Clinical Advisory: Ocular Syphilis in the United States

Clinical Advisory: Ocular Syphilis in the United States

Updated April 3, 2015

Clinical Advisory: Ocular Syphilis in the United States

Since December 2014, at least 15 cases of ocular syphilis from California and Washington have been reported to the U.S. Centers for Disease Control and Prevention. At least five other states have suspected cases under investigation. The majority of cases have been among MSM with HIV; and a few cases have occurred among HIV-uninfected persons including heterosexual men and women. Several of the cases have resulted in significant sequelae including blindness.

Neurosyphilis can occur during any stage of syphilis including primary and secondary syphilis. Ocular syphilis, a clinical manifestation of neurosyphilis, can involve almost any eye structure, but posterior uveitis and panuveitis are the most common. Additional manifestations may include anterior uveitis, optic neuropathy, retinal vasculitis and interstitial keratitis. Ocular syphilis may lead to decreased visual acuity including permanent blindness. While previous research supports evidence of neuropathogenic strains of syphilis, it remains unknown if some Treponema pallidum strains have a greater likelihood of causing ocular infections.

• Clinicians should be aware of ocular syphilis and screen for visual complaints in any patient at risk for syphilis. This includes MSM, HIV-infected persons, persons with risk factors, and persons with multiple or anonymous partners.
• All patients with syphilis should receive an HIV test if status is unknown or previously HIV-negative.
• Patients with positive syphilis serology and early syphilis without ocular symptoms should receive a careful neurologic exam, including all cranial nerves.
• Patients with syphilis and ocular complaints should receive immediate ophthalmologic evaluation.
• A lumbar puncture with cerebrospinal fluid (CSF) examination should be performed in patients with syphilis and ocular complaints.
• Ocular syphilis should be managed according to treatment recommendations for neurosyphilis. Aqueous crystalline penicillin G IV or Procaine penicillin IM with Probenecid for 10-14 days. See the 2010 STD Treatment Guidelines for more information.
• Cases of ocular syphilis should be reported to your state or local health department within 24 hours of diagnosis. Ocular syphilis cases diagnosed since December 1, 2014, should be reported through your local or state health department to CDC by email (address: ocularsyphilis2015@cdc.gov). The case definition for an ocular syphilis case is as follows: a person with clinical symptoms or signs consistent with ocular disease (i.e. uveitis, panuveitis, diminished visual acuity, blindness, optic neuropathy, interstitial keratitis, anterior uveitis, and retinal vasculitis) with syphilis of any stage.
•  If possible pre-antibiotic clinical samples (whole blood, primary lesions and moist secondary lesions, CSF or ocular fluid) should be saved and stored at -80°C for molecular typing.

To receive advice from CDC regarding clinical management of ocular syphilis, or assistance with shipment of clinical samples for molecular typing please contact Dr. Robyn Neblett Fanfair at (404) 639-6044 or iyo5@cdc.gov.

General information about syphilis can be found online at www.cdc.gov/std/syphilis; updates to this clinical advisory will be posted on the Syphilis: Treatment and Care section of the website.