Spirochaetal uveitis (including Syphilis)

Syphilis

• Treponema pallidum
• Transmitted sexually or transplacentally (congenital)
• Acquired vs Congenital

Primary (2-6 weeks from infection)

• Painless ulcer (chancre) with regional lymphadenopathy

Secondary (from 8 weeks)

• Maculopapular rash including palms/soles
• Generalised lymphadenopathy, malaise, fever
• Anterior/posterior uveitis: granulomatous or not, multifocal choroiditis/chorioretinitis with yellow plaque-like lesions
• Risk of retinal detachment
• Pigmentary retinopathy long-term

Tertiary (from 5 years)

• Aortitis, aortic regurgitation/dissection

• Meningitis, CNS vasculitis

• Tabes dorsalis and generalised paresis of the insane

• Anterior/posterior uveitis

• Interstitial keratitis

  • May be a manifestation of congenital syphilis, presenting within the first decade
  • Bilateral in 80% when congenital, but unilateral in 60% if acquired
  • Acquired IK typically presents between 3rd and 5th decade

• Argyll-robertson pupils

Tests

• Non-treponemal serology: VDRL

  • Tests disease activity
  • Negative in later stages

• Treponema serology (fluorescent treponemal antibody absorption)

  • Detects previous and current infections
  • Not specific for syphilis

• LP: raised protein, pleocytosis, positive VDRL

• HIV test

Management

• Coordinate with GU physician
• High-dose penicillin eg benzylpenicillin
• Jarisch-herxheimer reaction: spirochaete death causes transiently worse inflammation
• Topical corticosteroids for interstitial keratitis and uveitis
• Systemic steroids in sight-threatening posterior uveitis/scleritis

Borrelia burgdorferi (Lyme disease)

• Another spirochaetal cause of uveitis

• Ocular manifestations by stage of disease

  • Stage 1: follicular conjunctivitis
  • Stage 2: anterior, intermediate, posterior or pan-uveitis
  • Stage 3: keratitis

• Severe intraocular inflammation may indicate CNS involvement