Syphilitic retinitis and uveitis in HIV-positive adults

The incidence of new infection with syphilis is increasing, particularly in men who have sex with men, with HIV co-infection common. There has been a corresponding increase in ophthalmic manifestations that can be varied in presentation. Thirteen consecutive patients with syphilitic uveitis presenting to two ophthalmic departments in Sydney are described. Twelve patients were male, of whom 10 were homosexual and six HIV-positive. Peripheral retinitis with panuveitis was the commonest ophthalmic presentation ( n = 7, 54%), and six cases were initially treated with vitreous tap and intravitreal foscarnet as a precaution in case of viral retinitis. Retinitis was present in six of six (100%) HIV-positive and only one of seven (14%) HIV-negative patients ( χ10.6, P <0.01). Other ophthalmic presentations included anterior uveitis, vitritis, multifocal choroiditis, scleritis and papillitis. All patients responded to 10-14 days' intravenous penicillin with good final visual outcomes (6/12 or better in all eyes). This case series reinforces the importance of considering syphilis in the differential diagnosis of many ocular presentations, but in particular retinitis. Retinitis appears to be the predominant presentation in HIV-infected individuals, suggesting that HIV infection may somehow modulate the disease.