Secondary Syphilis with Suspected Retinitis Syphilis in HIV-infected

Patient: A Case Report

Haken Tennizar Toena, Qamariah, Devi Artami Susetiati, Agnes Sri Siswati, Satiti Retno Pudjiati

Department of Dermatovenereology, University of Gadjah Mada, Yogyakarta, Indonesia

Keywords: secondary syphilis, retinitis, ocular syphilis, syphilis HIV

Abstract: Secondary syphilis is a systemic vasculitis which caused by a high level of Treponema pallidum in a blood

and immunologic response. In HIV-infected patient, the course of syphilis could change, usually with more

severe lesions and complications. One of the complication is an ocular manifestation, which usually

happened at secondary and late stage of syphilis. We present a case of a 18-year old Human

Immunodeficiency Virus (HIV)-infected male, presented to Sexually Transmitted Disease Department with

1-month history of redness and scaly skin in both of palms, soles, and scrotum. He also complained about 3-

weeks of progressive deterioration of both of his eyesight and a visual field abnormality especially in the

left eye. Serology test showed results of TPHA + and VDRL 1/64. The patient was given Benzatin

Pennicilin 2,4 million IU injection and was referred to ophtalmologist department, which assesed his eye

complaint as a retinitis syphilis because there’s an inflammation in the left retina.

1 INTRODUCTION

An increase in the incidence of syphilis has been

reported across the world over the last decade. After

the marked decline in syphilis infection rates in the

1980s with the HIV/AIDS epidemic raising safe-sex

awareness, the recent increase is thought to be

primarily due to higher risk sexual behaviour,

particularly among men who have sex with men

(Hughes et al., 2010).

Moreover, syphilis has a variable clinical

presentation, as it can affect many organ systems of

the human body including the skin, heart, blood

vessels, bones, nervous system, and the eye

(Indriatmi, 2017; James and Berger, 2016).

Manifestations of ocular syphilis itself are also

diverse. Patients may complain of eye pain, vision

loss, floaters, flashing lights, eye pressure, or

photophobia. Syphilis has been documented to affect

almost every structure of the eye and may affect the

eye at both in the early and late stages of syphilis in

both HIV-uninfected and HIV-infected patients

(Dutta et al., 2017).

Syphilitic retinitis generally responds well to

intravenous penicillin leading to favorable visual

outcome, thus a high clinical suspicion and

recognition of syphilitic retinitis in HIV-infected

individuals followed by prompt initiation of

treatment are crucial for clinicians even in the

absence of objective evidence of syphilis (Shinha

and Weaver, 2016). Herein we report a case of

suspected syphilitic retinitis in a patient with

secondary syphilis and HIV-positive.

2 CASE

An 18-year-old male, a private employee, came to

the STI clinic in Sardjito General Hospital at July

2017 with a chief complaint of a reddish scaly spots

on the palms, soles, and his scrotum since the last 2

weeks, which is not itchy, nor does it painful. This

complaints was started in his palms, then spread to

the soles and scrotum. When asked about a history

of genital ulcer, he denied it. He also complaint

about visual impairment in both of his eyes since 1

month ago. This deterioration was progressive, he

can only see a light with his left eye, his right eye

still could see clearly but with a slight visual

impairment.

This patient was already diagnosed with HIV-

positive since November 2015, but never received

antiretroviral therapy since then. He previously

experienced similar complaints of reddish and scaly

patches in both of his palms and soles in March

Toena, H., Qamariah, ., Susetiati, D., Siswati, A. and Pudjiati, S.

Secondary Syphilis with Suspected Retinitis Syphilis in HIV-infected Patient: A Case Report.

DOI: 10.5220/0008159704610464

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 461-464

ISBN: 978-989-758-494-7

461

2016, was referred to STI clinic in Sardjito General

Hospital, and in there he was diagnosed as

Secondary Syphilis. He didn’t admit that he was

HIV-positive at that time to the doctor in STI clinic.

Benzatin Pennicilin G 2,4 million IU was injected

intramuscularly, and since then, he never came back

for serologic testing after the treatment.

The patient was a consumer of sex worker and

already had a sexual intercourse with more than 4

female sex workers. He also had sexual intercourse

with 1 male partner, usually become the receptive

one. The last time he had intercourse was about 1

year ago with sex worker, after being infected with

HIV.

From the physical examination, the patient was

fully alert and generally in a great condition. On

both of the palms and soles, as well as the scrotum,

there was a defined border erythematous plaque,

with a white scale on the surface of the lesion. Our

differential diagnosis was secondary syphilis,

palmolpantar psoriasis, and tinea manus and pedis.

Skin scraping examination with potassium

hydroxide showed no fungal element. Serologic test

for syphilis was done with results of VDRL 1/64

and TPHA +. Based on clinical and laboratory

examinations, the patient was diagnosed as a

secondary syphilis. The patient was administered

with an injection of Benzathine of Penicillin 2.4

million IU.

