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.