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HIV, syphilis coinfection increases risk for ocular syphilis
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Patients coinfected with HIV and syphilis are nearly twice as likely to experience symptoms of ocular syphilis compared with patients without HIV, according to a study in North Carolina.
Since 2014, syphilis cases in the United States have risen, and although the number of syphilis cases with ocular symptoms “remains small,” ocular syphilis reports are increasing as well, according to the study. Writing in Sexually Transmitted Diseases, Anna B. Cope, PhD, MPH, a CDC epidemiologist, and colleagues noted that, internationally, 30% of patients with ocular syphilis are coinfected with HIV, and in the U.S. that figure jumps to 50%.
“In our analysis, approximately 40% of all syphilis patients (early and latent) in North Carolina were also living with HIV,” Cope told Infectious Disease News. “According to the CDC, similar rates of coinfection are present nationally. Coinfection is particularly common among men who have sex with men.”
Cope and colleagues conducted a secondary analysis of all syphilis cases reported to the North Carolina Division of Public Health from 2014 to 2016.
According to the study, there were 7,123 confirmed cases of syphilis, of which 39.9% were living with HIV, 1.5% had ocular syphilis and 0.8% were coinfected with HIV and ocular syphilis. Cope and colleagues reported that all coinfected patients were men and were more likely to be older.
When estimating prevalence ratios, the researchers found that ocular syphilis was more prevalent among patients with syphilis who were also coinfected with HIV compared with patients with a negative or unknown HIV status (prevalence ratio [PR] = 1.8; 95% CI, 1.2-2.6). The researchers also observed that patients with viral loads greater than 200 copies/mL (PR = 1.7; 95% CI, 1-2.8) and a CD4 count of 200 cells/mL (PR = 2.3; 95% CI, 1.3-4.2) or less had a higher prevalence of ocular syphilis compared with other patients with HIV.
The researchers suggested that immunodeficiency related to HIV may increase the risk for ocular syphilis in coinfected patients.
“Among syphilis patients living with HIV, those diagnosed with ocular syphilis had lower CD4 cell counts than patients without ocular symptoms, which suggests that HIV-related immunodeficiency may contribute to the ocular manifestations of syphilis,” Cope said. “Furthermore, many patients with ocular syphilis were diagnosed with HIV and syphilis at the same time, suggesting this population is not receiving routine testing for either syphilis or HIV at earlier stages of their infection.” – by Marley Ghizzone
Disclosures: The authors report no relevant financial disclosures.
Perspective
Back to TopWith increasing rates of syphilis, the incidence of the less common clinical manifestations such as ocular, otic and hepatic is increasing. What do we know about ocular syphilis? It can occur during any stage of syphilis, it can affect any portion of the eye, half the cases are bilateral and only about 70% of cases will demonstrate a cerebrospinal fluid (CSF) abnormality (such as pleocytosis or a reactive venereal disease research laboratory test). Consequently, a normal CSF examination does not rule out the diagnosis of ocular syphilis. Although ocular syphilis and neurosyphilis are distinct entities, overlap exists and both conditions are treated with 10 to 14 days of intravenous antibiotics. The study by Cope and colleagues suggests that patients infected with HIV, especially those with more advanced immunosuppression, are more susceptible to the ocular complications of syphilis. Similar risk factors have been described in neurosyphilis as well, so the ocular association with immunosuppression is not surprising. The study, however, does not prove it. It is possible that patients with more advanced immunosuppression are more likely to be asked about ocular (and neurological) symptoms, leading to an outcome identification bias. The good news is that immunosuppression does not appear to impact outcomes after therapy. Clinicians, however, must be vigilant. All patients who present with evidence of syphilis should be asked about ocular symptoms (eg, vision loss, floaters, eye pain). If a patient endorses these symptoms, physicians should not delay referral to an ophthalmologist because delays have been associated with poor outcomes including permanent blindness.
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