Hypertensive Disc Edema or Ocular Syphilis? A Case Report of the Great Masquerader.

Introduction: Ocular syphilis is a rare manifestation of syphilis caused by Treponema pallidum which can occur at any stage of infection. It most commonly presents as posterior or panuveitis but can involve various ocular structures, complicating diagnosis.

Case presentation: We describe a case of a 38-year-old female with a 7-month history of progressive blurry vision, floaters, flashes, and photophobia. Upon presentation to the emergency department, the patient's symptoms were initially attributed to a hypertensive emergency given fundoscopic examination revealing of optic disc edema. Despite resolution of hypertensive episode, the patient's symptoms persisted and she presented to our ophthalmology clinic where optical coherence tomography (OCT) showed ellipsoid zone disruption and hyperreflective deposits. Routine screening done at the emergency department for sexually transmitted infections indicated infection with syphilis and human immunodeficiency virus (HIV), for which the patient was instructed to return to the hospital for treatment. Cerebrospinal fluid (CSF) analysis confirmed diagnosis of neurosyphilis, and the patient was treated with 14 days of intravenous penicillin G.

Conclusion: This case highlights the diagnostic challenges posed by ocular syphilis, especially when overshadowed by other conditions like hypertension. This patient's atypical presentation of optic neuritis without uveitis underscores the necessity of considering ocular syphilis in patients with chronic unexplained visual changes, particularly in high-risk populations.