Parenteral penicillin G is the preferred treatment for all stages of syphilis (Table 10-1). Although the formulation, dose, route of administration, and duration of therapy vary with the stage of the disease, patients with syphilitic uveitis should be managed as though they have neurosyphilis, regardless of immune status. The current Centers for Disease Control and Prevention (CDC) recommendation for the treatment of neurosyphilis is 18–24 million units (MU) of aqueous crystalline penicillin G per day, administered as 3–4 MU intravenously every 4 hours or as a continuous infusion for 10–14 days. This may be supplemented with intramuscular benzathine penicillin G, 2.4 MU weekly for 3 weeks. Alternatively, neurosyphilis may be treated with 2.4 MU/day of intramuscular procaine penicillin plus probenecid 500 mg 4 times a day, both for 10–14 days or with either intramuscular or intravenous ceftriaxone 2 g daily for 10–14 days.
Table 10-1 Treatment of Syphilis in Adults
The recommended treatment regimen for congenital syphilis in infants during the first months of life is intravenous aqueous crystalline penicillin G, 100,000–150,000 units/kg/day, administered intravenously as 50,000 units/kg/dose every 12 hours during the first 7 days of life and every 8 hours thereafter, for a total of 10 days. Alternatively, procaine penicillin G, 50,000 units/kg/dose, may be administered intramuscularly in a single daily dose for 10 days.
Penicillin remains the first choice for the treatment of neurosyphilis, congenital infection, or disease in pregnant women or patients coinfected with HIV. Patients with penicillin allergy may occasionally require desensitization and then treatment with penicillin. Alternative treatments in penicillin-allergic patients who show no signs of neurosyphilis and who are HIV-seronegative include doxycycline or tetracycline. Ceftriaxone and chloramphenicol have been reported to be effective alternatives in patients with ocular syphilis who are allergic to penicillin.
Patients should be monitored for the development of the Jarisch-Herxheimer reaction, a hypersensitivity response of the host to treponemal antigens that are released in large numbers as spirochetes are killed during the first 24 hours of treatment. Patients present with constitutional symptoms, such as fever, chills, hypotension, tachycardia, and malaise, but they may also experience concomitant worsening of intraocular inflammation that may require local and/or systemic corticosteroids. In most cases, however, supportive care and observation are sufficient.
Topical, periocular, and/or systemic corticosteroids, under appropriate antibiotic cover, may be useful adjuncts for treating the anterior and posterior segment inflammation associated with syphilitic uveitis. According to the CDC, syphilis is designated a nationally “notifiable” disease; thus, appropriate health authorities should be notified according to local regulations. Finally, the sexual contacts of the patient must be identified and treated, as a high percentage of these individuals are at risk for acquiring and transmitting this disease.
Amaratunge BC, Camuglia JE, Hall AJ. Syphilitic uveitis: a review of clinical manifestations and treatment outcomes of syphilitic uveitis in human immunodeficiency virus–positive and negative patients. Clin Exp Ophthalmol. 2010;38(1):68–74.
Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines. Atlanta: US Department of Health and Human Services; 2016. Available at https://www.cdc.gov/std/tg2015/toc.htm. Accessed November 29, 2018.
Eandi CM, Neri P, Adelman RA, Yannuzzi LA, Cunningham ET Jr; International Syphilis Study Group. Acute syphilitic posterior placoid chorioretinitis: report of a case series and comprehensive review of the literature. Retina. 2012;32(9):1915–1941.
Jumper JM, Randhawa S. Imaging syphilis uveitis. Int Ophthalmol Clin. 2012;52(4):121–129.
Excerpted from BCSC 2020-2021 series: Section 9 - Uveitis and Ocular Inflammation. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.