Rising Ocular Syphilis Rates Merit Rapid Intervention

Laurie Barclay, MD

November 03, 2016

Ocular syphilis cases increased from 2014 to 2015 in most jurisdictions studied, according to a surveillance report published November 4 in the Morbidity and Mortality Weekly Report.

"All patients diagnosed with syphilis that exhibit ocular manifestations should immediately be treated for neurosyphilis and be referred for formal ophthalmologic examination," write Sara E. Oliver, MD, from the Epidemic Intelligence Service, Centers for Disease Control and Prevention (CDC), and colleagues. "[E]ducation of both patients and providers is critical to identify ocular manifestations of syphilis and manage disease sequelae."

The investigators also recommend that all patients with inflammatory eye disease of unknown cause be tested for syphilis, regardless of risk factors. Findings suggesting ocular syphilis, which is an inflammatory eye disease caused by syphilis infection, include eye redness, blurred vision, and vision loss that can progress to blindness if untreated.

US incidence of syphilis has increased since 2000, but changes in the percentage of cases with ocular syphilis was undetermined, in part because ocular manifestations are not reportable to the CDC. Clusters of ocular syphilis in early 2015 in California and Washington suggested an outbreak, leading the CDC to issue a clinical advisory.

Eight jurisdictions (California excluding Los Angeles and San Francisco, Florida, Indiana, Maryland, New York City, North Carolina, Texas, and Washington) subsequently reviewed data from 2014 to 2015, which showed that 0.6% of syphilis cases had findings consistent with ocular syphilis (0.53% in 2014 and 0.65% in 2015). Among the jurisdictions, ocular syphilis percentage ranged from 0.17% to 3.9%.

Ocular Syphilis Can Occur at Any Stage

The increase in cases from 2014 to 2015 in five of seven jurisdictions with data for both years may reflect better detection or an actual increase in the percentage of syphilis cases with ocular involvement. Ocular syphilis was diagnosed among patients in any stage of syphilis; approximately half were in the early stage.

Suspected cases were more likely to be men (93%), particularly men who have sex with men (69%), and half (51%) were HIV-positive. Both HIV-positive and HIV-negative patients developed blindness and other severe complications. To avoid these outcomes, prompt diagnosis, urgent ophthalmologic assessment, and effective treatment are essential.

For neurosyphilis and ocular syphilis, recommended treatment is 18 to 24 million units intravenous aqueous penicillin G, given either daily as a continuous infusion or every 4 hours, for 10 to 14 days.

Uveitis Most Common Diagnosis

Uveitis was the most common specific diagnosis; more serious diagnoses included retinitis, optic neuritis, and retinal detachment. Unilateral or bilateral eye involvement were about equally common.

Characteristics of patients with suspected ocular syphilis included high rapid plasma reagin (RPR) titers (median, 128; range, 1 - 16,384); other symptoms of neurosyphilis, such as headache, neck pain, and altered mental status or hearing (22%); blurred vision (54%), and some degree of vision loss (28%). Cerebrospinal fluid was Venereal Disease Research Laboratory test–positive in 70% of those who had lumbar puncture.

Limitations of the report include varying diagnostic methods and capabilities among jurisdictions, failure to capture patients in whom ocular symptoms were not documented, causes other than syphilis infection for some symptoms, incomplete information in many cases, and lack of data for years before 2014.

"The absence of both a specific strain and epidemiologic links supports a hypothesis that manifestations of ocular syphilis occur in a subset of patients with syphilis infection, possibly influenced by undetermined risk factors," the authors conclude.

The authors have disclosed no relevant financial relationships.

Morb Mortal Wkly Rep. 2016;65:1185-1188. Full text

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