What is the treatment for uveitis due to syphilis?

Treatment of Uveitis Due to Syphilis

Syphilitic uveitis should be treated with the neurosyphilis regimen of aqueous crystalline penicillin G 18-24 million units per day, administered as 3-4 million units IV every 4 hours or by continuous infusion, for 10-14 days. 1

Diagnostic Approach

Before initiating treatment, the following steps should be taken:

1. CSF examination - Required for all patients with syphilitic eye disease to identify abnormalities and establish baseline for follow-up 1
2. HIV testing - All patients with syphilis should be tested for HIV 1
3. Ophthalmology consultation - Patients with eye disease should be managed in collaboration with an ophthalmologist 1

Treatment Regimens

First-Line Treatment

• Aqueous crystalline penicillin G 18-24 million units per day, administered as 3-4 million units IV every 4 hours or by continuous infusion, for 10-14 days 1

Alternative Regimen (if compliance can be ensured)

• Procaine penicillin 2.4 million units IM once daily PLUS
• Probenecid 500 mg orally four times a day, both for 10-14 days 1

Additional Treatment Considerations

• After completion of neurosyphilis treatment, benzathine penicillin 2.4 million units IM once per week for up to 3 weeks can be considered to provide a comparable total duration of therapy to that used for late syphilis 1

Penicillin Allergy Management

For patients with penicillin allergy:

1. Skin testing should be performed to confirm penicillin allergy (if available)
2. Desensitization should be performed in consultation with a specialist if allergy is confirmed
3. Ceftriaxone 2 g daily either IM or IV for 10-14 days can be used as an alternative, though cross-reactivity with penicillin exists 1

Follow-Up Protocol

1. If CSF pleocytosis was present initially, repeat CSF examination every 6 months until the cell count is normal 1
2. Follow-up CSF examinations can also evaluate changes in CSF-VDRL or CSF protein after therapy
3. Consider retreatment if:
   • Cell count has not decreased after 6 months
   • CSF cell count or protein is not normal after 2 years 1

Special Considerations

HIV Co-infection

• HIV-positive patients should be treated with the same regimens as HIV-negative patients 1, 2
• HIV-positive patients may present with more bilateral lesions but can still have favorable outcomes with appropriate treatment 3, 2

Monitoring for Treatment Response

• The leukocyte count in CSF is a sensitive measure of treatment effectiveness 1
• In immunocompetent persons and HIV-infected persons on HAART, normalization of serum RPR titer predicts normalization of CSF parameters 1

Common Pitfalls to Avoid

1. Delayed diagnosis - Consider syphilis in all patients with uveitis, even without obvious risk factors 3, 4
2. Inadequate CSF examination - Always perform CSF analysis in patients with ocular syphilis 1
3. Incomplete treatment - Full course of recommended therapy is essential for cure and prevention of relapse 2
4. Inadequate follow-up - Regular monitoring of CSF parameters is necessary to ensure treatment success 1
5. Missing HIV co-infection - Always test for HIV in patients with syphilis 1

Prompt diagnosis and appropriate treatment are paramount for preventing permanent visual impairment, as syphilitic uveitis generally responds well to early intervention with penicillin therapy 3, 5.