Elsevier

Journal of Infection

Volume 58, Issue 1, January 2009, Pages 32-36
Journal of Infection

Ocular syphilis – indicator of previously unknown HIV-infection

https://doi.org/10.1016/j.jinf.2008.11.004Get rights and content

Summary

Objectives

To detect the prevalence of HIV-co-infection in patients with ocular syphilis and to compare ocular syphilis in HIV-positive and -negative patients.

Methods

24 consecutive patients treated for ocular syphilis at our hospital between 1998 and 2006 were evaluated retrospectively. Patients' characteristics, laboratory results (including syphilis serology, HIV status, CSF examination), major ophthalmologic finding, treatment and course were assessed. Data of HIV-positive and -negative patients were compared.

Results

Of the 24 patients with ocular syphilis, 11 were co-infected with HIV. Notably, the HIV-infection had previously been unknown in 7 of the 11 HIV-positive patients. 6 of these were in an early disease stage (CDC category A). Clinical and laboratory findings did not differ between HIV-positive and -negative patients except for the C-reactive protein (CRP), which was significantly higher in HIV-infected patients.

Conclusions

Ocular syphilis led to new diagnosis of HIV-infection in an unexpectedly high number of patients, which emphasises that patients with ocular syphilis must be screened for HIV-co-infection. According to our study the expected benefit is high because most of the patients newly diagnosed with HIV had high CD4+ cell counts. These patients can be monitored and treated before the development of AIDS.

Introduction

Syphilis has been recognized as a reemerging disease. Following the all time low incidence in Western Europe and the USA at the turn of the century, a resurgence of syphilis infections has been noticed in these regions, most often in urban areas and among persons at risk for co-infection with HIV.1 In Germany, the overall incidence of syphilis (3.8/100,000 in 2006 with the highest local incidence of 16.8/100,000 in Berlin) is comparable to that reported for the USA (3.3/100,000 in 2006).2, 3 Due to this reemergence, ocular syphilis, previously a rare manifestation of the infection, is increasingly observed.4, 5, 6 Ocular manifestations of syphilis are heterogeneous and difficult to diagnose solely by clinical presentation. They may be the presenting symptom of a previously undetected syphilis infection and can involve any structure of the eye from cornea to optic nerve.7 Prompt diagnosis can prevent permanent disability because early treatment often leads to complete recovery.

Section snippets

Patients and methods

From 1998 to 2006, 24 patients (41 affected eyes) with ocular syphilis were treated at our institution. This is the only university hospital in Berlin and acts as a referral centre. It has 3200 beds, and 127,400 inpatients and 500,000 outpatients were treated here in 2006. Serologic testing for syphilis is part of the workup for unclear ocular symptoms and was conducted at the time of presentation. It led to the diagnosis, which was based on the following criteria:

  • (1)

    inflammatory disease of the

Results

The incidence of ocular syphilis at our hospital between 1998 and 2006 ranged from 0/year (1999) to 6/year (2004 and 2006) with a mean of 2.7 patients/year. The presenting complaints consisted of ocular symptoms in 23 cases and of somnolence and pysychotic symptoms in 1 case. Ocular symptoms were similar throughout: blurred vision, visual loss and ocular discomfort. The duration of the symptoms prior to the date of admission ranged from 5 to 120 days. 8 out of 13 HIV-negative patients (61%) and

Discussion

Contrary to previous reports, our study compared ocular syphilis in HIV-positive vs. HIV-negative patients, and was not limited to a certain age group.10, 11 In our cohort, diagnosis of ocular syphilis led to the detection of a concurrent, previously unknown HIV-infection in 7 out of 20 patients (35%). A survey of studies performed in the USA revealed a median HIV seroprevalence of 15.7% in syphilis patients,12 but numbers of new diagnoses of HIV-infection in patients presenting with syphilis

Acknowledgments

The authors would like to thank Frank Marzinzik (Department of Neurology, Charité Berlin) for recruiting patients for the study; Andrea Stroux (Institute of Biometrics and Clinical Epidemiology, Charité Berlin), Hans-Jörg Epple and Kristina Allers (Department of Medicine I, Charité Berlin) for their assistance with the statistical analysis; and Karin Ehrenberg (Department of Ophthalmology, Charité Berlin) for her help with the images. Rebekka Bode's support in revising the manuscript is

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