CASE REPORT

Bali Medical Journal (Bali Med J) 2020, Volume 9, Number 1: 208-210

P-ISSN.2089-1180, E-ISSN.2302-2914

Late latent syphilis accompanied by ocular syphilis

in a geriatric patient: A case report
Published by DiscoverSys CrossMark
Ni Made Dwi Puspawati,* Anak Agung Gede Putra Wiraguna,
I Gusti Agung Ayu Elis Indira, Ida Ayu Diah Purnama Sari

ABSTRACT

Background: Syphilis is an infectious disease caused by Treponema worse since 4 days ago. The laboratory results of complete blood
pallidum and is transmitted primarily through sexual intercourse. routine, renal function tests, liver function tests, blood sugar levels are
However, late latent syphilis accompanied by ocular syphilis in geriatric within normal limits. The titer result of VDRL was 1:16 and TPHA was
patients is quite seldom. This study aims to determine a case report 1: 160. Based on anamnesis, physical and laboratory examination, the
regarding late latent syphilis accompanied by ocular syphilis in a patient was diagnosed with late latent syphilis and ocular syphilis. The
geriatric patient. patient was given three weekly interval dose of Benzathine Penicillin G
Case Description: A 75 years old man, was consulted from the 2.4 million international units intramuscularly.
Ophthalmology Department to the Dermatology and Venereology Conclusion: One-month follow-up after the treatment, the patient’s
Department with suspect syphilis. Patient came with a chief complaint condition improved. Blurred vision in the right eye was reduced. There
of blurred vision in the right eye since 2 weeks ago, which is getting are no complaints of headache and hearing loss.

Keywords: late latent syphilis, ocular, geriatric

Cite This Article: Puspawati, N.M.D., Wiraguna, A.A.G.P., Indira, I.G.A.A.E., Sari, I.A.D.P. 2020. Late latent syphilis accompanied by ocular syphilis
in a geriatric patient: A case report. Bali Medical Journal 9(1): 208-210. DOI:10.15562/bmj.v9i1.1645

Dermatology and Venereology INTRODUCTION diagnosis and management of late latent syphilis
Department, Faculty of Medicine, accompanied by ocular syphilis in the elderly.
Universitas Udayana, Sanglah Syphilis is an infectious disease caused by
General Hospital, Bali, Indonesia Treponema pallidum and is transmitted primar-
CASE DESCRIPTION
ily through sexual intercourse; thus, it is more
common in the sexually active age group. Syphilis A 75 years old man, was consulted from the
is a chronic disease and can infect almost any organ Ophthalmology Department to the Dermatology
of the body, including the eyes.1,2 and Venereology Department with suspect syphi-
Ocular syphilis is a rare manifestation of syph- lis. Patient came with a chief complaint of blurred
ilis in the eye, which varies in clinical symptoms vision in the right eye since 2 weeks ago, which
including red eye, blurred vision, and blindness.3 is getting worse since 4 days ago. The patient
The incidence of ocular syphilis could affect the currently has no lesions on his skin or genitalia.
population in a different age. However, based on The patient brought the results of the Venereal
the previous study, the high frequency of ocular Disease Research Laboratory (VDRL) examination
syphilis occurred in the immunocompromised and reactive examination of Treponema Pallidum
patient like elderly.3 Haemagglutination Assay (TPHA).
Elderly is an age group in humans who have The patient denied the history of presence
entered the final stages of their life phase. According wound on his genitalia. He also never complaints
to the World Health Organization (WHO), an reddish rash on the body, palms and soles of the
*
Correspondence to: elderly person is someone who has more than 60 feet. Besides, the patient also never complaints
Ni Made Dwi Puspawati; years old of age.4 Data from the Centers for Disease headache and hair loss. History of other sexually
Dermatology and Venereology
Department, Faculty of Medicine,
Control, and Prevention shows that sexually trans- transmitted disease or history of systemic disease
Universitas Udayana, Sanglah mitted diseases also increase in the elderly group. were denied.
General Hospital, Bali, Indonesia More than two million cases of chlamydia, gonor- The patient already got treatment from the
dwi.puspawati@yahoo.com rhoea, and syphilis occur in this group with an Ophthalmology clinic at Sanglah Hospital 1 week
average age of sufferers from 55 to 64 years.5 ago due to complaints of blurred vision. The
Received: 2019-10-27
One case of late latent syphilis will be reported Ophthalmology Department diagnose patient with
Accepted: 2020-03-24 accompanied by ocular syphilis in an elderly person. anterior ocular uveitis et causa suspect syphilis.
Published: 2020-04-01 This case was reported to increase knowledge of the The patient was given prednisolone acetate eye

