To the Editor: A 37-year-old man infected with HIV through exposure to men who have sex with men (MSM) presented with a 6-week history of intermittent fevers, patchy alopecia and a widespread brown/grey macular rash involving his face, trunk, abdomen and all limbs, with scaling of the face, palms and soles. He had no symptoms of meningism or visual disturbance, and had a chronic mild intermittent headache with no recent change in frequency or intensity. His most recent CD4 cell count was 70 cells/μL and his HIV viral load was > 100 000 copies/mL.

On admission, a serological test for syphilis was reactive and showed a rapid plasma reagin (RPR) titre of 1 : 64 and a positive enzyme immunoassay for antibody (EIA-Ab), whereas at the onset of the rash 6 weeks previously, a serological test for syphilis was negative. A punch biopsy of the skin lesions showed a perivascular infiltrate with lichenoid inflammation consistent with secondary syphilis. An ophthalmological review showed a bilateral anterior uveitis. Examination of cerebrospinal fluid (CSF) showed a white cell count of 1 × 106/L (100% lymphocytes), a normal glucose level, a mildly elevated protein level of 0.45 g/L and a weakly positive result for a fluorescent treponemal antibody absorbed (FTA-ABS) test. CSF RPR, EIA-Ab and Treponema pallidum particle agglutination (TPPA) test results were all non-reactive.

The patient was diagnosed with asymptomatic ocular and neurosyphilis, and treated with intravenous benzylpenicillin (1.8 g 4-hourly for 15 days) and prednisolone eye drops (four times daily for 14 days). The rash faded and the anterior uveitis subsided in the first week of treatment.

There is currently a syphilis epidemic among MSM in Victoria, with the number of syphilis notifications increasing 25-fold between 2000 and 2006.1 A strong association between HIV infection and infectious syphilis has been demonstrated in recent years, including in Victoria.2 HIV-infected MSM with early syphilis have a 1.7% risk of having symptomatic early neurosyphilis3 and a 13% risk of having symptomatic ocular syphilis regardless of CD4 cell count.4 There is no pathognomonic finding in ocular syphilis, and the disease may manifest as uveitis, retinitis, optic neuritis, perineuritis, retinal detachment and papillitis.

It is recommended that all patients with ocular syphilis undergo CSF examination and be managed as if they had neurosyphilis.5 Current guidelines also recommend CSF examination in HIV-infected patients who have late-latent syphilis, syphilis of unknown duration, any neurological signs or symptoms, or suspected treatment failure.6

The finding of asymptomatic ocular syphilis in our patient suggests there should be a low threshold for eye examination in HIV-infected people with early syphilis, even in the absence of any ocular symptoms, as the diagnosis of ocular syphilis dramatically alters the management of these patients.