Delayed diagnosis of ocular syphilis that manifested as retinal vasculitis and acute posterior multifocal placoid epitheliopathy
A 55-year-old female patient hospitalized with a history of bilateral progressive visual loss for 4 months. Initial work-up done elsewhere revealed all tests including rapid plasma reagin (RPR) were negative. She then, had been treated with the high dose systemic steroids followed by bilateral intravitreal triamcinolone injection, but her eyes continued to deteriorate.\nBest corrected visual acuity (VA) was light perception in both eyes. Biomicrocopy revealed a few inflammatory cells and fundoscopy showed disc edema, multiple yellow placoid lesions and vasculitis in both eyes [Fig. and ]. Fluorescein angiography demonstrated early hypofluorescence and late leakage from the placoid lesions [Fig. and, ]. Indocyanine green angiography was not performed. Optical coherence tomography revealed severe macular intraretina edema in both [Fig. and ] eyes as well as a serous retinal detachment in the right eye [].\nWe repeated serologic tests including viral polymerase chain reaction, toxoplasma antibody, rheumatoid factor, antinuclear antibody, human leukocyte antigen B27, human immunodeficiency virus (HIV) antigen/antibody and fluorescent treponemal antibody-absorption (FTA-ABS). Whereas all other tests were negative, FTA-ABS test was positive. Subsequent tests for cerebrospinal fluid also revealed positivity in FTA-ABS and Venereal Disease Research Laboratory (VDRL). The titer of VDRL was 1:8. While she denied any history of previous systemic diseases, systemic evaluation revealed recent skin rashes on her palms and soles, which appeared to be characteristic signs of secondary syphilis [Fig. and ].\nTaken all together, she was diagnosed as secondary syphilis. After 2 weeks of intravenous penicillin G treatment (4 million units of aqueous penicillin G, 6 times a day), her vision slightly improved to hand motion in the right eye and finger count 30 cm in the left eye. Ocular examination showed a resolution of vasculitis and macular edema in her both eyes.\nDue to the delayed diagnosis, despite the massive intravenous antibiotic treatment, visual recovery was poor. On the last follow-up of 4 months following treatment, her VA was hand motion in the right eye and 0.03 in the left eye. There was no sign of active inflammation, but visual recovery was poor due to optic atrophy [Fig. and ] and macular ischemic thinning [Fig. and ]. While the central retinal thickness was significantly decreased, the subfoveal choroidal thickness seemed to be unaffected when examined with an enhanced depth imaging optical coherence tomography (Spectralis HRA-OCT; Heidelberg Engineering, Heidelberg, Germany) [Fig. and ]. Scotopic electroretinogram showed extinguished wave in both eyes.[]