Bilateral anterior uveitis as a presenting manifestation of sarcoidosis and syphilis

Case report

A previously healthy 34 year old Hispanic woman with a 2 week history of blurred vision was referred for evaluation. The patient had no systemic complaints. On examination her best corrected visual acuity was 20/30 in the right eye and 20/40 in the left. Slit lamp examination showed bilateral findings of moderate (2+) anterior chamber cells and non-granulomatous keratic precipitates (Fig 1). Fundus examination did not show any signs of vascular, retinal, or choroidal disease and a diagnosis of bilateral acute anterior uveitis was made. Treatment with topical prednisolone acetate and cyclopentolate drops resulted in mild improvement. Routine laboratory evaluation including complete blood count (CBC), blood chemistry, urinalysis, PPD, chest x ray, and syphilitic serology were performed. A markedly reactive serum FTA-ABS and low RPR titres (1:2) were obtained. Chest x ray showed bilateral hilar adenopathy and parenchymal infiltration (Fig 2A). HIV serological tests were negative. PPD test were also negative. Cerebrospinal fluid (CSF) examination was abnormal (mononuclear pleocytosis and increased protein concentration) with reactive VDRL. The patient was treated with 12 million units of aqueous penicillin G intravenously daily for 14 days with resolution of the anterior segment inflammation. A chest computed tomograph (CT) confirmed the findings of the chest x ray (Fig 2B). A transbronchial lung biopsy showed non-caseating granulomas (Fig 2C), in which no micro-organisms could be found with Zhiel-Nielsen, PAS, Grocott’s silver, or Wharthin-Starry stains and the diagnosis of sarcoidosis, stage 2 disease, was made. Pulmonary function tests were normal. No treatment was indicated for sarcoidosis because the patient was asymptomatic. The radiological lesions remained unchanged on the control performed after 6 months.

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Figure 1

Acute anterior uveitis in (A) the right eye and (B) the left eye.

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Figure 2

(A) Chest x ray, (B) chest CT. Bilateral hilar adenopathy and bilateral parenchymal infiltrates. (C) Histological section of the transbronchial lung biopsy showing non-caseating granuloma (haematoxylin and eosin, ×50).

Comment

During the past decade, there has been a significant resurgence of syphilis, especially among black and Hispanic patients, and an increased number of patients with ocular syphilis has been reported.^1,2 Syphilitic uveitis has no specific pattern of ocular involvement and, currently, it has been accepted that practically all patients with uveitis should be tested for syphilis. Sarcoidosis is another condition that can imitate any form of ocular inflammation.³ We are unaware of any previous reports of the association of sarcoidosis and syphilis in an asymptomatic patient with uveitis, and could find no reference to it in a computerised search using Medline.

The diagnosis of syphilitic uveitis requires a high index of suspicion and the patient’s clinical picture should be taken into consideration.⁴ The polymerase chain reaction (PCR) assay has been used to detect Treponema pallidum in CSF and serum but has not been used in routine diagnosis.⁵ In this case, syphilis was presumed to be the cause of the ocular inflammation because there was an associated inflammatory pleocytosis in CSF and this structure is embryologically related to the aqueous humour and, additionally, there was a marked improvement in the anterior segment inflammation with the syphilitic treatment. Moreover, the association of both diseases in this patient could be coincidental; however, it might be possible that the anergy induced by sarcoidosis could help the development of syphilis. We suggest a routine investigation in all cases of unexplained ocular inflammation including chest x ray and syphilitic serology to screen for sarcoidosis and syphilis, owing to their great mimicry. Other laboratory tests should be performed following a tailored approach.