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S. Li, A. Birnbaum, H. Tessler, D. Goldstein; Syphilitic Posterior Uveitis. Invest. Ophthalmol. Vis. Sci. 2010;51(13):5849.
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To review the clinical presentation of syphilitic posterior uveitis at the University of Illinois at Chicago Medical Center (UICMC), to determine the prevalence of HIV co-infection, evaluate the utility of CSF analysis, and determine response to treatment.
We reviewed charts of patients diagnosed by the Uveitis service at UICMC with syphilitic posterior uveitis between 1991 and 2009. Inclusion criteria included a clinical diagnosis of ocular syphilis, active inflammation, posterior segment findings, and positive serologic testing with both RPR and FTA-ABS.
12 patients with syphilitic posterior uveitis were identified, aged 30-67 years. All were male. Seven had a known history of HIV, and 3 were newly diagnosed with HIV due to their presentation with syphilis. One patient was HIV negative and one was not tested. Three of 8 patients with available data had CD4 count < 200 at the time of presentation. 3 patients had a previous history of treated syphilis, and 1 was being treated at the time of his presentation. Presentation varied and included localized infiltrative retinitis, diffuse retinal necrosis, multifocal choroiditis, and panuveitis. Uveitis was bilateral in 10 of 12 patients. Prominent findings included optic disc edema or disc pallor (58%) and vasculitis (50%). Only 1 of 8 tested patients had positive CSF VDRL, and that result was only weakly reactive. 9 patients were treated with IV penicillin for at least 10 days. One patient was treated with IM penicillin, one was treated with IM ceftriaxone, and one who was penicillin allergic refused desensitization and was lost to follow-up. Follow-up was available in 11 of 12 patients, with an average follow-up of 34 months (4 days - 16 years). All treated cases improved and, in many cases, the inflammatory lesions completely resolved without scarring. One patient developed chronic iritis and another developed chronic intermediate uveitis.
HIV infection is common in patients with syphilitic posterior uveitis, and syphilitic retinitis can be a presenting sign of HIV. All patients with retinitis should have work-up for syphilis, and all patients with ocular syphilis should have HIV testing. Patients should be treated regardless of CSF VDRL, as this result is often negative. Outcome of therapy may be excellent, even in patients with HIV.
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