LACDPH Advisory: Nearby Clusters of Ocular Syphilis Require Provider Vigilance

LACDPH Advisory 

Nearby Clusters of Ocular Syphilis Require Provider Vigilance

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This message is intended for primary care providers, HIV and infection disease specialists, ophthalmologists, optometrists, and other eye care providers.

Please distribute as appropriate.

Key messages

  • There have been clusters of ocular syphilis in Seattle/King County and San Francisco and several cases have resulted in a significant and permanent decline in visual acuity.
  • While no cluster has been identified in Los Angeles County, two independent cases of possible ocular syphilis are currently under investigation.
  • Providers should be vigilant for ocular syphilis, particularly in men who have sex with men and HIV-infected persons.

Situation

The Seattle/King County and San Francisco County Health Departments recently issued health advisories regarding clusters of ocular syphilis diagnosed in those counties since December 2014.  In both areas, the vast majority of patients affected were among men who have sex with men (MSM) and HIV-infected persons. Several of the cases have resulted in a significant and permanent decline in visual acuity.

These current clusters raise the concern of specific strains of Treponema pallidum with a greater likelihood of causing ocular infections.

Currently, the Los Angeles County Department of Public Health (LAC DPH) has not identified a cluster of ocular syphilis cases but two independent cases of possible ocular syphilis are currently under investigation.  We are asking for assistance from all LAC providers to be vigilant for potential cases in their own patients and to act promptly.

Actions Requested of Providers

  • Consider syphilis in patients presenting with visual complaints if they have risk factors for syphilis. Take a sexual history to determine risk for syphilis. In LA County, most cases of syphilis occur in MSM and over half are HIV-infected.
  • Test for syphilis in all sexually active patients presenting with genital, oral, or anal ulcers, or rash.
  • Ask patients with known or suspected syphilis about changes in their vision and about headache and changes in their hearing (including hearing loss or tinnitus) in order to identify persons who may have ocular syphilis, otologic syphilis, or neurosyphilis.
  • Refer immediately all patients with syphilis and ocular complaints for ophthalmologic evaluation.
  • Obtain a lumbar puncture in all patients with suspected ocular, otologic, or neurosyphilis.
  • Promptly treat patients diagnosed with ocular syphilis according to CDC guidelines for CNS syphilis, (i.e., intravenous penicillin G or intramuscular procaine penicillin plus oral probencid for 10 days) (see www.cdc.gov/std/treatment/2010/default.htm)
  • Report suspected ocular syphilis cases in LAC within 24 hours by calling 213-744-3106 or via confidential morbidity report (CMR) [see below for more reporting information].  Every case of ocular syphilis will be investigated by LAC DPH.

Additional Guidance Related to Diagnosis and Therapy of Syphilis

Please keep in mind the following:

  • The most common finding in syphilitic eye disease is uveitis, although it can affect any part of the eye.  Initial symptoms can be subtle, including floaters, flashing lights (photopsia), blurring of vision, and ocular pain.  If untreated, these symptoms can progress to loss of vision and permanent blindness.
  • False negative RPRs can occur in the setting of high RPR titers.  If you suspect syphilis and the RPR result is negative, ask the lab to check for prozone phenomenon.
  • All patients being evaluated for syphilis should be tested for HIV infection unless they have a prior HIV diagnosis.
  • Initiate penicillin therapy in all patients in whom syphilis is suspected without waiting for laboratory confirmation of the diagnosis.
  • For consultation regarding a possible syphilis case, call LAC DPH’s STD Consultation Line at 213-744-3106.

Report suspected ocular syphilis (and all cases of syphilis) within 24 hours:

Clinically suspect cases in Los Angeles County (except Long Beach and Pasadena):

Clinically suspect cases in the cities of Long Beach or Pasadena, please contact their local health departments:

  • City of Long Beach Health Department: 562-570-4302
  • City of Pasadena Health Department: 626-744-6043

The successful detection and control of syphilis in LAC has been due in large part to our excellent partnership with medical providers such as yourselves. Thank you for your continuing efforts.

This Health Advisory was sent by Dr. Sonali Kulkarni, Medical Director, Division of HIV and STD Programs, Los Angeles County Department of Public Health.

To see this and other health alerts, please visit:

publichealth.lacounty.gov/eprp/lahan/lahan.htm

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