Ocular syphilis is an uncommon condition that can cause diverse ocular pathology. Panuveitis is the most common sequelae, though the rise in syphilis over the past decade has increased identification of extensive ocular manifestations including optic nerve pathology. The disease can resemble other inflammatory disorders, thus recognizing uncommon presentations is crucial to prevent misdiagnosis. We highlight a case of isolated bilateral papillitis, an atypical ophthalmologic presentation of this disease. 

A 27-year-old male with asthma, eczema, and psoriasis presented with four days of bilateral transient visual obscurations. History was notable for a recent resolved gluteal rash, chronic cough, hair loss, and unprotected sexual activity. Ophthalmologic exam showed significant bilateral disc edema, blurred disc margins, peripapillary flame hemorrhages, and retinal venous tortuosity without other ocular sequelae. Visual acuity, ocular motility, confrontational visual fields, and color vision were normal along with the remainder of the neurologic examination. MRI brain was unremarkable, and orbits showed optic disc edema. Lumbar puncture yielded a lymphocytic pleocytosis (WBC 21, 74% lymphocytes) with normal opening pressure, and a broad infectious, autoimmune, and neoplastic workup was sent. Humphrey visual field testing demonstrated an enlarged blind spot while optical coherence tomography and fluorescein angiogram confirmed bilateral papillitis. Infectious studies revealed a high RPR titer (>1:1024), negative CSF VDRL, and positive TT-PA confirming a diagnosis of ocular syphilis, and likely neurosyphilis, prompting initiation of IV penicillin. Notably, HIV testing was negative. 

Syphilitic ocular involvement can present with optic nerve pathology, and cases have described optic neuritis, perineuritis, retinitis, and optic disc edema which can mimic papilledema. Symptoms occur more commonly in immunocompromised hosts, particularly when co-infected with HIV. Few cases report isolated bilateral papillitis without other ocular or neurologic sequelae. Clinicians should be aware of the spectrum of pathologic findings in ocular syphilis to prevent significant complications if untreated.