Background: Co-infection with HIV has been known to accelerate the natural course of syphilis and alter its clinical presentation. Ocular syphilis is a rare manifestation of syphilis and has had an estimated incidence of 0.6% in HIV positive patients (pts) in the pre HAART era. From October 2001 to October 2002, we have observed a surprisingly high incidence of ocular syphilis in HIV⁺ patients receiving HAART at our clinic.

Methods: Retrospective chart and pt data base review.

Results: In the post HAART era since 1997–2002, 350 pts in our clinic were screened for syphilis; 111 were screened from 2001–2002. A total of 11.4% of pts (40/350) were diagnosed with syphilis. During the past year, 13.5% of pts (15/111) were diagnosed with syphilis of which 40% (6/15) had neurosyphilis and 20% (3/15) had ocular syphilis. In the post HAART era, we estimate the prevalence of ocular syphilis to be 7.5% (3/40). All of the pts with ocular syphilis were male homosexuals with a mean age of 42 yrs, mean CD₄ of 495 cells/mm³ (range 388–594 cells/mm³), and were receiving HAART with well-controlled plasma viremia. The mean CD₄ was 476 cells/mm³ for pts with syphilis without ocular involvement over the past year. Presenting symptoms included blurred vision, loss of vision, central scotomas, and bilateral ocular involvement. The date of diagnosis from onset of symptoms ranged from 2 wks to 24 wks. The most common ocular manifestation of syphilis was posterior chamber uveitis; one pt also had a retinal detachment. Serum RPR ranging from 1:64–1:256 and FTA-ABS were reactive in all 3 pts. All pts demonstrated a cerebrospinal fluid pleocytosis and elevated total protein. Two (2) of the 3 had a positive CSF VDRL. They each received a 21-day course of penicillin G 24 million units IV daily with improvement of visual symptoms.

Conclusion: Our data demonstrates an unexpectedly high incidence of ocular syphilis in our HIV⁺ pts receiving HAART. Syphilitic uveitis may occur as a result of a complex interaction between T. pallidum and immunological recovery associated with HAART. A diagnosis of ocular syphilis should be entertained in any HIV⁺ pt irrespective of the pt’s CD₄ count who presents with visual symptoms.