Unilateral hypopyon associated acute syphilitic posterior placoid chorioretinitis: Unusual presentation leading to HIV diagnosis

Abstract

Syphilis has a wide variety of ocular presentations such as anterior or posterior uveitis, chorioretinitis, retinal vasculitis, retinitis, perineuritis, papillitis, retrobulbar neuritis, optic atrophy and optic nerve gumma. Therefore, it is recommended to test every patient with ocular inflammation for syphilis. It is, however, a relatively rare cause of uveitis in HIV disease. A few studies suggested that HIV contributes to the ocular manifestations of syphilis and HIV co-infection in approximately 30%. Acute syphilitic posterior placoid chorioretinopathy is a rare ocular manifestation in immune-competent patients characterised by the development of a deposit in the outer retina. We describe an unusual such presentation with hypopyon.

Keywords

Syphilis acute syphilitic posterior placoid chorioretinitis HIV

Case report

A 25-year-old men presented with complaints of diminution of vision and floaters in the right eye for 15 days with no other systemic complaints. Ocular examination revealed best corrected visual acuity (BCVA) of 6/36 in the right eye and 6/6 in left eye. Right eye examination showed a few fine pigmented keratic precipitates, aqueous cells and flare grade 4 with hypopyon, and a sluggishly reacting pupil with few pigment cells on the anterior surface of lens (Figure 1(a)). Intraocular pressure on applanation tonometry was normal in both eyes. Fundus examination of right eye gave a slightly hazy view due to vitreous cells but showed a normal disc with yellowish placoid lesions involving the retina nasal to the optic disc, characteristic of acute syphilitic posterior placoid chorioretinitis (ASPPC) with certain vitreous exudates inferiorly (Figure 1(b)). Examination of the retinal periphery demonstrated no evidence of vasculitis or chorio-retinitis in the right eye. Examination of both anterior and posterior segments in the left eye revealed no abnormality.

Figure 1.

(a) Anterior segment photo of right eye showing aqueous cells and flare grade 4 with hypopyon, sluggishly reacting pupil with few pigments on the anterior surface of lens. (b) Fundus photo of same eye showing yellowish-white placoid lesions involving retina nasal to optic disc characteristic of acute syphilitic posterior placoid chorioretinitis with certain vitreous exudates inferiorly.

A general physical examination revealed no evidence of skin lesions, oral or penile ulcers. On repeated questioning, the patient gave a history of a widespread painless macular rash on palms, soles and trunk three months prior that had spontaneously resolved within three weeks; he had contact with multiple sexual partners.

Haematological investigations showed a normal complete blood count, Human lecocyte antigen-B5 (HLA-B5) was negative and polymerase chain reaction for toxoplasma, cytomegalovirus, herpes zoster and simplex virus and serum angiotensin converting enzyme were normal. Both Rapid plasma reagin (RPR) (1:64) and Treponema pallidium haemagglutination assay (TPHA) (1:320) tests for syphilis were positive. Both Western Blot and ELISA tests for HIV were also positive, with a CD4 count of 301 cells/µl.

Intravenous penicillin G 24 million units/day for 14 days was administered as well as intramuscular benzathine penicillin 2.4 million units as weekly dosage for three weeks; highly active antiretroviral treatment was also commenced. At four weeks’ follow-up, BCVA in the right eye had improved to 6/9. Anterior segment examination revealed a quiet eye with faint flare and grade 1 vitreous haze. Fundus examination showed grade 1 media, completely healed placoid retinal lesions with only residual pigment mottling (Figure 2). The patient was advised regular follow-up and continued on antiretroviral therapy.

Figure 2.

Fundus photo of right eye showing grade one media, completely healed placoid lesions in retina with only residual pigment mottling post treatment at four weeks.

Discussion

Syphilis can present with varied ocular presentations in form of anterior or posterior uveitis, chorioretinitis, retinal vasculitis,neuritis, optic atrophy and optic nerve gumma.¹ Despite being a relatively rare cause of uveitis in HIV, it contributes to the ocular manifestations of syphilis and HIV co-infection in approximately 30%.^2--6 Ocular syphilis is a relatively rare but important cause of uveitis.⁷ Syphilis can affect any structure of the eye with posterior uveitis as the main feature presenting with vitritis, vasculitis, chorioretinitis, neuroretinitis and papillitis. The clinical course is rapidly progressive, more extensive with HIV co-infection and tends to be bilateral in presentation.⁸

Hypopyon is not characteristically seen in these patients. ASPPC is a relatively rare ocular manifestation of syphilis and is bilateral in 60% of cases.⁹ Unilateral ASPPC with hypopyon as the presenting feature of ocular syphilis, leading to diagnosis of HIV has not been described till now. Chorio-retinitis in ASPPC with hypopyon suggested other possible differential diagnosis including Behcet’s disease, which was ruled out by a negative HLA-B5 test.

ASPPC may result from direct spirochaetal invasion or as a consequence of indirect immune-mediated hypersensitivity.¹⁰

As syphilis is the underlying cause of uveitis in c.16% of all cases and HIV is found in approximately 30% pf syphilitic patients, all uveitis patients diagnosed with syphilis should be compulsory tested for HIV and vice versa.^8,10

Our case emphasises that the ‘great imitator’ can present with unusual features especially in settings of undetected HIV.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ashok Kumar

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