From the Guidelines
The plan for a patient with ocular syphilis and HIV infection, who is currently undetectable on Antiretroviral Therapy (ART), is to treat with benzathine penicillin G as the first-line option.
Treatment Options
- Benzathine penicillin G is the preferred treatment for syphilis, including ocular syphilis, in patients with HIV infection, as stated in the study by Susan Tuddenham and Khalil G. Ghanem 1.
- Doxycycline is an acceptable alternative option for early and late latent syphilis if penicillin cannot be used.
Diagnostic Approach
- In patients with isolated ocular signs and symptoms, reactive syphilis serologic results, and confirmed ocular abnormalities, a diagnostic cerebrospinal fluid (CSF) examination is not necessary, as up to 40% of patients would have no CSF abnormalities 1.
Management Considerations
- Repeated CSF examinations are not necessary for HIV-infected patients on antiretroviral therapy who exhibit appropriate serologic and clinical responses after treatment for neurosyphilis 1.
- The patient's undetectable HIV status on ART suggests that their immune system is well-managed, which is crucial for effective treatment of syphilis.
- The treatment plan should be individualized based on the patient's clinical presentation, serologic response, and HIV status.
From the Research
Plan for a Patient with Ocular Syphilis and HIV Infection
The plan for a patient with ocular syphilis and HIV infection, who is currently undetectable on Antiretroviral Therapy (ART), involves the following steps:
- Diagnosis: A presumptive diagnosis of ocular syphilis relies on serological testing, both treponemal and nontreponemal tests 2.
- Treatment: The Centers for Disease Control and Prevention recommend that ocular syphilis be managed according to its treatment guidelines for neurosyphilis, with parenteral aqueous crystalline penicillin G the drug of choice 2.
- Assessment for Neurosyphilis: All patients with ocular syphilis should have their cerebrospinal fluids tested for the co-existence of neurosyphilis 2.
- HIV Co-infection Testing: All patients with ocular syphilis should have their blood tested for human immunodeficiency virus co-infection 2.
- Monitoring and Follow-up: Patients should be monitored for visual impairment and recurrence of ocular syphilis, with follow-up appointments scheduled as needed 3, 4, 5.
- Importance of Prompt Treatment: Delayed diagnosis and treatment of ocular syphilis can lead to long-term visual impairment and poor prognosis of best-corrected visual acuity (BCVA) 3, 4, 5.
Key Considerations
- CD4 Count and Virological Suppression: The effect of CD4 count and virological suppression on clinical manifestations and diagnostic laboratory values should be evaluated 3.
- Visual Acuity: Changes in visual acuity in HIV-infected patients should prompt an immediate assessment for ocular syphilis, as delays in diagnosis and therapy can lead to irreversible visual loss 5.
- Recurrence: Patients should be monitored for recurrence of ocular syphilis, which can occur even after treatment 5.