After the treatment was given, the patient felt the

reddish plaques improve. Plaques on the scrotum

disappeared, and the lesions on both of the palms

and soles have faded. However the patient

complained of blurred vision in both of his eyes, so

we refer the patient to the ophtalmology department.

Based from examination with ophtalmoscope, there

was an inflammation in the left retina and a keratitis

in the right cornea. Visus for both of his eye were

6/18 for the right eye, and 1/300 for the left one. He

was assesed as retinitis syphilis, with a differential

diagnosis of retinitis CMV, because laboratory

examination showed results of increased level of

IgG Anti CMV (28 UA/mL), but with a normal level

of IgM Anti CMV (0,1 UA/mL). He was given

erythromycin eye drop for his right eye, but no

treatment for the left one. The patient was also

complaining about headache, so we refer the patient

to neurology department and to get CSF

examination. In neurology department, MRI was

done with normal results, but they didn’t do a

lumbal puncture examination. The patient was

assessed as Tension Headache and was given

NSAID to relieve his headache.

3 DISCUSSION

In this report, we described a case of secondary

syphilis with suspected retinitis due to syphilis in a

patient with AIDS. Retinal involvement due to

syphilis has been described in individuals with

advanced HIV infection (Shinha and Weaver, 2016;

Matsuo et al., 2017; Wells et al., 2017; Maves et al.,

2008; Doris et al., 2006). Our case posed a

diagnostic challenge since the fundoscopic findings

were also suspicious for viral retinitis, particularly

CMV. CMV retinitis is characterized by dense

retinal whitening, which can vary in appearance

from “fluffy” to “dry and granular.” Hemorrhage is

frequently present, but in highly variable amounts,

and may be absent (Heiden et al., 2007). In our case,

ophthalmologist department only mention about

inflammation and dilated vessel in the left retina.

Retinitis CMV doesn’t need to be checked for

laboratory examinations, the diagnosis could be

made just from clinical presentation which is typical

(Heiden et al., 2007). Based from the examination

results from the ophthalmologist, we still can’t draw

out a conclusion about the retinitis, is it due to

syphilis or CMV.

Though ocular syphilis is typically thought to

occur in the secondary or tertiary stages of syphilis,

it can occur at any stage. Panuveitis is the most

common complication associated with ocular

syphilis; however, it can affect nearly all ocular

structures. Patients may present with eye pain, vision

loss, floaters or photophobia. The diagnosis of

ocular syphilis includes serologic evidence of

syphilis and clinical symptoms or signs consistent

with ocular disease, but there are almost no eye

findings that are absolutely specific for syphilis. As

ocular syphilis may be associated with

neurosyphilis, a lumbar puncture should be

performed (Powell and Carbo, 2017). The United

States Center for Disease Control and Prevention

recommends performing a lumbar puncture to

evaluate for neurosyphilis in all individuals with

ocular syphilis.

Examination of the CSF is mandatory in patients

with syphilitic optic neuritis to confirm the diagnosis

of neurosyphilis and subsequently to plan treatment.

Major indications of performing a lumbar puncture

in patients with ocular syphilis are: 1) syphilis with

neurological involvement, 2) re-treatment of patients

with a relapse, 3) before treatment with a non-

penicillin regimen, and 4) infants with congenital

syphilis (Dutta et al., 2017). In our case, lumbar

puncture wasn’t performed by neurology

department. This is a weakness in our report,

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

462

because if the VDRL from the cerebrospinal fluid

was positive, we can make a definitive diagnosis of

ocular syphilis. Up to 70% of patients with ocular

syphilis will have evidence of neurosyphilis in

lumbar puncture (Herbort, 2011). Neurosyphilis was

one of the manifestation of tertiary stage of syphilis,

when T. pallidum invade central nervous system. It

usually happened in the interval of 5 – 12 years after

primary infection (Indriatmi, 2017). We should

suspected neurosyphilis when the patient had a

symptoms of headache, neck stiffnes, memory loss,

weakness of extremity, and personality disorder. Our

patient complained about a headache. From MRI

scan, none of any problem was found.

In HIV-infected individuals with syphilis,

atypical clinical manifestations are not uncommon.

More severe clinical manifestations, lack of response

to penicillin therapy and inappropriate antibody

responses, have been described in the literature. The

ocular manifestations of syphilis are diverse since it

can involve any anatomical structures of the eye. In

a study of 22 cases of ocular syphilis in HIV

negative individuals, non-granulomatous anterior

uveitis was the most common presentation (18/22)

Figure 1: Red patches on both of palms.

Figure 3: Red Patches on right sole.

(Wells et al., 2017). Although anterior uveitis is

common in immunocompetent individuals, posterior

segment involvement has been described more

commonly in HIV-infected individuals with

advanced stages of immunosuppression. Ocular

syphilis may be complicated by central nervous

system involvement, thus investigation for

neurosyphilis should be considered especially for

patients with AIDS. Another study reported a high

proportion of neurosyphilis in HIV-infected patients

with syphilitic uveitis; 7 of 9 patients (77.8%)

demonstrated CSF abnormalities (Herbort, 2011).

