Discussion
Syphilis might mimic different systemic and ocular diseases, and as a result, it is known as a ‘great masquerader’, leading to diagnostic and proper treatment delay 12. The ocular involvement is broad: from anterior uveitis to neuroretinis. Ocular manifestation may appear at any stage of the disease, but it is more common in secondary and tertiary diseases 3. Our patient had been treated for syphilis twice in the previous years (2017, 2019), however, he had no documentation confirming the cure. Thus, it remains unclear whether this is a later stage of syphilis or a reinfection. The most frequent form of ocular syphilis is uveitis 45 6. However, the presence of the disease in the eye is not usual; hence a high level of vigilance is required in patients with uveitis to avoid wrongful treatment and as a consequence poor visual outcome7. In the large observational study conducted in Brasil in 2018, approximately one-half of the patients during follow-up visit had the improvement of BCVA of 2-lines or more 8. Our patient had significant visual acuity improvement, during follow-up his visual acuity improved by 5 lines in the right eye and by 8 lines in the left eye. The spectacular visual recovery might be the effect of the thorough medical interview, prompt diagnosis and treatment.
Ocular syphilis should be considered a form of neurosyphilis regarding treatment approach 2 . The main treatment is parenterally administered penicillin G, in any stage of the disease 4. Although, the use of corticosteroids might be controversial; they are used in ocular manifestations of syphilis. Topical steroids are used in anterior uveitis and keratitis, whereas oral and intravenous steroids are the treatment for posterior uveitis, scleritis, and optic neuritis6. All patients with syphilis infection should be tested for HIV infection, as the risk factors are similar and the progression of syphilis might be faster in HIV-positive patients 9. Moreover, patients with HIV infection should be routinely checked for syphilis infection, as it is crucial for prevention of irreversible visual loss 89. Our patient has been in a stable relationship for a year; however, his partner was never diagnosed for syphilis. It is always necessary to diagnose and treat all sexual partners. As we have seen in our patient, the role of the ophthalmologists might be critical in diagnosing infection with T.pallidum , as ocular manifestation could be the first and only presenting symptom of the disease.