Objective:

To describe five patients presenting with visual symptoms and disc edema who were diagnosed with ocular syphilis.

Background:

The Centers for Disease Control and Prevention (CDC) reported that in 2017-2021, men accounted for 83% of syphilis cases. Gay, bisexual, and other men who have sex with men account for 53% of male cases.  Human immunodeficiency virus (HIV) positivity increases a patient’s risk of developing neurosyphilis.

Design/Methods:

Case series

Results:

The mean age of patients was 49 years (range 42-57).  All were male.Three patients were positive for HIV but had undetected viral loads at the time of ocular syphilis diagnosis.  Patients presented with varying degrees of impaired visual acuity, and each had improvement of visual acuity with treatment.  RPR titers were elevated at the time of diagnosis and improved with treatment.  CSF VDRL was negative in each case.  Each patient was diagnosed with ocular syphilis and treated with 18-24 million units of intravenous aqueous crystalline penicillin daily for 10-14 days.  Response to treatment was recorded based on examination and rapid plasma reagin (RPR) titers at 3 months. 

Conclusions:

Ocular syphilis and neurosyphilis can be seen even in immunocompetent patients.  Isolated ocular syphilis is an uncommon presentation of neurosyphilis, and may be associated with normal CSF evaluation.  In our patients, treatment had been initiated prior to sampling of CSF, which could contribute to nonreactive VDRL.  It is important to consider ocular syphilis in middle-aged male patients who present with vision loss and disc edema as it is a treatable and potentially reversible cause of vision loss.