eMedicine Specialties > Ophthalmology > Infectious Disease
Ocular Manifestations of Syphilis: Differential Diagnoses & Workup
Updated: Dec 26, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Other Problems to Be Considered
Iritis
Chorioretinitis
Retinal vasculitis
Papillitis
Iris papules
Neurosyphilis
Genital warts
Condyloma acuminata
Lymphogranuloma venereum
Chancroid
Traumatic superinfected lesions
Carcinoma
Mycotic infection
Granuloma inguinale
Lichen planus
Fungal infection
Venereal chlamydial infections
Drug eruptions
Pityriasis rosea
Viral exanthem
Workup
Laboratory Studies
- Serologic nontreponemal tests include Venereal Disease Research Laboratory (VDRL) and rapid plasma reagin (RPR).
- Nontreponemal tests detect antibodies directed against cardiolipin (lecithin) cholesterol antigens.
- It is simple and convenient for routine screening at the local level. It is a frequent local requirement for premarital and prenatal serology. The false-positive rate for pregnant women is 1-2%.
- A minimum of 1-3 weeks must pass from the onset of infection for the test to turn positive. It usually is positive in primary syphilis and invariably positive in secondary syphilis.
- A high titer (>1:16) usually indicates active disease. Biologic false-positive tests (usually <1:8) occur in intravenous drug users, in many acute infections (eg, infectious mononucleosis, mycoplasmal infection, malaria, leprosy), in a variety of chronic disorders (eg, systemic lupus erythematosus), and possibly pregnancy.
- Quantification of VDRL always should be performed before onset of treatment.
- Nontreponemal test titers should decrease by 4-fold within 3 months of adequate treatment of primary or secondary disease, and they should decrease by 8-fold within 6 months following therapy for early latent disease.
- The cerebrospinal fluid (CSF) titer also should diminish with adequate therapy for neurosyphilis; however, the serum nontreponemal test titer may not change in patients with late latent syphilis.
- The VDRL titer reflects the systemic activity of the disease. Its major value is in monitoring the response to treatment.
- A persistent fall in VDRL titers after treatment provides essential evidence of an adequate response to therapy.
- Reactive and weakly reactive tests should be confirmed with fluorescent treponemal antibody absorption (FTA-ABS).
- Serologic treponemal tests include micro-hemagglutination T pallidum (MHA-TP), FTA-ABS, T pallidum particle agglutination (TPA).
- Their greatest value is in distinguishing false-positive from true-positive reagin test results and in diagnosing late syphilis when blood and CSF reagin test results may be negative.
- These are highly sensitive and specific tests.
- Titers are not correlated with clinical activity.
- The FTA-ABS test is not useful in monitoring response to therapy because it typically remains positive for life.
- The FTA-ABS test is 98% sensitive, even in latent syphilis.
- FTA-ABS test and TPA test are preferred over MHA-TP.
Other Tests
- Dark-field immunofluorescence microscopy (direct technique)
- Fluorescein-labeled anti-T pallidum antibodies are used in an immunofluorescence analysis of exudate or samples are taken from a lesion suggestive of syphilis.
- The antibody attaches to syphilitic organisms displaying a motile apple-green, corkscrew-shaped T pallidum.
- Electron microscopy: T pallidum organisms can be seen in interstitial and perivascular spaces.
- Ganzfeld electroretinogram (ERG)
- Ganzfeld ERG was markedly reduced in a case of acute syphilitic posterior placoid chorioretinitis.
- Multifocal ERG in the affected area was not recordable.
- Indocyanine green (ICG) angiography
- ICG angiography may be a valuable tool in the assessment of patients with active ocular syphilis.
- ICG angiography can help identify retinal and choroidal vascular anomalies that would otherwise go undetected by funduscopy and/or fluorescein angiography.
- ICG angiography can also be useful in monitoring antitreponemal therapy.
- The following 2 types of anomalies were observed:
- Late-phase scattered hyperfluorescent spots
- Persistent staining of retinal vessels
Procedures
- Lumbar puncture
- Evaluation for asymptomatic neurosyphilis
- Patients with positive syphilitic serologic tests should have their CSF examined for VDRL titers, total protein, and cell counts, including a differential count.
- An elevated WBC count with a predominance of lymphocytes in the CSF or an elevated total protein level, even without a positive CSF VDRL test, is indicative of neurologic involvement, and the patient should be treated accordingly, as for neurosyphilis.
- HIV evaluation
- Patients with ocular syphilis should be evaluated for HIV and vice versa.
- Reports indicate that young adult patients who are HIV positive often have ocular syphilis.
- Patients who have HIV may experience an aggressive course of syphilis, rendering standard therapy for primary and secondary syphilis inadequate.
- Polymerase chain reaction
- Diagnostic role in unusual or atypical ocular inflammation
- Aqueous or vitreous specimens
Histologic Findings
The organisms usually are superficial in epithelial lesions. A diffuse or focal lymphocytic infiltration is characteristic, particularly perivascularly. The tissue reaction is notable for stenosing intimal fibroplasia of small arteries and arterioles (eg, onion-skinning, obliterative endarteritis), as well as perivascular plasma infiltrate with some lymphocytes and macrophages. It may be found in the iris, ciliary body, or choroid. Chronic granulomatous inflammation containing epithelioid histiocytes and multinucleated giant cells is present. Overlying epidermal changes in skin can be hyperplastic (eg, condylomata lata) or ulcerating (eg, chancre). In tertiary disease, gummas are present (ie, areas of coagulative necrosis surrounded by lymphocytes, plasma cells, and possibly giant cells), and organisms are more abundant. Warthin-Starry silver stain, a specialized direct staining technique, sometimes is used.
More on Ocular Manifestations of Syphilis |
| Overview: Ocular Manifestations of Syphilis |
 Differential Diagnoses & Workup: Ocular Manifestations of Syphilis |
| Treatment & Medication: Ocular Manifestations of Syphilis |
| Follow-up: Ocular Manifestations of Syphilis |
| Multimedia: Ocular Manifestations of Syphilis |
| References |
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Further Reading
Keywords
ocular syphilis, interstitial keratitis, episcleritis, scleritis, iritis, iris papules, chorioretinitis, papillitis, retinal vasculitis, exudative retinal detachment, primary syphilis, secondary syphilis, latent syphilis, tertiary syphilis, quaternary syphilis, Treponema pallidum, T pallidum, lues, chancre, gumma, sexually transmitted disease, STD, HIV, AIDS
