Clinical Advisory: Ocular Syphilis in the United States

Updated March 24, 2016

Between December 2014 and March 2015, 12 cases of ocular syphilis were reported from two major cities, San Francisco and Seattle. Subsequent case finding indicated more than 200 cases reported over the past 2 years from 20 states. The majority of cases have been among HIV-infected MSM; 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.

Ocular syphilis 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. Ocular syphilis can be associated with neurosyphilis. Both ocular syphilis and neurosyphilis can occur at any stage of syphilis, including primary and secondary syphilis. 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 (MSM, HIV-infected persons, others 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 neurological 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)
• 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 to your local or state health department. 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.

Pre-antibiotic clinical samples (whole blood in EDTA tubes, primary lesions and moist secondary lesions, CSF or ocular fluid) should be saved and stored at -80°C immediately upon collection for molecular typing.

If you are a healthcare provider and need advice from CDC regarding the clinical management of ocular syphilis, contact Dr. Kimberly Workowski at 404-639-1898 or kgw2@cdc.gov. If you are planning on collecting clinical specimens for molecular typing and need assistance with the collection procedure or shipment of samples, please contact Dr. Allan Pillay at 404-639-2140 or ajp7@cdc.gov.