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  • Undiagnosed HIV in Patients With Ocular Syphilis

    By Lynda Seminara
    Selected By: Prem S. Subramanian, MD, PhD
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    Journal Highlights

    British Journal of Ophthalmology
    Published online March 27, 2020

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    The global prevalence of syphilis is growing, and ocular syphilis has reemerged as a key contributor to uveitis. Mathew and Smit evaluated clinical and laboratory traits of ocular syphilis and neurosyphilis in people with and without HIV infection. They found that those with HIV were more likely to be younger, to have bilateral involvement, and to have posterior uveitis and panuveitis. They also found that nearly 25% of patients were unaware of their HIV status when they presented for ocular care.

    This retrospective study included 215 eyes (146 patients) with ocular syphilis treated during a five-year period at Tyger­berg Hospital in South Africa. All patients underwent detailed ophthalmic evaluation at presentation, including a workup to rule out other causes of intraocular inflammation. HIV testing was offered to all patients; for those who tested positively, a CD4+ count was requested along with measurement of HIV viral load. Clinical and laboratory data were collected and included demographics, visual acuity of affected eyes, laterality of inflammation, and findings from serology and cerebrospinal fluid testing.

    According to the diagnostic algorithms used by the research­ers, 43 of the 146 patients had neurosyphilis (16 confirmed, 27 probable). Eight of the 16 confirmed cases also were HIV positive; the proportion was similar among those with probable neurosyphilis (14 of 27).

    HIV coinfection was present in 76 patients overall (52.1%). Median age was lower for HIV-positive patients (p = .02), and more males were affected. Fifty-eight (76.3%) of those with HIV had been diagnosed previously; the remaining 18 (23.7%) were diagnosed at presentation for ocular care. CD4+ counts were available for 63.8% of patients with previously diagnosed HIV; the median value was 411 cells/μL (range, 45-726). Ocular inflammation was nongranulomatous in 192 eyes (89.3%). Eyes of patients with HIV were more likely to have poorer visual acuity.

    Bilateral ocular involvement occurred in 47.3% of patients, 68.1% of whom were HIV positive. The most common intraoc­ular inflammation was posterior uveitis (40.9%), followed by panuveitis (38.1%), both of which were more prevalent among HIV-positive patients.

    According to the authors, their study is the largest of concomitant HIV and ocular syphilis and this imparts some strengths. Some of their findings, such as more severe and bilateral disease in HIV-positive patients, are confirmatory, but others, such as their finding an equal rate of positive syphilis testing in the cerebrospinal fluid of both HIV-positive and HIV-negative patients, refutes data from prior, smaller studies. Overall, the authors emphasized the importance of establishing HIV status for patients with ocular syphilis, especially since many may be unaware of this infection.

    The original article can be found here.