Abstract
Ocular manifestations of syphilis are usually seen in the secondary or tertiary stages of the disease, which is a nonspecific inflammatory response. We report a case of unilateral nodular scleritis in a patient with late latent syphilis, which resolved with intravenous crystalline penicillin for 2 weeks, topical fluorometholone, and tobramycin eye drops for 3 weeks.
Keywords
Introduction
Syphilis, known as the “Great Masquerader,” has the potential to mimic a variety of ocular diseases, most commonly uveitis, but also interstitial keratitis, chorioretinitis, retinitis, retinal vasculitis, and optic and cranial neuropathies. 1 Overall, 2.5–5% of uveitis cases seen in reference centers are caused by syphilis. 2
Case
A 23-year-old female came to us with complaints of pain, redness, and swelling in the right eye of two weeks' duration. One year previously, she had been diagnosed with syphilis in pregnancy, with a high titre Venereal Disease Research Laboratory (VDRL) result. She had received treatment in pregnancy with intramuscular benzathine penicillin 2.4 megaUnits. The pain was associated with mild, non-purulent discharge of one week. The patient was referred to the ophthalmology department. On examination, there was a solitary, solid, injected, non-mobile 5 mm × 6 mm nodule located on the inferotemporal sclera of the right eye (Figure 1). The visual acuity, intraocular pressure, and fundoscopic examination was unremarkable. The left eye examination was normal. Blood investigations were done to rule out other causes of nodular scleritis, including erythrocyte sedimentation rate, —rheumatoid factor, Mantoux test, anti nuclear antibody, angiotensin converting enzyme levels, anti neutrophil cytoplasmic antibody, and VDRL titre. All the tests were negative except for erythrocyte sedimentation rate 40 mm/hr and VDRL positive at a titre of 1:16. Thus, a diagnosis of nodular syphilitic scleritis was made. The patient was evaluated thoroughly for neuro- and cardiovascular syphilis. Cerebrospinal fluid examination, including VDRL, was normal. A two dimensional echocardiogram and a plain chest radiograph were also normal. Hence, the patient was treated with intravenous aqueous crystalline penicillin 24 million units per day for 2 weeks and fluorometholone with tobramycin eye drops for 3 weeks. The patient had complete resolution of symptoms with in 3 weeks (Figure 2). Solitary, solid, injected, 5 mm × 6 mm nodule located on the inferotemporal sclera of the right eye. Complete resolution of the nodule after 3 weeks of treatment.
Discussion
Treponema pallidum can infect various organ systems, including skin, heart, blood vessels, bones, nervous system, and eye, leading to various clinical manifestations. 3 Ocular syphilis is considered a state of tertiary syphilis; hence, a patient with ocular syphilis should be evaluated thoroughly for other components like neurosyphilis and cardiosyphilis. Ocular manifestations include panuveitis, interstitial keratitis, intermediate uveitis, chorioretinitis, retinitis, retinal vasculitis, perineuritis, papillitis, retrobulbar neuritis, optic atrophy, and optic nerve gumma. 4 Syphilis, being the great imitator in the field of medicine and surgery, should always be considered in the differential diagnosis. The differential diagnosis for anterior nodular scleritis includes autoimmune disorders such as rheumatoid arthritis, sarcoidosis, systemic lupus erythematosus, Wegener’s granulomatosis, giant cell arteritis and polyarteritis nodosa, and infectious causes such as tuberculosis and syphilis, plus lymphoma. 5 Syphilis is thought to be responsible for less than 5% of all uveitis cases. Syphilitic scleritis responds minimally to steroids, but one may find a dramatic response to penicillin therapy. Ocular syphilis management consists of 18–24 MU of aqueous crystalline penicillin G per day, administered as 3–4 MU intravenously every 4 h or as continuous infusion for 10–14 days. Alternatively, 2.4 MU of intramuscular procaine penicillin OD along with probenecid 500 mg qid can be administered, both for 10–14 days.
Conclusion
The occurrence of scleritis in syphilis is rare in this antibiotic era. Thus, a high index of suspicion, prompt diagnosis, correct staging of syphilis, appropriate treatment, and long-term follow-up of the patient with VDRL titers are essential to reduce the morbidity caused by this disease.
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.
