Ocular Syphilis in a HIV positive male
The following case appears in Case Reports in Infectious Diseases.

A 36-year-old white male presented to the emergency department complaining of seeing intermittent “floaters” over the past 3 weeks and acute, progressive vision loss over the past 4-5 days. He reported only being able to make out shadows in the left eye and blurry figures in the right eye. The patient also reported a new-onset rash around the eyes. He denied painful vision, headache, photophobia, neck stiffness, nausea, vomiting, and focal neurological deficits.

He had used intravenous methamphetamines for the past 15 years but denied use of other illicit drugs, alcohol, and tobacco. He also endorsed having unprotected sex with numerous men in the past, although he had been in a monogamous relationship for the last 2 years.

On physical examination, he had a bilateral periocular, maculopapular, erythematous rash with clear sclera. Visual acuity of the right eye was 20/400, but the left eye was only able to distinguish the presence of hand-waving. Fundoscopic examination revealed edema of the left optic nerve. Slit lamp examination and fluorescein angiography revealed bilateral optic nerve head edema, severe (3+/4) bilateral vitritis in all 3 chambers, extensive cellular debris, and white, inflammatory lesions in the retina.

Also noted were bilateral posterior synechiae (adherence of the iris to the lens) creating an irregular shape to the pupils. Multiple injection sites were noted on the forearms, consistent with recent methamphetamine use.

Subsequent results of laboratory and microbiology tests included a positive HIV ELISA and confirmatory western blot. The CD4+ cell count was 377 cells/mL and the HIV RNA level was 122,480 copies/mL (log 10 = 5.1). A serum syphilis EIA screen was positive and the serum RPR titer was 1 : 256.

The patient was informed of the diagnoses of HIV infection and neurosyphilis with ocular involvement. He subsequently disclosed that his current partner was HIV-positive, though the patient had never been tested for HIV. He did, however, recall being diagnosed with and treated for primary syphilis in the past. It was unknown if his partner had ever had syphilis. The patient was started on intravenous penicillin G, and both his rash and bilateral vision improved.

He was discharged to complete 14 days of intravenous penicillin G. It was recommended that his partner undergoes evaluation for syphilis. Antiretroviral therapy was subsequently initiated and the patient voluntarily entered an inpatient substance abuse treatment program.

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