US patient with blurred vision found to have ocular syphilis

US clinicians have described their management of a patient with ocular syphilis in BMJ Case Reports.

The authors shared that a previously healthy man in his 50s presented to a Michigan hospital with a three-week history of blurred vision in both eyes. The blurred vision was painless and worse in his right eye than his left.

As part of a social history taken by the clinicians, the patient reported having unprotected sex with multiple female and male partners in the past. His best corrected visual acuity was 20/350 in his right eye and 20/30 in his left eye.

A dilated fundal examination found bilateral papilloedema, while a CT scan of the brain revealed a 5 mm left subdural haematoma.

Following blood tests and a sexually transmitted infections workup, ophthalmology and infectious disease specialists agreed that the presentation was consistent with ocular syphilis.

After commencing penicillin treatment, the patient developed a Jarisch-Herxheimer reaction. He experienced a fever, rash and worsening headaches due to the enlargement of subdural haematoma for which he underwent a burr hole drainage.

Following the 14-day course of penicillin treatment, his vision started to improve but did not completely resolve.

Reflecting on the case, the authors highlighted that syphilisis a “great imitator” that can present in many different forms with symptoms that are initially vague.

“Ocular syphilis should be suspected in any patient with known syphilis or risk factors for syphilis such as men who have sex with men, advanced age, people living with HIV, drug use, and reinfection after a previous infection,” the authors shared.