eMedicine Specialties > Ophthalmology > Infectious Disease

Ocular Manifestations of Syphilis: Treatment & Medication

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

Treatment

Medical Care

Patients with ocular syphilis should be treated the same as patients with neurosyphilis.

  • The treatment regimen is the same even without CSF evidence of neurosyphilis. The blood-ocular barrier is similar to the blood-brain barrier in terms of decreasing the penetration of drugs. Patients with syphilitic ocular inflammation may have CNS syphilis without a VDRL-positive CSF.
  • According to the Morbidity and Mortality Weekly Report (MMWR) No. RR-14, which is the most recent guideline for the treatment of syphilis, the treatment of neurosyphilis is as follows:
    • Administer aqueous crystalline penicillin G, 2-4 million U IV q4h for 10-14 days. Alternatively, give procaine penicillin IM qd plus probenecid, 500 mg PO qid both for 10-14 days.
    • In addition to the MMWR treatment guidelines for neurosyphilis, the administration of benzathine penicillin is preferred, 2.4 million U IM for 3 weeks, following either of the regimens to achieve a duration of therapy comparable to that of other forms for late syphilis.

Surgical Care

In cases of interstitial keratitis, rehabilitative interventions include a penetrating keratoplasty.

Consultations

  • Collaboration with an infectious disease specialist is ideal in cases of suggestive of syphilis. A lumbar puncture may be performed to exclude the possibility of neurosyphilis.
  • An allergologist consult may be warranted in cases of penicillin allergy.

Medication

The goal of pharmacotherapy is to eradicate the infection, to prevent complications, and to reduce morbidity.

Parenteral penicillin is DOC for all stages of syphilis. T pallidum is extremely sensitive to penicillin. Since T pallidum resistance to penicillin has not surfaced, the need for alternative drugs in treating syphilis is reserved for penicillin-allergic cases.

Doxycycline, erythromycin, or tetracycline has been suggested for patients allergic to penicillin. Nonpenicillin regimen has been shown to be less effective in the treatment of neurosyphilis; therefore, attempts at penicillin desensitization may be worthwhile.

Antibiotics

Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.


Penicillin G aqueous, benzathine (Pfizerpen, Bicillin LA)

Bactericidal against penicillin-susceptible microorganisms during stage of active multiplication. Inhibits biosynthesis of cell wall mucopeptide, rendering the cell wall osmotically unstable. Not active against penicillinase-producing bacteria, which include many staphylococcal strains.

Adult

2-4 million U of aqueous crystalline penicillin G IV q4h for 10-14 d, followed by 2.4 million U of benzathine penicillin G IM qwk for 3 wk

Pediatric

Dose depends on age and stage of disease; suggested dosages are as follows:
Syphilis <1 year: 50,000 U/kg IM once; not to exceed 2.4 million U
Syphilis > 1 year: 50,000 U/kg IM qwk for 3 doses; not to exceed 2.4 million U

Probenecid can increase penicillin effectiveness by decreasing clearance; coadministration with tetracyclines and other bacteriostatic antibiotics can decrease effectiveness of penicillin

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in impaired renal function and patients with history of significant allergies and/or asthma


Doxycycline (Bio-Tab, Doryx, Vibramycin, Doxy)

Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Adult

100-200 mg/d PO qd or divided bid

Pediatric

<8 years: Not recommended
>8 years: 2-5 mg/kg/d qd or divided bid; not to exceed 200 mg/d

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Documented hypersensitivity; severe hepatic dysfunction

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines


Erythromycin (E.E.S., E-Mycin, Ery-Tab)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.
In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double the dose.

Adult

250 mg erythromycin stearate/base (or 400 mg ethylsuccinate) PO q6h, or 500 mg q12h (1 h ac or 2 h pc)
Alternatively, 333 mg PO q8h; increase to 4 g/d depending on severity of infection

Pediatric

30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6-8h; double dose for severe infection

Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin, increases risk of rhabdomyolysis

Documented hypersensitivity; hepatic impairment

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur


Tetracycline (Sumycin)

Treats gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s).

Adult

250-500 mg PO q6h
Mild-to-moderate infections: 500 mg PO bid or 250 mg PO qid for 7-14 d
Severe infections: 500 mg PO qid for 7-14 d

Pediatric

<8 years: Not recommended
>8 years: 25-50 mg/kg/d (10-20 mg/lb) PO qid

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants

Documented hypersensitivity; severe hepatic dysfunction

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Uricosuric agents

Used primarily to elevate and prolong plasma levels of penicillin.


Probenecid

The generic name is 4-[(dipropylamine-)sulfonyl)]benzoic acid. Inhibits tubular secretion of penicillin, and usually increases penicillin plasma levels by any route the antibiotic is given. A 2-fold to 4-fold elevation has been demonstrated for various penicillins. Used in treatment of hyperuricemia associated with gout and gouty arthritis. Also used as an adjuvant to therapy with penicillin or ampicillin, methicillin, oxacillin, cloxacillin, or nafcillin, for elevation and prolongation of plasma levels by whichever route the antibiotic is given.

Adult

500 mg PO qid 10-14 d

Pediatric

Initial: 25 mg/kg body-weight or 0.7 g/m2 body surface
Maintenance: (next 9-13 d) 40 mg/kg body-weight or 1.2 g/m2 body surface divided qid

Salicylates at high dosages and nitrofurantoin may decrease effects of probenecid; increases levels/toxicity of methotrexate, beta-lactam antibiotics, acyclovir, thiopental, clofibrate, dyphylline, pantothenic acid, ketorolac, benzodiazepines, rifampin, sulfonamide, dapsone, zidovudine, sulfonylureas

Documented hypersensitivity; children <2 years; known blood dyscrasia or uric acid kidney stones; coadministration of ketorolac as levels/toxicity of ketorolac are increased significantly

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Crosses placental barrier; use of any drug in women of childbearing potential requires anticipated benefit be weighed against possible hazards; caution in history of peptic ulcer

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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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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