Even with no evidence of neurosyphilis, syphilitic

retinitis should be treated with the same regimen for

neurosyphilis; a 10–14 day course of intravenous

penicillin is recommended. Syphilitic retinitis

generally responds well to penicillin therapy with

good visual outcome (Dutta et al., 2017). Another

weakness in our report was this patient wasn’t given

any treatment for his retinitis. If it was caused by

syphilis, we should give the treatment as the same as

neurosyphilis, i.e. intravenous aqueous crystalline

penicillin G 18–24 million units per day for 10 to 14

days (Dutta et al., 2017).

Figure 2: red patches on left sole.

Figure 4: Red Patches on scrotum.

Secondary Syphilis with Suspected Retinitis Syphilis in HIV-infected Patient: A Case Report

463

4 CONCLUSION

We report a case of HIV-infected male with

secondary syphilis lesions in both of palms and

soles, and the scrotum. The lesions improved after

being given Benzatin Pennicilin G 2,4 million IU

intramuscularly. Complaints of visual disturbance,

especially in the left eye, was assesed as retinitis

syphilis by ophtalmologist department. It’s

important for a clinician to suspected ocular syphilis

in a syphilis patient with visual complaint, as ocular

syphilis could be happened in any syphilis stadium.

REFERENCES

Doris, J. P., Saha, K., Jones, N. P., & Sukthankar, A.,

2006. Ocular syphilis: the new epidemic. Eye, 20(6),

703-705.

Dutta Majumder, P., Chen, E. J., Shah, J., Ching Wen Ho,

D., Biswas, J., See Yin, L., ... & Agrawal, R., 2017.

Ocular Syphilis: An Update. Ocular immunology and

inflammation, 1-9, Available from:

https://doi.org/10.1080/09273948.2017.1371765..

Heiden, D., Ford, N., Wilson, D., Rodriguez, W. R.,

Margolis, T., Janssens, B., ... & Sabapathy, K., 2007.

Cytomegalovirus retinitis: the neglected disease of the

AIDS pandemic. PLoS medicine, 4(12), 1845–1851.

Herbort, C.P., 2011. Ocular Syphilis. Retina Inflammation

Eye Disease, 1–7.

Hughes, E. H., Guzowski, M., Simunovic, M. P., Hunyor,

A. P., & McCluskey, P., 2010. Syphilitic retinitis and

uveitis in HIV‐positive adults. Clinical &

experimental ophthalmology, 38(9), pp. 851-856.

Indriatmi, W., 2017. Infeksi Menular Seksual dengan

Penyebab Bakteri - Sifilis. In: Infeksi Menular

Seksual. 5th ed. Jakarta: Fakultas Kedokteran

Universitas Indonesia, p. 103–29.

James, W.D., Berger, T.G. E.D., 2016. Syphilis, Yaws,

Bejel, and Pinta. In: Andrew’s Diseases of the Skin :

Clinical Dermatology. 18th ed. Philadelphia: Elsevier

Inc. p. 18–44.

Matsuo, T., Mori, N., Furukawa, K., & Furukawa, K.,

2017. Ocular involvement with secondary syphilis in a

non-HIV infected man. IDCases, 10, 30-31, Available

from:

http://linkinghub.elsevier.com/retrieve/pii/S22142509

17301257..

Maves, R. C., Cachay, E. R., Young, M. A., & Fierer, J.,

2008. Secondary syphilis with ocular manifestations in

older adults. Clinical Infectious Diseases, 46(12),

e142-e145, Available from:

http://www.ncbi.nlm.nih.gov/pubmed/18462103..

Powell, C. A., & Carbo, A. R., 2018. The Great Imitator:

Visual Changes in a 37-Year-Old Man with HIV. The

American journal of medicine, 131(1), e19-e20,

Available from:

http://linkinghub.elsevier.com/retrieve/pii/S00029343

17308112..

Shinha, T., & Weaver, B. A., 2016. Necrotizing retinitis

due to syphilis in a patient with AIDS. IDCases, 6, 17-

19, Available from:

http://dx.doi.org/10.1016/j.idcr.2016.08.005..

Wells, J., Wood, C., Sukthankar, A., & Jones, N. P., 2018.

Ocular syphilis: the re-establishment of an old

disease. Eye, 32(1), 99, Available from:

http://www.nature.com/doifinder/10.1038/eye.2017.15

Zambon, F., Silva, F. L. N., Cavalcante, A. F. D. S.,

Nakashima, Y., & Helal Jr, J., 2010. Syphilitic retinitis

and panuveitis simulating acute retinal necrosis: case

report. Arquivos brasileiros de oftalmologia, 73(3),

pp. 288-290.

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

464