Page 7 - Mecklenburg_Medicine_April-2016

Feature

Wily Old Pathogen Up to
New Tricks: Ocular Syphilis

By Laura H. Bachmann, MD, MPH, Wake Forest Baptist Medical Center

and Stephen R. Keener, MD, MPH, Mecklenburg County Health Department
S yphilis is an ancient disease that was thought to be
near elimination in the early 2000s. Unfortunately, in order to determine if
the recently released 2014 CDC STD Surveillance strain differences or
other unidentified

Report makes it abundantly clear that syphilis — and co-factors are responsible

other sexually transmitted diseases (STDs), such as gonorrhea for the more severe

and chlamydia — continue to present real threats to American presentations documented

society (www.cdc.gov/std/stats14/toc.htm). Specifically, primary recently (www.

In addition to the and secondary syphilis cdc.gov/std/syphilis/
(known as infectious clinicaladvisoryos2015.htm).

concerns about syphilis) rates for 2014 are An ocular syphilis case is
the highest since 1994 (6.3 defined as “a person with clinical
increased syphilis rates,
the CDC recently issued cases/100,000 population) symptoms or signs consistent with ocular
a clinical advisory with North Carolina disease, with syphilis of any stage.” Clinical recommendations from
ranked as the ninth highest the CDC include:
incidence state in the • Clinicians should be aware of ocular syphilis and screen for
country in 2014. After visual complaints in any patient at risk for syphilis (MSM,

regarding the emergence declines in Mecklenburg HIV-infected persons, others with risk factors and persons with
County from a high of 188 multiple or anonymous partners).
of ocular syphilis. cases in 2006 to 91 cases • All patients with syphilis should receive an HIV test if status is
in 2008, cases of primary, unknown or previously HIV-negative.

secondary and early latent • Patients with positive syphilis serology and early syphilis

syphilis increased to 269 in 2014. In the first nine months of 2015, without ocular symptoms should receive a careful neurological

217 new cases were reported. As if the numbers are not sobering exam including all cranial nerves.

enough, an additional trend bears notice. • Patients with syphilis and ocular complaints should receive

In addition to the concerns about increased syphilis rates, the immediate ophthalmologic evaluation.

CDC recently issued a clinical advisory regarding • A lumbar puncture with cerebrospinal fluid (CSF) examination should

the emergence of ocular syphilis. Between be performed in patients with syphilis and ocular complaints.

December 2014 and March 2015, 12 • Ocular syphilis should be managed according to CDC

cases of ocular syphilis were reported treatment recommendations for neurosyphilis

from San Francisco and Seattle. (www.cdc.gov/std/tg2015/).

Subsequent case finding discovered • Cases of ocular syphilis should be reported to your

more than 150 cases reported from state or local health department within 24 hours of

20 states during the last two years. diagnosis. Ocular syphilis cases diagnosed since

Most cases have occurred among December 1, 2014 should be reported through your

HIV-infected men who have sex local or state health department to CDC by email at

with men (MSM), with several ocularsyphilis2015@cdc.gov.

cases resulting in long-term vision • If possible, pre-antibiotic clinical samples (whole

problems, including blindness. Ocular blood, primary lesions and moist secondary lesions, CSF

syphilis is a clinical manifestation of or ocular fluid) should be saved and stored at -80°C for

neurosyphilis and can involve almost any molecular typing.

eye structure. Posterior uveitis and panuveitis For more information, or to report cases of syphilis (including

are the most common findings, with additional manifestations ocular syphilis) in Mecklenburg County, call 704-336-3349 or

including anterior uveitis, optic neuropathy, retinal vasculitis and 704-614-2993. Clinical information about syphilis and other STDs

interstitial keratitis. The cases resulting in blindness have led to can be obtained through the National Network of STD Prevention

increased concern, and the situation is actively being investigated Training Center Consultation Line (www.stdccn.org).

Mecklenburg Medicine • April 2016 | 7