Incidence of Syphilis Has Been Increasing, and Uveitis May Be Its First Sign

Because of the potentially devastating neurologic consequences of syphilis, this sexually transmitted disease should be considered in all patients who initially appear with uveitis.

Syphilis is a highly contagious sexually transmitted disease that can be cured with penicillin. After the introduction of penicillin in the United States in the 1940s, a downward trend in the number of reported U.S. cases of syphilis occurred during most of the rest of the 20th century, except for an outbreak in the early 1990s.

However, since 2002 there has been a resugeance of syphilis in the United States. Much of this increase is attributable to men having sex with men, but syphilis in bisexual or heterosexual women is also a concern, particularly in pregnant black or Hispanic women and their fetuses.

Syphilis can invade the nervous system at any stage, and ocular syphilis is one clinical manifestation of neurosyphilis. Although ocular syphilis can affect almost any eye structure, posterior uveitis and panuveitis are its most common manifestations.

In a recent case report published in Optometry and VIsion Science, a trio of authors stressed the importance of keeping syphilis in mind as a potential cause of uveitis and taking a detailed sexual history to ensure timely diagnosis of ocular syphilis.

The authors reported a mild, unilateral case of anterior uveitis in an otherwise asymptomatic 64-year-old white man. The patient complained of 3 days of mildly reduced vision, photophobia, and pain in the left eye. He denied having had similar episodes previously, and no contributing history was revealed during questioning.

Corrected distance visual acuities were found to be 20/25+ in the right eye and 20/20− in the left. Slit lamp examination findings included moderate circumlimbal flush, many fine keratic precipitates, and a moderate number of white blood cells in the anterior chamber. On the basis of these findings, a diagnosis of acute, idiopathic, nongranulomatous, anterior uveitis was made, and the patient was treated with a topical steroid plus a cycloplegic agent.

The patient initially responded to this treatment, although somewhat sluggishly. However, on day 44 of treatment, the uveitis suddenly worsened. An increase in anterior chamber cells, several mutton-fat keratic precipitates, and elevated intraocular pressure were found.

On the basis of the results of a systemic diagnostic workup, neurosyphilis was diagnosed, and the patient admitted that he engaged in high-risk sex. The case was reported to the local health department within 24 hours of syphilis diagnosis.

After treatment with 24 million units per day of intravenous aqueous penicillin-G for 14 days, uveitis completely resolved.

The authors concluded their case report by noting that ocular syphilis is an uncommon but curable cause of ocular inflammation. Having noted that the incidence of syphilis appears to be increasing, they added that although syphilis is curable, untreated syphilis can cause devastating damage. As a result, they recommended that clinicians should suspect syphilis as a potential cause of ocular inflammation in all uveitis patients.