This 39YO HIV positive male presented with 5 days of bilateral decreased vision. Vision was 20/100 OD and 20/200 OS.
Optos color RG imaging shows bilateral whitish macular and peripapillary placoid lesions extending nasal to the nerves. Fundus autofluorescence (FAF) more dramatically shows these hyper-FAF placoid lesions, which resemble a butterfly in his left eye. OCT scanning shows variable loss of the outer retinal bands associated with hyperreflective deposits above the RPE.
VDRL was positive, and he was referred to his social security unit for systemic treatment. Seven weeks later, following two weeks of parenteral penicillin, vision improved to 20/20 OD and 20/20-2 OS, with improved funduscopic and OCT findings.
Learning Points:
Ocular manifestations of syphilis vary widely and include virtually all variations of anterior and posterior segment inflammation. Originally described by Gass (Ophthalmology 1990;97:1288-1297), placoid chorioretinitis is one of the more common presentations.
Inflammation is localized to the outer retina and RPE and appears on OCT as disruption of the outer retinal bands and hyperreflective pyramidal lesions as seen in our patient (Hu et al, Ophthalmology Retina 2022;6:172-178). The outer retinal damage unmasks the underlying RPE, accounting for the hyperfluorescent placoid lesions.
