Recent reports show that ocular syphilis is becoming an increasingly common clinical problem, reflecting a growing incidence of syphilis in immunocompetent subjects of all ages and in particular in patients with HIV infection [1, 2]. Eye infection can occur at any stage of the disease, and includes interstitial keratitis, anterior, intermediate, and posterior uveitis, chorioretinitis, retinitis, retinal vasculitis and cranial nerve and optic neuropathies [1–3]. Ocular findings may be associated with Central Nervous System involvement or be the sole presenting manifestation [3–6].
Attention has been mainly focused on Treponema Pallidum and HIV co-infection, as concurrent HIV frequently alters the natural course and typical clinical features of disease, and of neurosyphilis in particular [5, 6]. Furthermore, clinical and laboratory diagnosis is often uncertain in HIV-infected patients [7]. Although specific treatment can improve vision, recurrences have been observed [2, 5, 7].
We report the favorable outcome of a case of bilateral chorioretinitis and uveitis in an HIV–infected patient, which started out as a unilateral ulcer on the lower eyelid.
Case presentation
In January 2011, a 45-year-old Italian bisexual man, known to be HIV-infected since 1998, presented to the Infectious Diseases Unit with partial vision loss in both eyes.
Since 2000, HIV infection had been treated with combination antiretroviral therapy (cART) including zidovudine, lamivudine and lopinavir/ritonavir. Nadir absolute CD4+ T-cell count was 320/mm3.
The patient had been regularly attending different Day Hospital Services and was adhering well to cART. He had received two lines of cART, including ritonavir-boosted protease inhibitor regimens without experiencing virological failure.
On admission, his absolute CD4+ T-cell count was 385/mm3, HIV viremia was undetectable and his cART consisted of tenofovir emtricitabine and boosted atazanavir.
The patient's past treatment history revealed that he had received a single intramuscular injection of 2.4 million units of penicillin G benzathine for primary syphilis contracted in November 2000 after unprotected heterosexual exposure. At that time, he had a penile lesion with inguinal adenopathy, and he tested positive for syphilis as follows: serum Venereal Disease Research Laboratory (VDRL) test ++, Treponema pallidum haemoagglutination assay (TPHA) 1: 1280, positive FTA-Abs. Serological post-treatment follow-up showed that the VDRL test had reverted to non-reactivity within 12 months. His last known non-reactive VDRL test result was in June 2009.
Two weeks before admission to the Infectious Diseases Unit, the patient had noticed an ulcer on his left upper eyelid and four days before admission he had begun to experience reduced visual acuity, with associated photophobia and mild headache which had subsequently improved. His general practitioner suspected a chalazion and the patient was referred to our Ophthalmology Section because of visual impairment.
A small, painless, resolving ulceration with barely elevated edges was present above the external canthus of the LE (Figure 1). No other abnormalities were seen in the remainder of his eyelids, eyelashes, cornea, bulbar conjunctiva, the other eye or on the rest of his face. His left preauricular and submandibular nodes were slightly enlarged, non-tender and firm.
Best corrected Snellen visual acuity was 20/32 in both eyes. Fine pigmented keratic precipitates, aqueous cells, flare and posterior synechiae were seen in the anterior chamber. Examination of the posterior chamber revealed vitreitis, retinal vasculitis with perivascular sheathing and hemorrhages, edematous retinal areas and disc swelling. Intravenous fluorescein angiogram showed masked retinal areas, optic disc hyperfluorescence and leakage from retinal venules (Figures 2a, 2b and 2c).
Structured face-to-face interviews were conducted with the patient to obtain information about his behavioral risk factors and symptoms. He had a history of multiple sexual partners in the previous year and unprotected oral sex intercourse with a sperm contamination of his eyes. His sexual contacts were traced and two immunocompetent young men tested positive for syphilis.
Complete blood count was unremarkable. Hematologic values were within normal range and Polymerase Chain Reaction (PCR) for Toxoplasma gondii, Herpes viruses, Mycobacterium tuberculosis (MT), non-tuberculous mycobacteria (NTM) and other pathogens which are epidemiologically relevant in our geographic area (i.e. Rickettsia conorii, Brucella spp) gave negative results. Negative results were obtained for CMV DNA (using Real Time for amplification of the IE region) and CMV pp65 antigen in 200000 leukocytes. EBV-DNA (amplifying the Bam Hi W region) and HSV DNA (amplifying viral polymerases) were also negative. Serum VDRL titer was 1 : 16, and TPHA titer was 1 : 1280.
Macroscopic and humoral studies of cerebrospinal fluid (CSF) performed at the time of admission were negative. CSF VDRL and CSF PCR test results for the above-mentioned microorganisms were also negative.
The patient was treated with intravenous penicillin G (24 MU/day) for two weeks and received 1 intramuscular dose of penicillin G benzathine (2.4 MU) after completing the I.V. therapy [7, 8].
He was treated topically with dexamethasone qid and atropine 1% bid, and was prescribed 60 mg of oral prednisone daily, tapered over 4 weeks.
At the two-week follow-up visit, papillitis had disappeared, and retinal vasculitis and uveitis had improved. Best corrected Snellen visual acuity remained unchanged. The topical therapy was tapered.
After one month, aqueous cells and flare had further decreased but some retinal hemorrhages and perivascular sheathing were still observed.
At 2-months follow-up, signs of uveitis had disappeared, posterior synechiae were sporadic and fundus examination showed a normal disc and peripheral hyalinized vessels with attached retina (Figures 3a and 3b).
One year after treatment, serological testing for syphilis was repeated, showing positive VDRL 1:2 and positive TPHA 1:80.
At present, the patient is regularly attending our Day Care Unit where we can monitor his adherence to therapy.
His last CD4+ T-cell count was 530cells/mm3 and viral load was undetectable.
Ocular examination showed that both eyes were quiet.