) were obtained in all 6 patients. Posterior uveitis was the commonest presenting finding (5/8 eyes), panuveitis was seen in 3 eyes at presentation. Posterior uveitis manifests as chorioretinitis with or without vitritis, optic neuritis, neuroretinitis. Panuveitis – granulomatous anterior uveitis, neuroretinitis, vitritis. One patient with bilateral involvement, had rare symptom – syphilitic roseola of the iris. Five patients were treated with intravenal benzylpenicilin and one – oral cefriaxoneConclusion Ocular syphilis presented most frequently as posterior segment inflammation. An increasing trend in the number of cases of ocular syphilis in the past four years was observed in Vilnius region population

Visual evoked potential (VEP) and multifocal electroretinogram (mfERG) in ocular syphilitic posterior segment inflammation

The aim of this study is to correlate multifocal electroretinogram (mfERG) and visual evoked potential (VEP) changes with visual acuity and clinical features in patients with posterior segment inflammation secondary to syphilis. A retrospective interventional case series of 4 patients with visual loss secondary to syphilitic uveitis is reported. The mfERG (P1) showed diminished amplitudes and prolonged latency in 7 affected eyes. Visual acuity rapidly improved 2 weeks after initiation of therapy. OCT demonstrated anatomical recovery at 1 month. In three patients, visual acuity was restored to 6/6 at 6-9 months but mfERG responses remained significantly reduced and delayed for 12-15 months before recovery to normal levels. One patient developed a retinal detachment, but achieved 6/9 vision at 30 months. VEP changes, interpreted in combination with mfERG responses, showed evidence of optic nerve involvement in 6 eyes. Ocular findings, including posterior placoid chorioretinitis, are important diagnostic features of secondary and tertiary syphilis. Visual acuity and clinical recovery occur early with appropriate diagnosis and treatment, and precede full electrophysiological recovery of the outer retina-RPE complex. Ophthalmologists have the opportunity to play a key role in undetected or missed diagnoses of syphilis, and with appropriate treatment the visual prognosis is excellent.

Ocular Manifestations of Acquired Immunodeficiency Syndrome in Korea

The clinical features of HIV/AIDS-related ocular manifestations in Korean patients were investigated in this study. Data on 200 consecutive Korean patients diagnosed with AIDS who visited the Seoul National University Hospital from January 2003 to June 2008 were reviewed. Fifty-seven patients (28.5%) had ocular manifestations, and they showed significantly lower CD4+ T cell count than patients without ocular manifestations. Among them, 23 (40.3%) patients showed retinal microvasculopathy, and 22 (38.5%) patients showed cytomegalovirus (CMV) retinitis. Other manifestations included retinal vein occlusion (n = 4), herpes zoster ophthalmicus (n = 4), syphilitic uveitis (n = 2), acute retinal necrosis (n = 1), and progressive outer retinal necrosis (n = 1). The mean CD4+ lymphocyte counts of the patients with retinal microvasculopathy and cytomegalovirus retinitis were 108.5 cells/µL and 69.4 cells/µL, respectively. In conclusion, ocular manifestations including CMV retinitis are common complications in Korean patients with AIDS even in the era of highly active anti-retroviral therapy. Compared to previous reports in western countries, prevalence of CMV retinitis is relatively low and CD4+ lymphocytes count at the time of diagnosis is relatively high.

Syphilis oculaire : à propos de deux cas

Introduction Whereas syphilis is a classical cause of uveitis, it is still often under-recognized. Treatment recommendations are not based on specific clinical studies. Case reports We report two patients with syphilitic uveitis diagnosed and treated at the University Hospital of Angers. Ocular involvement was inaugural in both patients. Each had a specific treatment but none had a complete recovery of visual function. Conclusion Syphilis must be discussed in all patients diagnosed with uveitis or papillitis. Although not evidence-based, prompt therapy may lead to functional recovery.

Posterior syphilitic uveitis: clinical characteristics, co-infection with HIV, response to treatment

To describe the characteristics and clinical course of patients with active posterior syphilitic uveitis evaluated between 1991 and 2009. Retrospective chart review. Thirteen patients with active posterior syphilitic uveitis were identified at a single institution. All were men, and all with available data were men having sex with men (MSM). Ten of 12 (83%) with available data were HIV positive. Four (31%) had a history of syphilis. Clinical findings included infiltrative retinitis, necrotizing retinitis and optic neuritis. Two of 8 patients tested (25%) had a positive Venereal Disease Research Laboratory test in the cerebrospinal fluid. Treatments included intravenous penicillin, intramuscular penicillin and intramuscular ceftriaxone. All treated cases improved and, in some cases, inflammatory lesions completely resolved without scarring. In this series, syphilitic posterior uveitis presented only in men, and all with available data were MSM. The majority were concomitantly infected with HIV. Clinical presentations varied and all patients demonstrated either significant improvement or complete resolution of inflammation.

O3-S1.01 British Ocular Syphilis Study (BOSS): National Surveillance Study of intraocular inflammation secondary to infectious syphilis

BackgroundSyphilis poses a significant public health problem. There has been a 1032% increase in the incidence of syphilis between 1999 and 2008 in the UK. There are currently no epidemiological...