Ocular manifestations of syphilis can occur at any stage of the disease with varied clinical presentations. Syphilis can involve almost any ocular structure, but posterior uveitis and panuveitis are the most common presentations, usually unilateral, and if untreated may lead to blindness. 43-year-old white female presented with progressive right eye pain associated with blurry vision and black spots. The patient also developed multiple non-pruritic red papules, 5 to 10 mm in size on the face, trunk, and extremities. The patient was taking spironolactone 25 mg daily for hypertension and NSAIDs over the counter. She mentioned having 3 sexual partners in the past 8 months without barrier contraception. There was no prior history of blood transfusions or recent travel, sexually transmitted diseases, or autoimmune diseases. The patient was seen by an ophthalmologist who described a tough view of the posterior segment with 20/800 uveitis OD with associated posterior synechiae of iris OD and optic nerve swelling. The left eye was unaffected and was given one dose of triamcinolone, atropine sulfate 0.01% was given to the affected eye twice a day, and daily prednisolone acetate 1% in both eyes without improvement. The patient reported mild improvement of blurriness and tested positive for RPR, Treponema pallidum antibodies (FTA-Abs) and ANA 1/180 speckled pattern Hep C abs. HIV serology was negative. The patient was hospitalized and a lumbar puncture was done as the patient started complaining of headaches during hospitalization, but the CSF analysis was normal. The patient was started on aqueous crystalline penicillin G, 3 to 4 million units IV every 4 hours for a total of 14 days. The patient noticed an improvement in vision and the papules decreased in size. The patient’s partner was also counselled for outpatient treatment. In 2020, 133,945 cases of syphilis were reported in the US. A total of 12.7 primary and secondary syphilis cases per 100,000 were reported in Alabama, with increasing cases each year. Syphilis is a very protean disease and should be considered before starting treatment in a patient with otherwise unexplained unilateral acute vision loss, especially compounded by skin manifestations. In this case, uveitis appeared days before skin manifestations. Point-of-care tests could be done if there is high suspicion and treatment should be started as soon as possible.

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Alabama STD report https://www.alabamapublichealth.gov/std/statistics.html

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