Acute syphilitic necrotizing retinitis associated with placoid chorioretinitis in an immunocompetent patient

PURPOSE: We report an atypical case of combined acute syphilitic necrotizing retinitis and a contiguous acute syphilitic posterior placoid chorioretinitis (ASPPC) in an HIV-negative, immunocompetent patient.

METHOD: Observational case report.

RESULTS: A 56-year-old male presented with a one-week history of pain and blurred vision in the left eye. He also complained of left-sided hearing loss for several months. Ocular examination demonstrated a unilateral panuveitis with a yellowish placoid macular lesion involving the outer retina contiguous with an ovoid area of full-thickness retinitis extending temporally. Vitreal polymerase chain reaction (PCR) analysis for HSV, CMV, VZV and T. gondii were negative but syphilis serology was reported as positive. An MRI of the head revealed bilateral enhancement along the facial nerves, more marked on the left side, consistent with syphilitic involvement. He was treated as neurosyphilis with a 14-day course of systemic procaine penicillin and oral probenecid. Oral prednisolone (1 mg/kg/day) was commenced 24 hours prior to initiating antibiotics to prevent Jarisch-Herxheimer reaction and treat his panuveitis.

CONCLUSION: To our knowledge, this is the first report of combined syphilitic necrotizing retinitis and ASPPC occurring in continuity in the same eye. This case highlights the diversity of possible presentations of ocular syphilis, even in HIV-negative immunocompetent patients.