| OCR Text |
Show Journal of Cli" ical Neuro- ophthalmology 12( 3): 171- 172, 1992. Neuroretinitis Due to Seronegative Syphilis Associated with Human Immunodeficiency Virus Lawrence S, Halperin, M. D. © 1992 Raven Press, Ltd., New York Syphilis serologic testing is felt to be extremely reliable. A case of syphilitic neuroretinitis is reported where serologic testing was negative due to human immunodeficiency virus infection. A prompt response to high- dose intravenous penicillin was achieved. Key Words: Neuroretinitis- Seronegative syphilisHuman immunodeficiency virus. Dr. Halperin is in private practice in Fort Lauderdale and Boca Raton, Florida, U. S. A. Address correspondence and reprint requests to Dr. Lawrence S. Halperin, 5601 North Dixie Highway, Suite 307, Fort Lauderdale, FL 33334, U. S. A. CASE REPORT A 31- year- old bisexual man presented with 3 days of painless, severe, bilateral visual loss. Conjunctivitis developed 5 days earlier, and 2 days earlier he had bilateral visual loss. He had a history of treated gonorrhea, and he may have had contact with syphilis but had a negative serology. Vision was RE counting fingers, LE 20/ 200. Pupils were sluggish. He had moderate, bilateral conjunctivitis, a quiet anterior chamber, and no keratic precipitates. Moderate vitritis was present in both eyes. Fundus examination showed bilateral, severe optic nerve swelling with flame hemorrhages and peripapillary serous elevation of the retina. A stellate pattern of hard exudate was present in the macula ( Fig. 1). He had cervical lymphadenopathy. 171 FIG. 1. Photograph of right eye demonstrating disk edema, peripapillary hemorrhages, and serous elevation of the macula with hard exudate. Vision was count fingers. 172 L. S. HALPERIN FIG. 2. Photograph of right eye showing decrease of disk edema and hemo~ rhages. The elevation of the macula IS gone and the amount of hard exudate has increased. Vision was 20/ 30. A complete blood count was normal, except for a hemoglobin of 13.2. Serum chemistries, chest x- ray, and computed tomography scan of the head and orbits were within normal limits. A VORL and fluorescent treponemaI antibody absorption ( FTAABS) were nonreactive. A serum IgG antibody titer for the varicella zoster virus was slightly elevated. Cerebrospinal fluid evaluation revealed one lymphocyte, a protein of 62 ( elevated), a glucose of 70 ( elevated), and a nonreactive VORL. Human immunodeficiency virus enzyme- linked immunosorbent assay ( ELISA) and Western blot were both positive. Lyme titers were negative. The patient was started on 2 million units of intravenous penicillin every 4 hours for a presumptive diagnosis of syphilis. In 3 days, vision was RE 20/ 40, LE 20/ 40. The optic disk edema and serous retinal elevation had decreased. The amount of hard exudate increased as the fluid was absorbing ( Fig. 2). After 14 days of penicillin, 18 million units a day, vision was 20/ 30 in both eyes and the clinical examination markedly improved. DISCUSSION This patient was started on high- dose intravenous penicillin on the clinical suspicion that syphilis was the cause of the optic nerve and ocular inflammation. The patient was monitored carefully for a clinical response to penicillin, and, if the visual acuity had not improved in 2 to 3 days, other diagnoses and treatments would have been considered. Syphilis is a well- known cause of optic neuritis and visual loss. A stellate pattern of exudate centered on the foveola with disk edema has been described ( 1). There have been several reports concerning syphilis and acquired immunodeficiency syndrome ( 2- 4). All of these cases had positive serologic testing of the serum and/ or cerebrospinal fluid. Most responded extremely well to highdose, intravenous penicillin. This case is unique in that all serologies were negative. Haas et a1. ( 5) found that 7% of patients asymptomatic and 38% symptomatic for human immunodeficiency virus ( HIV positive) became seronegative to syphilis testing. Hicks et a1. ( 6) reported one patient with human immunodeficiency virus infection, who required skin biopsy to demonstrate spirochetes, as all serologic tests were repeatedly negative ( 6). REFERENCES 1. Fewell AG. Unilateral neuroretinitis of syphilitic origin with a striate figure at the macula. ArcIJ OplJlIJalmol 1932; 8: 615. 2. Zambrano W, Perez GM, Smith JL. Acute syphilitic blindness in AIDS. JClin Neuro- oplJlhalmoI1987; 7: 1. 3. CarterJB, Hamill RJ, Matoba AY. Bilateral syphilitic optic neuntis In a patient with a positive test for HIV. Arch OpIJtlzalmoI1987; 105: 1485. 4. Winward KE, Hamed LM, Glaser JS. The spectrum of optic nerve disease In human immunodeficiency virus infection. Am J OpIJtIJalmoI1989; 107: 373. 5. Haas JS, Bolan G, Larsen SA, et al. Sensitivity of treponemal tests for detecting pnor treated syphilis during human ImmunodefiCiency VirUS infection. JInfect Dis 1990; 162: 862. 6. HICks CB, Benson PM, Lupton GP, et al. Seronegative secondary syphilis In a patient infected with the human immunodeficiency virus with Kaposi sarcoma. Ann Intern Med 1987; 107: 492. |
