Syphilitic uveitis as the presenting feature of HIV.

A 25-year-old male presented with visual loss in the right eye for 20 days and best-corrected visual acuity of counting fingers in the right eye and 20/20 in the left eye. The anterior chamber (AC) had old keratic precipitates, no AC reaction, dense vitritis, active multifocal retinochoroiditis, and retinal vascular sheathing in all quadrants. The left eye showed sheathed blood vessels with chorioretinal atrophy [Fig. 1].

Figure 1

(a) Color fundus montage of the right eye shows vitritis, vascular sheathing, and retinochoroidal infiltrates. (b) Enlarged view of multifocal retinochoroidal infiltrates with vitreous exudates in the right eye. (c) Color fundus montage of left eye showing vascular sclerosis and healed retinochoroiditis in the superotemporal quadrant

The regular bacteriologic and viral investigations on the aqueous and vitreous samples were negative. ELISA for HIV 1 and 2 was positive. Rapid plasma regain (RPR) was reactive at a dilution of >1:32, and Treponema pallidum hemagglutination assay (TPHA) was positive at more than 1:1280 dilution [Table 1].

Table 1

Investigations carried out and their results

The patient was started on tapering dose of oral steroids (1 mg/kg/day), antiretroviral therapy (tenofovir 300 mg, lamivudine 300 mg, and efavirenz 600 mg once daily). Intramuscular penicillin was administered for 3 weeks (2.4 million units every week).

After 2 months, visual acuity improved to 20/30, and vitreous inflammation cleared leaving behind retinal pigment epithelium mottling [Fig. 2].

Figure 2

Color fundus montage picture of the right eye showing resolution of vitritis and retinochoroiditis with retinal pigment epithelium mottling 2 months following initiation of treatment

Discussion

Syphilis is caused by the spirochete, Treponema pallidum. The disease has also been referred to as the great imitator.[12]

The prevalence of syphilis had decreased in the preceding two decades. At present, up to 70% patients with ocular syphilis are HIV positive. Syphilis is the underlying cause of uveitis in 16.4% of all cases.[3] Generalized creamy white infiltrates and diffuse retinitis is a peculiar feature of advanced syphilitic uveitis.[4]

Syphilis elicits both a humoral and a cell-mediated immune response and can be detected by RPR and TPHA tests.[5]

This case emphasizes that syphilitic uveitis can present as a feature of undetected HIV. One needs to have a high degree of suspicion to arrive at a correct diagnosis and to institute prompt therapy.

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Conflicts of interest

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