LAUSR

© BMJ Publishing Group Limited 2021. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION A 59yearold man who has sex with men presented to the emergency department with a 1week history of bilateral central vision loss. Visual acuity (VA) was 6/60 and 6/18 in the left and right eye, respectively. Slitlamp examination revealed mild, bilateral anterior and intermediate uveitis, optic nerve head swelling, placoid lesions at the macula and chorioretinitis encompassing the optic nerve and macula in a circinate distribution (figure 1). Haematological investigation revealed a reactive enzyme immune assay and a rapid plasma reagin titre of 1:160, suggestive of acute syphilitic posterior placoid chorioretinitis (ASPPC). Syphilis is a systemic infection secondary to the spirochete Treponema pallidum, of which the incidence is increasing in developed nations, especially in specific groups such as men who have sex with men and intravenous drug users. 2 Moreover, syphilis can commonly present as a coinfection with HIV. 2 The manifestations of syphilis are vast and can often masquerade as different systemic and ophthalmological presentations leading to delay of diagnosis and management and potential irreversible visual loss. 2 ASPPC is a rare manifestation of ocular syphilis, with placoid lesions likely developing secondary to chorioretinal inflammation with outer retinal immune complex deposition, although the exact pathophysiology is not known. 3 Optical coherence tomography in patients affected by ASPPC is useful in aiding diagnosis and reveals disruption of the outer ellipsoid zone and nodular lesions from the retinal pigmented epithelium (figure 2). 3 Treatment of this entity primarily involves the use of antibiotics. In some instances, antiinflammatory agents such as tumour necrosis factor alpha inhibitors or corticosteroids may be considered to reduce inflammation and to prevent JarischHerxheimer reaction. 3 4 The patient was initially treated with intravenous benzylpenicillin for two weeks and a tapering course of prednisone initiated 36 hours after commencing antibiotics. At 11week final followup, the VA was 6/9 bilaterally and there was regression of the outer retina placoid lesions.