There is currently a resurgence of infectious syphilis in the UK (http://www.hpa.co.uk) and the rate remains high in the USA (http://www.cdc.gov/std) and in the Russian Federation states.1 In the past the protean manifestations of syphilis earned it the title of “the great imitator”. The high prevalence of syphilis before, and during, the second world war meant that it always featured highly in the differential diagnosis of any ophthalmic problem. Antibiotic treatment has reduced the prevalence to the extent that it is seldom considered first nowadays.2
The interaction of syphilis and HIV has stimulated renewed interest in this ancient disease and has challenged some of the long held ideas about the investigation and treatment of syphilis.
A case of secondary syphilis is presented in which a sudden loss of vision occurred despite initial treatment with benzathine penicillin and doxycyline with corticosteroid cover. The natural history, investigation, treatment and follow up for neurosyphilis are discussed.
A 44 year old homosexual man presented with a macular rash on his palms and soles, but not elsewhere. He was diagnosed as having secondary syphilis. Serological examination disclosed positive syphilis ELISA IgG/IgM, positive rapid plasma reagin (RPR) (1:32), moderately positive Treponema pallidum particle agglutination assay (TPPA) consistent with recent active treponemal infection. He was also found to have concommittant non-gonococcal, non-chlamydial urethritis. There was no regional lymphadenopathy and examination of the rectum and penis was normal. Neither he, nor his partner, gave a history of injecting drug misuse or previous sexually transmitted infection (STI). In particular he was HIV negative and remained so throughout follow up. Treatment, based on local guidelines, was started with weekly benzathine penicillin 2.4 million units intramuscularly for three weeks and doxycycline 100 mg orally twice daily for one week for the urethritis. He was also given prednisolone 30 mg …
[1]
H. Wilhelm,et al.
Clinical Neuro-Ophthalmology
,
2007
.
[2]
P. C. van Voorst Vader,et al.
European guideline for the management of syphilis
,
2001,
International journal of STD & AIDS.
[3]
O. Cars,et al.
Studies of the killing kinetics of benzylpenicillin, cefuroxime, azithromycin, and sparfloxacin on bacteria in the postantibiotic phase
,
1997,
Antimicrobial agents and chemotherapy.
[4]
H. Ward,et al.
Epidemics of syphilis in the Russian Federation: trends, origins, and priorities for control
,
1997,
The Lancet.
[5]
P. Selwyn,et al.
Effects of HIV Infection on the Serologic Manifestations and Response to Treatment of Syphilis in Intravenous Drug Users
,
1993,
Annals of Internal Medicine.
[6]
C. E. Margo,et al.
Ocular syphilis.
,
1992,
Survey of ophthalmology.
[7]
H. Handsfield,et al.
Invasion of the central nervous system by Treponema pallidum: implications for diagnosis and treatment.
,
1988,
Annals of internal medicine.
[8]
D. Felsenstein,et al.
Alteration in the natural history of neurosyphilis by concurrent infection with the human immunodeficiency virus.
,
1987,
The New England journal of medicine.
[9]
N. Flynn,et al.
Penetration of oral doxycycline into the cerebrospinal fluid of patients with latent or neurosyphilis
,
1985,
Antimicrobial Agents and Chemotherapy.
[10]
N. Miller,et al.
Failure of penicillin G benzathine in the treatment of neurosyphilis.
,
1980,
Archives of internal medicine.
[11]
Ellison Ac,et al.
Ocular penetration of orally administered minocycline.
,
1979
.
[12]
A. Ellison,et al.
Ocular penetration of orally administered minocycline.
,
1979,
Annals of ophthalmology.
[13]
P. Bird,et al.
Neurosyphilis and penicillin levels in cerebrospinal fluid.
,
1976,
JAMA.
[14]
R. M. Smibert,et al.
Inhibition of growth of treponemes by antimicrobial agents.
,
1971,
The British journal of venereal diseases.