HIV-infected man with acute visual impairment and panuveitis due to syphilis despite initially negative RPR

We read the article by Marx et al.¹ with great interest. We recently admitted a 71-year old man with well-controlled HIV on highly active antiretroviral therapy (324 CD4 cell/mm³ and HIV viral load of <20 copies/mm³) who presented with four months of worsening bilateral blurry vision. Patient reported unprotected sexual encounters with a number of male partners.

On this initial presentation to clinic, he was able to count fingers with the right eye and had 20/63 visual acuity on the left. A retinologist was consulted and diagnosed panuveitis of the right eye and potential acute retinal necrosis on the left. Because of concern for CMV and herpesvirus infection, he was initially treated with oral valcyclovir and intravitreal gancyclovir since he had positive IgM titers to varicella-zoster virus and herpes simplex viruses 1&2. There was modest improvement in his vision. Syphilis anti-treponemal antibody testing was positive, RPR was non-reactive. Urine nucleic acid amplification testing for both gonnorrhea and chlamydia were negative.

Despite 1 month of treatment with anti-virals, the patient’s vision did not improve further, and he presented to us with a one-week history of new bilateral palmar and scrotal rash without lymphadenopathy and a 10 lb weight loss. His repeat RPR was reactive with a titer of 1:2048. The previous non-reactive RPR was retrospectively attributed to a prozone effect. A lumbar puncture was not performed as the patient was on chronic coumadin anticoagulation for a mechanical aortic valve replacement and his INR was >3.0.

He was treated with intravenous penicillin G for two weeks and one week of prednisone with an additional dose of intramuscular penicillin benzathine 2.4 million units on the last day of his treatment. His treatment was complicated by suspected Jarisch-Herxheimer reaction to his initial dose of penicillin with symptoms of chills, fever, and joint pain. The patient has had nearly full recovery of his vision less than two months after completion of his treatment.