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The many faces of ocular syphilis: case-based update on recognition, diagnosis, and treatment

Published:February 04, 2021DOI:https://doi.org/10.1016/j.jcjo.2021.01.006

      Abstract

      In recent years, syphilis (Treponema pallidum) has become increasingly prevalent in Canada, and as a result, rates of ocular syphilis are also rising. Classically, syphilis was seen primarily in men who have sex with men; now, it is increasingly seen in people of all age groups, sexes, and sexual orientations. We present a series of 26 cases of ocular syphilis from London, Ontario, 5 of which are discussed in detail to illustrate the varied presentations and diagnostic challenges of ocular syphilis. The presentations include uveitis, iris granuloma (gumma), retinitis (acute syphilitic posterior placoid chorioretinitis), vasculitis, optic neuritis, and serous retinal detachment. The 5 cases are mostly middle-aged heterosexual men and women without the typical risk factors that would alert the examiner to suspect syphilis. We emphasize the importance of testing for syphilis when assessing and treating inflammatory eye disease, regardless of demographics and known risk factors, given the increasing prevalence of this disease. Diagnosis of syphilis relies on serologic testing, which is complex and has undergone significant changes from historical reliance on the Venereal Disease Research Laboratory test. We provide an overview of the strategy and rationale for modern serologic testing. The mainstay of treatment remains intravenous penicillin G, with alternative antibiotics (e.g., ceftriaxone) being less effective.
      Depuis quelques années, la prévalence de la syphilis (Treponema pallidum) au Canada ne cesse d'augmenter, au même titre que le taux de syphilis oculaire. Historiquement, la syphilis était surtout diagnostiquée chez les hommes qui avaient des relations sexuelles avec des hommes; de nos jours, les cas de syphilis sont de plus en plus fréquents, sans égard à l’âge, au sexe, ni à l'orientation sexuelle. Le présent article porte sur une série de 26 cas de syphilis oculaire diagnostiqués à London, en Ontario, dont 5 font l'objet d'un examen approfondi afin d'illustrer les présentations diverses et les difficultés diagnostiques propres à la syphilis oculaire. Au nombre de ces présentations, citons l'uvéite, le granulome de l'iris (gomme syphilitique), la rétinite (choriorétinite syphilitique placoïde postérieure aiguë), la vascularite rétinienne, la névrite optique et le décollement rétinien séreux. Ces 5 cas intéressaient pour la plupart des hommes et des femmes hétérosexuels d’âge moyen qui ne présentaient aucun des facteurs de risque typiques associés à la syphilis. Compte tenu de la prévalence croissante de cette infection, nous insistons sur l'importance du dépistage de la syphilis devant un tableau d'affection oculaire inflammatoire, peu importe les caractéristiques démographiques et les facteurs de risque connus du sujet. Le diagnostic de la syphilis est d'ordre sérologique et repose sur des examens complexes qui ont beaucoup évolué depuis l’époque où l'on se fiait au test VDRL (Venereal Disease Research Laboratory). Nous présentons à cet égard un survol de la stratégie et des motifs à l'origine du dépistage sérologique moderne. Comme toujours, le traitement fait essentiellement appel à la pénicilline G par voie intraveineuse. Il est à noter que d'autres antibiotiques (p. ex., la ceftriaxone) sont moins efficaces.
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