Syphilis Retinal Pigment Epitheliitis and Optic Neuritis - Before Treatment

These are fundus photographs and fluorescein angiogram frames of a 33 year old man with HIV infection and a history of syphilis who complained of 2 weeks of blurred vision and lights in the left eye. His T4 count was 300, his HIV RNA titer was undetectable, and his RPR was positive with a titer of 1:128. His visual acuity was 20/20 right, 20/40 left. There was no uveitis, but the disc margin on the left was blurred slightly and there were tan pigment epithelial flecks on the left (white arrows). The fluorescein angiogram shows leakage of fluorescein from the optic disc (yellow arrow) and granular pigment epithelial hyperfluorescence (orange arrows). He was placed on penicillin G intravenously for 10 days. Retinal manifestations of syphilis constitute neurosyphilis and require continuous intravenous penicillin therapy, not intramuscular injections. See the "After Treatment" image for follow-up on this case.