Acute vision changes as the presenting symptom of ocular syphilis - A case series of two

Syphilis, a bacterial infection caused by Treponema pallidum, can affect a wide variety of organ systems of its host. We aim to present the cases of two patients who presented to an urban, tertiary care, academic Emergency Department with ocular symptoms who underwent imaging, laboratory, and specialist evaluation and were ultimately diagnosed with ocular syphilis.

The first patient is a 46-year-old female who presented to the Emergency Department with painless complete vision loss in a unilateral eye. Her exam was significant for bilateral papilledema, and further workup revealed a retinal detachment in the affected eye. Rapid plasma reagin (RPR) titers resulted positive with 1:128 and a reactive fluorescent treponemal antibody (FTA). Further workup including lumbar puncture and magnetic resonance imaging were unable to be obtained due to patient refusal and multiple discharges against medical advice. The second patient is a 38-year-old female with a history of intravenous drug use who presented for bilateral circumferential peripheral vision loss with central sparing. The examination showed bilateral papilledema. Lumbar puncture was performed with normal intracranial pressure. RPR titers resulted positive with 1:128. MRI and ophthalmology evaluation did not reveal any other etiology or explanation for papilledema.

This case series highlights the importance of considering syphilis as a possible cause of ocular symptoms in high risk patient populations and the need for prompt and appropriate treatment given the increasing prevalence of syphilis worldwide.