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Neurosyphilis with optic neuritis: an update
  1. G T Smith1,
  2. D Goldmeier2,
  3. C Migdal1
  1. 1Western Eye Hospital, London, England
  2. 2Genitourinary Department, St Mary’s Hospital, London, England
  1. Correspondence to:
 MrG T Smith
 Western Eye Hospital, Marylebone Road, London NW1 5QH, England; guytheeye{at}

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There is currently a resurgence of infectious syphilis in the UK ( and the rate remains high in the USA ( and in the Russian Federation states.1 In the past the protean manifestations of syphilis earned it the title of “the great imitator”. The high prevalence of syphilis before, and during, the second world war meant that it always featured highly in the differential diagnosis of any ophthalmic problem. Antibiotic treatment has reduced the prevalence to the extent that it is seldom considered first nowadays.2

The interaction of syphilis and HIV has stimulated renewed interest in this ancient disease and has challenged some of the long held ideas about the investigation and treatment of syphilis.

A case of secondary syphilis is presented in which a sudden loss of vision occurred despite initial treatment with benzathine penicillin and doxycyline with corticosteroid cover. The natural history, investigation, treatment and follow up for neurosyphilis are discussed.


A 44 year old homosexual man presented with a macular rash on his palms and soles, but not elsewhere. He was diagnosed as having secondary syphilis. Serological examination disclosed positive syphilis ELISA IgG/IgM, positive rapid plasma reagin (RPR) (1:32), moderately positive Treponema pallidum particle agglutination assay (TPPA) consistent with recent active treponemal infection. He was also found to have concommittant non-gonococcal, non-chlamydial urethritis. There was no regional lymphadenopathy and examination of the rectum and penis was normal. Neither he, nor his partner, gave a history of injecting drug misuse or previous sexually transmitted infection (STI). In particular he was HIV negative and remained so throughout follow up. Treatment, based on local guidelines, was started with weekly benzathine penicillin 2.4 million units intramuscularly for three weeks and doxycycline 100 mg orally twice daily for one week for the urethritis. He was also given prednisolone 30 mg …

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  • Conflicts of interest: none.