Serious Syphilitic Uveitis Cases Almost Tripled Over 10-Year Period

Syphilitic uveitis cases requiring hospitalization increased from 2010 to 2019 in the U.S., amid a national shortage of the standard-of-care injectable penicillin G, according to a retrospective cross-sectional study.

Looking at data on all inpatient admissions from this time period, the national incidence was 0.15 per 100,000 population, with the lowest incidence rate in 2011 (0.08 per 100,000 population) and the highest in 2019 (0.23 per 100,000 population; P=0.04), reported Tahreem A. Mir, MD, of Vanderbilt University Medical Center in Nashville, Tennessee, and colleagues in JAMA Ophthalmology.

Syphilitic uveitis disproportionately affected men (78.9%), Black adults (32%), those living in the South (42.1%), and those in the lowest median household income quartile (38.8%).

The findings of this study “correlated well with our clinical experience,” Mir told MedPage Today. “We are going to be seeing a lot more cases.”

Mir said she launched the study with colleagues after noticing an increase in patients with syphilitic uveitis, a vision-threatening condition that causes inflammation in the eye. “A lot of the time we’ve been the ones to make the diagnosis. Patients come in with visual changes, but have no idea they have syphilis,” she explained.

Uveitis is a fairly common condition with a number of causes, including syphilis. According to the CDC, the rates of primary and secondary syphilis — both especially infectious — have grown almost every year since reaching historic lows in 2000 and 2001. The rate jumped by 28.6% from 2020 to 2021 alone. Cases among men who have sex with men accounted for an estimated 46.5% of male cases in 2021.

In an interview with MedPage Today, neuro-ophthalmologist Lulu Bursztyn, MD, of Western University in London, Ontario, said the gold-standard treatment for syphilitic uveitis is intravenous penicillin, which is highly effective when given promptly. However, the condition “is still rare enough that most ophthalmologists won’t think about it right away,” she said.

Delayed diagnosis can be devastating, she added. “I published a review paper earlier this year on the visual outcome in ocular syphilis [in patients with HIV], and we found that the strongest predictor of poor vision is poor visual acuity at the time of presentation. This means that if patients lose vision while waiting for the correct diagnosis, they may not get it back.”

To complicate matters, the U.S. is facing a shortage of injectable penicillin G. “With no end in sight for the shortage, one treatment option from the CDC is 10 to 14 days of ceftriaxone delivered intramuscularly or intravenously, although data for this treatment protocol are not as robust as that for IV penicillin,” Debra A. Goldstein, MD, of Northwestern University Feinberg School of Medicine in Chicago, told MedPage Today.

For this study, Mir and colleagues used the Nationwide Inpatient Sample to identify all inpatient admissions with a diagnosis of syphilitic uveitis in the U.S. from 2010 to 2019. Of 444,674 patients (median age 53, 54.8% men), they identified 5,581 syphilitic uveitis-related hospitalizations during this period. Median age was 45, and 23% had comorbid HIV.

Patients with syphilitic uveitis are typically hospitalized, at least briefly, for the placement of peripherally inserted central catheter lines to deliver treatment. The median hospitalization period was 6 days. The median inflation-adjusted hospitalization charge was $39,464 in 2019.

Study limitations included possible misdiagnosis and the treatment of patients outside the hospital.

Mir urged colleagues to keep syphilitic uveitis in their differential diagnoses. A simple blood test is all that’s needed to diagnose syphilis, she said, adding that patients with syphilitic uveitis must be evaluated for neurosyphilis.

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