Exposing the Great Masquerader: Five Consecutive Cases of Ocular Syphilis with Heterogeneous Clinical Presentations

Abstract

INTRODUCTION: Ocular syphilis has a highly heterogeneous clinical presentation, which can overlap with many other etiologies. Its diagnosis requires a high index of suspicion. Ophthalmological manifestations may appear in virtually all anatomical regions of the eye, in both the anterior and posterior segments. Uveitis is the most common ophthalmologic presentation of syphilis, and the timing of onset is variable and unpredictable. The purpose of this work is to describe 5 consecutive cases of ocular inflammation, with heterogeneous manifestations, eventually diagnosed as ocular syphilis.
METHODS: A case-series report of consecutive eyes, including 5 cases of patients diagnosed and treated for ocular syphilis in Hospital Pedro Hispano – Unidade Local de Saúde de Matosinhos, in the year of 2022. Patients were managed in collaboration between the ophthalmologic and infectious diseases departments and were hospitalized for systemic treatment.
RESULTS: Case 1 reports a 29-year-old man with bilateral non-granulomatous iridocyclitis. Case 2 refers to bilateral asymmetrical papillitis. Case 3 consists of a unilateral panuveitis with dense vitritis, in a patient with HIV co-infection. Case 4 depicts bilateral asymmetrical neuroretinitis. Case 5 reports granulomatous iridocyclitis in a patient with a hypermature cataract, initially regarded as lens-induced uveitis.
CONCLUSION: Syphilitic uveitis may occur at any stage of the systemic disease. A high clinical suspicion is necessary, and it must be considered in all cases of unexplained ocular inflammation. HIV-coinfection is common, and results in more severe disease, with worse prognosis. Poor initial visual acuities appear to be related to bad visual outcomes. Systemic treatment should be started promptly when there is suspicion of the infection. Detailed medical history and systemic physical examination are essential tools to help the diagnosis.