Ocular Jarisch-Herxheimer reaction causing a transient sub-foveal lesion in ocular syphilis

Author Block: Christine E. Ashenhurst ¹, Patrick Mitchell², Michael Y. K. Mak³, Micheal T. Kryshtalskyj².  ¹University of Victoria, ²University of Calgary, ³McGill University.

Author Disclosure Block: C.E. Ashenhurst:   None.  P. Mitchell:  None.   M.Y.K. Mak:  None.  M.T. Kryshtalskyj:  None.

Abstract Body:

​Purpose:  To report a novel progression of ocular syphilis where a Jarisch-Herxheimer reaction to intravenous penicillin resulted in the development of a novel, transient retinal lesion.  

Study Design:  Case Report 

Methods:  A review of patient’s clinical records, history, referrals, and imaging in addition to the relevant literature was conducted. 

Results:  A 51-year-old female presented to emergency with a one-month history of phosphenes, palinopsia and patchy scotomas in the setting of a maculo-papular rash and new sexual partner. Clinical examination revealed uncorrected visual acuity of 20/20 oculi uterque (OU), vitreous cells, as well as bilateral placoid chorioretinal lesions and disc edema. Syphilis enzyme immunoassay (EIA) and rapid plasma regain (RPR) testing were positive and intravenous penicillin G was administered. Three days post intravenous therapy, her vision deteriorated to 20/400 in the right eye, with worsening papilledema and vitritis, as well as a new, yellow, raised sub-foveal lesion despite a reduction in size of the placoid lesion. Although there was acute worsening of her ocular status, the patient did not experience any other classic symptoms of systemic Jarisch-Herxheimer reaction. By one month, her sub-foveal lesion, disc swelling, and placoid lesions had nearly resolved, and at her ten-week follow-up, her visual acuity was 20/20.  

Conclusions:   To our knowledge, this report of a transient retinal lesion post Jarisch-Herxheimer reaction is novel. We hypothesize this lesion to represent clumping of degenerated photoreceptors from heightened outer-retinal inflammation from a syphilitic ocular Jarisch-Herxheimer reaction.