eMedicine Specialties > Ophthalmology > Infectious Disease

Ocular Manifestations of Syphilis: Follow-up

Author: Manolette R Roque, MD, MBA, DPBO, FPAO, President and CEO, Chief of Service, Ocular Immunology and Uveitis, Consulting Staff, Cornea and Refractive Surgery, Eye Republic Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines Co; Consulting Staff, CME Liaison, Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center
Coauthor(s): Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, EYE REPUBLIC Ophthalmology Clinic; C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institute
Contributor Information and Disclosures

Updated: Dec 26, 2007

Follow-up

Further Inpatient Care

  • Following treatment, monitor titers for evidence of response or treatment failure. A 4-fold decrease in antibody titers should be evident. The decline in antibody titers is slower in late latent and neurosyphilis.

Further Outpatient Care

  • Repeat serum and CSF VDRL titers to monitor adequacy of treatment.
  • Clinical manifestations often improve after effective treatment.
  • Seroconversion or stable low titers of nontreponemal tests also indicate effective treatment.
  • A 4-fold and 8-fold decrease in nontreponemal titers should occur in 3 and 6 months, respectively.
  • Patients with neurosyphilis should be monitored with CSF examination every 6 months for decreasing cell count. If there is no decrease in 6 months, or if the cell count does not return to normal in 2 years, retreatment should be considered.

Inpatient & Outpatient Medications

  • After inpatient intravenous treatment, 2.4 million U of benzathine penicillin G IM is administered every week for 3 weeks.

Deterrence/Prevention

  • Safe sex practices
  • Condom use

Complications

  • The Jarisch-Herxheimer reaction is the release of endotoxin when a large number of organisms are killed by antibiotics. The Jarisch-Herxheimer reaction is not a dose-related phenomenon; administering a smaller dose is of no value. This reaction occurs about 8 hours after the first injection, usually consisting of mild fever, malaise, and headache and lasting a few hours.
    • Occurs in 50% of patients with primary syphilis
    • Occurs in about 90% of patients with secondary syphilis
    • Rarely seen in quaternary syphilis as a severe reaction
  • Irreversible end-organ damage
  • Paroxysmal cold hemoglobinemia (PCH)
    • PCH is a rare type of autoimmune hemolytic anemia, occurring primarily in children. PCH manifests as massive intravascular hemolysis with anemia and hemoglobinuria, usually of abrupt onset in the setting of an infectious disease.
    • Secondary PCH may also occur in association with infections in adults. In the latter half of the 19th century, the most common cause was congenital or tertiary syphilis. A near total disappearance of the recurrent, chronic form of secondary PCH occurred with the ability to treat syphilis with antibiotics.
  • See also Pathophysiology.

Prognosis

  • Ocular syphilis, if clinically diagnosed and appropriately treated early in its course, usually results in full visual recovery.
    • If syphilitic intraocular inflammation is left untreated, chronic progressive intraocular inflammation may ensue.
    • Inflammation leads to secondary glaucoma, chronic vitritis, retinal necrosis, and optic atrophy.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Misdiagnosis will lead to nontreatment or treatment with the wrong medication, allowing the disease to progress and result in its potentially blinding sequelae.
  • A high index of clinical suspicion is required. Remember that syphilis can mimic almost any intraocular inflammatory condition.

Special Concerns

  • Pregnancy
    • The penicillin treatment regimen is appropriate for syphilis with pregnancy. The potential problem arises when a penicillin-allergy exists. The optimal treatment of pregnant patients is controversial. An alternate therapy is erythromycin.
    • Avoid doxycycline because of its potential adverse effects on both the mother and the fetus.
    • Penicillin skin testing, and, if necessary, desensitization are recommended.
    • Both an OB-GYN and a pediatrics infectious disease specialist should be invited into the management team.
  • Infants/children
    • Treat infants if the mother has untreated syphilis, if the infant has clinical syphilis, if the VDRL or RPR is 4 times that of the mother, or if there is a reactive CSF VDRL test or positive FTA-ABS immunoglobulin M test.
    • Evaluate infants for congenital syphilis when the mother has been treated for syphilis prior to pregnancy.
    • Perform a nontreponemal serologic test on the infant's sera and a CSF test for cells, protein, and VDRL.
    • Perform an antitreponemal testing on the infant and cord or placenta.
    • Perform long bone radiographs and other tests, as clinically indicated.
    • Suspect child abuse and/or molestation in a pediatric patient exhibiting syphilitic lesions.
  • Patients who are infected with HIV
    • Treat syphilis in patients who are infected with HIV aggressively with a course sufficient for neurosyphilis, regardless of the CNS examination.
    • In most patients with HIV infection, serologic tests for syphilis are accurate, although there are reports of false-negative test results and delayed seroconversion.
    • Anecdotal evidence suggests that patients infected with HIV are at an increased risk of developing neurosyphilis and have higher treatment failure rates.
    • Do not standardize the treatment of patients who are infected with HIV.
  • Penicillin allergy
    • This is not a contraindication to penicillin. When challenged with penicillin, most individuals with a history of penicillin allergy do not manifest symptoms, or the symptoms are mild and affect the skin.
    • Treatment guidelines recommend provocative testing and desensitization, if necessary. Penicillin is the preferred treatment of all types of syphilis.
  • Sexual partners
    • Partners of patients who are infected should be evaluated clinically and serologically, and then treated presumptively, if in sexual contact with primary, secondary, or latent syphilis within the preceding 90 days.
    • One third of the patients exposed will contract syphilis in 10-90 days. If the 90-day period has elapsed and the partner is reliable, then treat according to the clinical and serologic evaluation. Presumptive treatment is warranted if follow-up care is in doubt.
 


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

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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

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Contributor Information and Disclosures

Author

Manolette R Roque, MD, MBA, DPBO, FPAO, President and CEO, Chief of Service, Ocular Immunology and Uveitis, Consulting Staff, Cornea and Refractive Surgery, Eye Republic Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines Co; Consulting Staff, CME Liaison, Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center
Manolette R Roque, MD, MBA, DPBO, FPAO is a member of the following medical societies: American Academy of Ophthalmic Executives, American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Administrators, American Uveitis Society, International Ocular Inflammation Society, Philippine Medical Association, Philippine Ocular Inflammation Society, and Philippine Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, EYE REPUBLIC Ophthalmology Clinic
Disclosure: Nothing to disclose.

C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institute
C Stephen Foster, MD, FACS, FACR, FAAO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, Sigma Xi, and Washington State Medical Association
Disclosure: Nothing to disclose.

Medical Editor

John D Sheppard, Jr, MD, MMSc, Associate Professor of Ophthalmology, Microbiology and Immunology, Director for Thomas R Lee Center for Ocular Pharmacology, Director, Uveitis Service, Eastern Virginia School of Medicine; Consulting Staff, Virginia Eye Consultants
John D Sheppard, Jr, MD, MMSc is a member of the following medical societies: American Academy of Ophthalmology, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Contact Lens Association of Ophthalmologists
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

J James Rowsey, MD, Director of Corneal Services, St Luke's Cataract and Laser Institute, Florida
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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