hiv - infected individuals are at increased risk of developing a wide variety of ophthalmologic opportunistic infections with advanced degrees of immunosuppression .
retinitis or acute retinal necrosis ( arn ) is commonly caused by various viruses , such as cmv , hsv and vzv , in patients with aids , , , .
other non - viral etiologies of retinitis or arn also include toxoplasmosis , lymphoma and syphilis , , .
although syphilis can involve any anatomical structures of the eye , anterior uveitis is the most common presentation in immunocompetent hosts .
importantly , however , posterior segment involvement has been more commonly described in patients with aids .
for example , seronegative secondary syphilis has been reported in hiv - infected patients , , , .
reported a case of secondary syphilis in an hiv - infected man with kaposi sarcoma .
serology testing of syphilis was repeatedly nonreactive which necessitated biopsy of a skin lesion for diagnosis .
non - treponemal tests may also be negative in hiv - infected patients with ocular syphilis .
syphilitic retinitis generally responds well to intravenous penicillin leading to favorable visual outcome , thus a high clinical suspicion and recognition of syphilitic retinitis in hiv - infected individuals followed by prompt initiation of treatment are crucial for clinicians even in the absence of objective evidence of syphilis .
a 39-year - old african american female with a history of aids was in her usual state of health until 5  days prior to presentation when she developed sudden onset of loss of vision .
she was diagnosed with hiv infection 2 months prior to presentation and she was not yet on highly active antiretroviral therapy ( haart ) .
two days later , she also developed decreased vision with blurriness in the right eye .
she denied eye pain , conjunctival redness , and flashes of light or floaters in her visual fields .
her past medical history was also significant for gonorrhea and syphilis diagnosed 13 years before .
the temperature was 98.2  f , blood pressure 111/65  mm hg , pulse 95 beats per minute , respirations 16 breaths per minute and oxygen saturation 95% on room air .
a 0.5  cm ulcerative lesion with irregular edges was noted in the genital area posterior to the anus .
the ophthalmologic examination revealed visual acuity of hand motion in right eye and light perception in the left .
the pupil size was 2.5  mm in the right eye and 4.5  mm in the left .
fundoscopy showed vitritis and extensive white - yellow retinal lesions , compatible with necrotizing retinitis .
laboratory studies revealed a white blood cell count of 4800  cells / mm , hemoglobin of 12.3  g / dl , and platelets of 157,000  cells / mm .
the cd4 count was 29 cells/l and the hiv viral load was 3,100,000 copies / ml . based on the fundoscopic examination demonstrating necrotizing retinitis , a presumptive diagnosis of cmv retinitis was made and the patient was started on intravenous ganciclovir . on the third day after admission ,
based on the patient s past medical history of syphilis and positive treponema antibody ( tp - pa ) on admission , the patient was started on intravenous penicillin for suspected syphilitic retinitis , though serum rpr was negative .
subsequently , the patient underwent lumbar puncture ; csf was colorless with wbc 8  cells / mm , protein 69  mg / dl and glucose 34  mg / dl .
the patient demonstrated dramatic improvement of her vision and fundoscopic examination of both eyes . at the time of completion of 10  days of penicillin therapy , her visual acuity was 20/30 in the right eye and 20/50 in the left .
in this report , we described a case of necrotizing retinitis due to syphilis in a patient with aids . retinal involvement due to syphilis has been described in individuals with advanced hiv infection , , , .
our case posed a diagnostic challenge since the fundoscopic findings were suspicious for viral retinitis , particularly cmv .
although the patient has a remote history of presumably treated syphilis , rpr was non - reactive at the time of admission .
in fact , the patient was initially treated with ganciclovir for a presumptive diagnosis of cmv retinitis . after various viral pcr assays obtained from the anterior chamber aspiration returned negative ,
the decision was made to initiate penicillin which resulted in dramatic clinical improvement . in hiv - infected individuals with syphilis ,
more severe clinical manifestations , lack of response to penicillin therapy and inappropriate antibody responses , have been described in the literature .
non - treponemal tests may be negative in hiv - infected patients with ocular syphilis .
our patient demonstrated inadequate serology responses to rpr due to her immunosuppressed status with advanced stages of hiv - infection .
conversely , polyclonal gammopathy and possible coexistent anticardiolipin antibodies in the presence of hiv may make non - treponemal tests be falsely positive .
in addition , a failure to decrease serologic titers of syphilis in the absence of immune reconstitution with antiretroviral therapy has been reported . considering the uncertainty regarding syphilis serology testing in hiv - infected individuals , clinical judgment with a low threshold for
the ocular manifestations of syphilis are diverse since it can involve any anatomical structures of the eye . in a study of 22 cases of ocular syphilis in hiv - negative individuals ,
although anterior uveitis is common in immunocompetent individuals , posterior segment involvement has been described more commonly in hiv - infected individuals with advanced stages of immunosuppression . in a retrospective study of ocular syphilis in hiv - infected patients ,
tran et al . investigated ocular manifestations due to syphilis for 20 eyes in 12 hiv - infected individuals ; necrotizing retinitis was noted in 7 eyes ( 35% ) , posterior chorioretinitis in 6 eyes ( 30% ) and optic nerve involvement in 5 eyes ( 25% ) . in addition , syphilitic retinitis is more commonly seen in hiv - infected individuals with more advanced stages of immunosuppression . in a study of 101 hiv - infected patients ,
posterior uveitis was significantly more common in those with cd4 count < 200 cells / mm ( p  =  0.002 ) .
ocular syphilis may be complicated by central nervous system involvement , thus investigation for neurosyphilis should be considered especially for patients with aids . in a study of neurosyphilis during the aids epidemic in san francisco ,
another study reported a high proportion of neurosyphilis in hiv - infected patients with syphilitic uveitis ; 7 of 9 patients ( 77.8% ) demonstrated csf abnormalities .
even with no evidence of neurosyphilis , syphilitic retinitis should be treated with the same regimen for neurosyphilis ; a 1014  day course of intravenous penicillin is recommended .
although ophthalmologic manifestations of syphilis are diverse , posterior segment involvement is common in hiv - infected individuals with more advanced stages of immunosuppression .
lack of appropriate clinical responses to ganciclovir for presumed viral retinitis , negative pcr analysis for viral retinitis , remote history of syphilis led us to initiate penicillin therapy empirically with excellent visual outcome .
recognition of syphilitic retinitis in patients with aids is paramount for clinicians and a threshold to initiate penicillin should be lower even in the absence of objective evidence of syphilis .
 the ocular manifestations of syphilis are varied . 
 ocular syphilis can occur during any stage of infection and involve virtually any part of the eye . in immunocompetent individuals , 
 the most common etiologies include syphilitic uveitis . 
 although the clinical presentation of ocular syphilis in hiv - infected patients is also widespread , posterior segment involvement has been more commonly described particularly in patients with aids . 
 the diagnosis of syphilitic retinitis is challenging since its clinical presentation mimics retinitis caused by other viral etiologies . 
 in addition , hiv - infected individuals with syphilis are more likely to develop aberrant serologic responses . 
 recognition of syphilitic retinitis and prompt initiation of penicillin therapy is of critical importance since syphilitic retinitis generally responds well to treatment and loss of vision is reversible . in this report , we describe a 39-year - old female with advanced stages of aids who developed necrotizing retinitis due to syphilis . 
 prompt initiation of intravenous penicillin led to excellent visual outcome for this patient despite significantly decreased visual acuity on presentation . 
Introduction
Case presentation
Discussion
Conclusions