Syphilis Retinal Pigment Epitheliitis and Optic Neuritis - After 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. The left fundus showed a blurred disc margin, vitreous debris and cells, and outer retinal yellow spots (white arrows). The fluorescein angiogram showed fluorescein leakage from the optic disc (aqua arrow) and mottled macular RPE hyperfluorescence in a window pattern. After ten days of IV penicillin G 4 million units every 4 hours the visual acuity improved, the symptoms resolved, and the fundus signs resolved. The spots are gone (yellow arrows compared to white arrows) and the optic disc leakage of fluorescein has resolved (orange arrow compared to aqua arrow). All HIV positive patients with retinal inflammatory signs need investigation for syphilis, which is a treatable disease.