Subacute loss of vision in one eye • rash on hands and feet • plaques with scaling on genitals • Dx?

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Case Reports

Subacute loss of vision in one eye • rash on hands and feet • plaques with scaling on genitals • Dx?

J Fam Pract. 2017 December;66(12):E9-E11

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References

1. Lynn WA, Lightman S. Syphilis and HIV: a dangerous combination. Lancet Infect Dis. 2004;4:456-466.

2. Butler JN, Throne JE. Current status of HIV infection and ocular disease. Curr Opin Ophthalmol. 2012;23:517-522.

3. Patton ME, Su JR, Nelson R, et al. Primary and secondary syphilis–United States, 2005-2013. MMWR Morb Mortal Wkly Rep. 2014;63:402-406.

4. Woolston S, Cohen SE, Fanfare RN, et al. A cluster of ocular syphilis cases–Seattle, Washington, and San Francisco, California, 2014-2015. MMWR Morb Mortal Wkly Rep. 2015;64:1150-1151.

5. Kirby JS, Goreshi R, Mahoney N. Syphilitic palmoplantar keratoderma and ocular disease: a rare combination in an HIV-positive patient. Cutis. 2009;84:305-310.

6. Shimizu S, Yasui C, Tajima Y, et al. Unusual cutaneous features of syphilis in patients positive for human immunodeficiency virus. Clin Exp Dermatol. 2009;35:169-172.

7. Giovani EM, de Paula Neto ER, Vieira BC, et al. Conventional systemic treatments associated with therapeutic sites of local lesions of secondary syphilis in the oral cavity in patients with AIDS. Indian J Dent Res. 2012;23:670-673.

8. Kunkel J, Schürmann D, Pleyer U, et al. Ocular syphilis–indicator of previously unknown HIV-infection. J Infect. 2009;58:32-36.

9. Kishimoto M, Lee MJ, Mor A, et al. Syphilis mimicking Reiter’s syndrome in an HIV-positive patient. Am J Med Sci. 2006;332:90-92.

10. Jenkins TC, Gardner EM, Thrun MW, et al. Risk-based human immunodeficiency virus (HIV) testing fails to detect the majority of HIV-infected persons in medical care settings. Sex Transm Dis. 2006;33:329-333.

DISCUSSION

After reaching an all-time low in the mid-1990s, several recent reports indicate that the incidence of syphilis is again increasing in North America.^1-3 In the United States, annual incidence rates have increased from 2.1/100,000 in 2000 to 5.3/100,000 in 2013.³ The increase has been most notable in younger men, men who have sex with men (MSM), and those with HIV infection.¹

A 2015 Centers for Disease Control and Prevention advisory highlights an unusual collection of cases of ocular syphilis, predominantly in HIV-infected MSM, from California and Washington.⁴ Disease sequelae in this outbreak have resulted in blindness.

A recent increase of syphilis in the United States has been most notable in younger men, men who have sex with men, and those with HIV infection.

HIV coinfection has been reported in 27.5% of males and 12.4% of females with new diagnoses of syphilis.¹ Patients with HIV are more likely to have asymptomatic primary syphilitic infection, and may have an earlier onset of secondary syphilis and neurosyphilis.^1,5,6 Cutaneous findings such as malignant syphilis (characterized by ulcerating, pustular, or rupioid lesions), as well as other atypical rashes mimicking eczema, leprosy, mycosis fungoides, or keratoderma blenorrhagicum, may all be more common in those with HIV coinfection.⁶ Ageusia or dysgeusia is rare in syphilis, and to our knowledge has only been described with concomitant oral lesions.⁷

MANAGEMENT

Our patient was treated with a continuous daily infusion of 20 million units of penicillin G for 14 days, one drop of 1% ocular prednisolone in each eye 4 times daily for 4 weeks, one drop of 2% cyclopentoate in each eye 2 times daily for 4 weeks, and 60 mg/d of oral prednisone tapered over 3 months. For the HIV infection, he was started on antiretroviral therapy soon after diagnosis.

Patients with HIV are more likely to have asymptomatic primary syphilitic infection, and may have an earlier onset of secondary syphilis and neurosyphilis.

Within 48 hours of initiating penicillin, he reported a marked improvement in vision and regained the ability to taste. After one week of therapy, near resolution of the palmoplantar rash was noted and the patient was discharged on hospital Day 8. At a 3-month follow-up visit, he was asymptomatic, with return of normal sensation. Repeat ophthalmologic examination showed no evidence of disease.

THE TAKEAWAY

This case complements other sporadic reports of symptoms of ocular and cutaneous syphilis serving as the initial presentation of HIV infection.^5,8,9 Risk-factor based screening for HIV often leads to missed diagnoses, and early recognition of this constellation of symptoms may aid in prompt diagnosis and treatment of syphilis and HIV.¹⁰

Subacute loss of vision in one eye • rash on hands and feet • plaques with scaling on genitals • Dx?

References

DISCUSSION

MANAGEMENT

THE TAKEAWAY

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