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Syphilis: old problem, new strategy

BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7356.153 (Published 20 July 2002) Cite this as: BMJ 2002;325:153

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Bilateral Optic Neuritis in Secondary Syphilis

To the editor:

We read the article by Doherty L et al (1) with great interest, and
we would like to comment our experience. In the lasts years we have
witnessed a resurgence of infectious syphilis in our hospital, with an
increase in the incidence as much of the new diagnoses cases as of the
secondary forms of the diseases, with the appearance of non usual forms of
the disease. We would like to report an interesting case.

A 35-year-old man presented to our hospital with an acute visual loss
involving his right eye. He had being well until one month when he started
to loos vision, he had neither pain nor other symptoms but sensation of
fever and the appearance of cutaneous lesions in soles. He also referred
the existence of some ulcers in the mouth that prevented him to eat. He
has HIV infection, stage C3 (last control CD4 112 cells/ml, viral load
105000 copies/ml) and a past history of IV drug addiction (actually on
substitutive treatment with methadone). He referred that some years ago he
had an ulcer in his penis that treated, but he could not tell us which
drug was prescribed for. On physical examination he had a visual deficit
in his right eye, he was hardly able to count fingers to 1 distance meter,
and the presence of some cutaneous hyperqueratotic lesions in both soles
(figure 1) and an erythematous rash on his trunk (figure 2). The
funduscopic examination revealed disc edema without other abnormalities.
Results of routine blood studies, chest x-ray film, and cranial CT were
normal. MRI of the head revealed a focal lession located on occipital
cortex of possible vasculitic origin. Visual evoked potentials
were interpreted as optic bilateral neuritis, with axonal loss in right
eye. Serologic studies performed showed RPR 1/256 and an FTA-ABS positive.

Figure 1

Figure 2

With the suspicion of neuroshypilis a lumbar puncture was made, and
yielded clear, colourless fluid under normal opening pressure. The fluid
contained 80 leukocytes (95% lymphocytes), the proteins value was 70 mg/dl
and the glucose value was39 mg/dl (serum glucose at the same time 90
mg/dl). FTA-ABS and RPR were positive in CSF. Microbiologic studies, which
included Gram´s stain, india ink stain, Ziehl-Nielsen acid-fast bacilli
satin, cryptococcal antigen, cytologic studies for neoplastic cells and
cultures for bacteria and fungus, were performed and were negative. A skin
biopsy specimen was interpreted as consistent with secondary syphilis.

We
started treatment with Ceftriaxone 1g/day IM during 10 days with no
improvement in visual accuracy. Several months after discharge the patient
is asymptomatic, although he has not recovered the visual loss.

The importance of syphilis as a cause of ocular disease has been
recognized since 1858 (2) being able to be produce very diverse types of
lesions, uveitis, iritis, retinitis, retinochoroiditis, epiescleritis,
retinal vasculitis and others (3). Early diagnosis is important, in view
of the potentially sight-threatening sequelae of syphilitic optic disease
(4). The syphilitic neurological affectation is frequent and precocious in
patient with HIV infection, being able to cause damage in the optic nerve
(5) nevertheless, the luetic optic neuritis is a rare entity (6), and its
presence usually takes associate the existence of other manifestations of
meningeal inflammation like migraine, audition loss, etc (7). Our patient
had no signs of meningeal affectation different from the optic neurititis,
and meningeal inflammation was only observed after the realization of the
lumbar punction that yielded a fluid with pleocytosis and elevated protein
levels. The determination of positive FTA-ABS confirmed the diagnosis of
neurosyphilis.

Although we cannot be entirely certain of the precise stage of our
patient´s syphilitic infection, we believe that his clinical findings are
more consistent with the secondary stage. The typical maculopapular rash
with the involvement of the palms and soles occurs much more frequent in
the secondary stage (8) as the subsequent biopsy confirmed. The clinical
picture presented would correspond, therefore, to an oligosymptomatic
neurosyphilis, and a possible explanation for this way of presentation
could be the existence of an inadequate previous treatment (9), let us
remember that our patient had, among his antecedents, the doubtful history
of treated syphilis.

Finally, we would like to remark that, as we pointed above, early
diagnosis is very important, because the delay in the instauration of
correct treatment may end in a permanent impaired vision as happened in
our patient.

REFERENCES

1. Doherty L, Fenton KA, Jones J, et al. Syphilis: old problem, new
strategy. BMJ 2002;325:153-156

2. Ross WH, Sutton HF. Acquired syphilitic uveitis. Arch Ophthalmol
1980;98:496-498

3. Tamesis RR, Foster CS. Ocular syphilis. Ophtalmology 1990;97:1281-1287

4. Musher DM. Syphilis, neurosyphilis, penicillin and AIDS. J Infect Dis
1991;163:1201-1206

5. Gartaganis S, Georgiou S, Monastirli A, et al. Asymptomatic bilateral
optic perineuritis in secondary syphilis. Acta Derm Veneorol 2000;80:75-76

6. McLeish WM, Pulido JS, Holland S, et al. The ocular manifestation of
syphilis in the human immunodeficiency virus type-1 infected host.
Ophtalmology 1990;97:196-203

7. Weinstein JM, Lexow SS, Ho P, Spickards A. Acute syphilitic optic
neuritis. Arch Ophthalmol 1981;99:1392-1395

8. Chapel TA. The signs and symptoms of secondary syphilis. Sex Transm Dis
1980;7:161

9. Cisse A, Souare IS, Larkhis B, et al. Atypical neurosyphilis: 28-case
series at University Hospitasl Center of Conakry, Guinea. Med Trop (Mars)
2002;62:150-154

Figure 1: Hyperkeratotic lesions in soles

Figure 2. erythematous rash on trunk

Competing interests:
None declared

Editorial comment
The patient whose case is described has given his signed informed consent to publication.

Competing interests: No competing interests

18 February 2003
Jorge Parra-Ruiz
Feb, 11 2003
MAngeles Martinez-Perez, Leopoldo Muñoz-Medina, Rafael Castillo-Amaro, Jose Hernandez-Quero
Infectious Diseaseés Unit. Saint Cecil Clinic Hospital. Avda Dr. Olóriz s/n 18014. Granada. Spain