208 Open access: www.balimedicaljournal.org and ojs.unud.ac.id/index.php/bmj

 CASE REPORT

drops every 6 hours, Cendo Lyteers every 4 hours, The patient was consulted to the Neurology
and atropine every 8 hours on the right ocular. Department and no clinical manifestation was
After the VDRL and TPHA examination, the found to neurosyphilis. The patient also asked to the
patient consulted to Dermatology and Venereology Voluntary Counseling and Testing (VCT) of Sanglah
Department. Hospital for screening Human Immunodeficiency
Patient work as a driver and also as a guide using Virus (HIV) and obtained non-reactive results.
private car since he was 30 years old. The patient One-month follow-up after the treatment, the
had multiple sexual partners since he was teenag- patient’s condition improved. Blurred vision in the
ers. Patient's sexual orientation is heterosexual. right eye was reduced. There are no complaints of
Other than his wife, the patient also has sexual headache and hearing loss. There was a decrease of
intercourse with women sex workers. Sexual inter- VDRL titer to 1: 8.
course is urogenital and genito-genitally without
using condom. The last sexual intercourse was with
DISCUSSION
his wife 13 years ago and with a female sex worker
about 3 years ago. History of tattoos, smoking, Syphilis is a sexually transmitted infection with a
alcohol, narcotics, psychotropic, other addictive chronic course. Stage of syphilis is divided into early
substances consumption was denied. syphilis and latent syphilis. Early syphilis occurs
Physical examination showed that the patient's within 1 year after primary infection, consist of
general condition is good and compos mentis. primary syphilis, secondary syphilis and early latent
Present and general status are within normal syphilis. Latent syphilis occurs after 1 year from
limits. Dermatology and venereology status, no the appearance of primary lesions, consist of late
skin lesions were found from all over the body latent syphilis and tertiary syphilis which includes
(Figure 1A-E) and also no lesions were found in the neurosyphilis triad, cardiovascular syphilis and late
external genitalia mucous (Figure 1G-G). benign syphilis or gummatous syphilis.1,2
The laboratory results of complete blood By definition, a person diagnosed with latent
routine, renal function tests, liver function tests, syphilis when serological examination for reactive
blood sugar levels are within normal limits. The syphilis (high titers on nontreponemal and trepo-
titer result of VDRL was 1:16 and TPHA was 1: 160. nema serological tests), has never been treated and
Based on anamnesis, physical and laboratory exam- shows no clinical manifestations.1 According to the
ination the patient was diagnosed with late latent Centers for Disease Control and Prevention (CDC),
syphilis and ocular syphilis. The patient was given latent syphilis is divided into an early and late latent
three weekly interval dose of Benzathine Penicillin infection, which is 1 year after infection occurs.
G 2.4  million international units intramuscularly. Patients who get infection 1 year after the initial
There is no Jarisch-Herxeimer reaction after treat- lesion are categorized as early latent syphilis while
ment. For further observation, the patient was those who get more than 1 year infection or if the
scheduled for VDRL titer observation at 1, 3, 6, 12 duration of infection is unknown are categorized
and 24 months. as late latent syphilis. The importance of distin-
guishing early latent and late latent because late
latent infection requires a more extended period
of treatment and people with early latent syphilis
are considered more likely to transmit the disease
through sexual contact.1,2,5
In this case, the patient had a history of
multi-partner sexual and never used condom.
The last sexual intercourse was 3 years ago with a
female sex worker. The patient was never aware of
the history of the wound on his genitalia. From the
physical examination found no clinical manifesta-
tions of syphilis but serological test for syphilis was
reactive with VDRL titer 1: 16 and TPHA titer 1:
160; so the patient was diagnosed with late latent
syphilis.
Recent years have reported an increased inci-
dence of ocular syphilis in developing countries.
Figure 1 No skin lesions were found from all over the body such as (A) head; Ocular syphilis manifestation can be varied and
(B) Chest; (C) Back; (D) Hand; (E): Feet; (F-G) Genitalia external also can occur at all stages of syphilis, including late

Published by DiscoverSys | Bali Med J 2020; 9(1): 208-210 | doi: 10.15562/bmj.v9i1.1645 209
CASE REPORT

latent syphilis. Syphilis can affect all eye compo- difference in the diagnosis and management of
nents including intra-ocular components such syphilis in the elderly or the productive age group.
as the uvea.6 There are two types of uveitis due to One thing to be kept in mind and emphasized is
syphilis; first, anterior uveitis which is an unspeci- that as long as a person is still sexually active, the
fied type but most often occurs in syphilis patients risk of sexually transmitted infection remains, so
with ocular involvement. Second, posterior uveitis old age is not a reason for the elderly not too aware
which can be accompanied by vitritis, focal retini- their safety in sexual intercourse.
tis, chorioretinitis, retinal bleeding, papillitis, neuro
retinitis and vascular occlusion.6,7
CONFLICT OF INTEREST
Ocular syphilis patients generally present with a
chief complaint of blurred vision and can be accom- There is no competing interest regarding the
panied by nonspecific symptoms such as red-eye, manuscript.
eye pain, and no response to steroid therapy. Ocular
syphilis can be the only clinical manifestation of
FUNDING
syphilis. Failure to make a diagnosis and delay in
treatment lead to possible transmission of infec- None.
tion, poor visual prognosis (blindness) and neuro-
logical deficits resulting in neurosyphilis. Syphilis
AUTHOR CONTRIBUTION
serological tests should be performed especially
if ocular inflammation has an unusual character- All of the authors are equally contributed to the
istic of severe inflammation. After the diagnosis study from finding particular cases, data gathering
is established, all patients with ocular syphilis are and reporting the results of the study.
recommended for a lumbar puncture to detect
neurosyphilis.3,6,7
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This work is licensed under a Creative Commons Attribution

CONCLUSION
We reported a case of late latent syphilis accompa-
nied by ocular syphilis in the elderly. There is no

210 Published by DiscoverSys | Bali Med J 2020; 9(1): 208-210 | doi: 10.15562/bmj.v9i1.1645