Grand Rounds

A patient was referred to the emergency department by an optometrist for bilateral optic nerve edema. Visual acuity was 20/20 in both eyes and slit-lamp examination was unremarkable. Fundoscopic evaluation revealed bilateral grade 2 optic disc edema with posterior vitritis. Given the concern for idiopathic intracranial hypertension (IIH), neuroimaging and lumbar puncture were performed, both ruling out increased intracranial pressure. Laboratory workup revealed an elevated C-reactive protein (9.4 mg/L) and erythrocyte sedimentation rate (104 mm/hr). Syphilis serology was markedly positive, with an RPR titer of 1:8192, treponemal antibody positivity, and a CSF VDRL confirming neurosyphilis. A meningoencephalitis panel additionally detected Haemophilus influenzae in the CSF, indicating concurrent bacterial meningitis. The patient was treated with intravenous penicillin G, broad-spectrum antibiotics, and initiated on antiretroviral therapy. At follow-up visit, there was significant improvement in visual function, with resolution of disc edema, and mild vitritis. Visual field defects improved, emphasizing the importance of early recognition and treatment of neurosyphilis and its potential co-infections in immunocompromised patients.

Presentation Date: 03/20/2025
Issue Date: 04/03/2026