Molecular investigation of <i>Treponema pallidum</i> strains associated with ocular syphilis in the United States, 2016–2020

Ocular syphilis is a serious complication of <i>Treponema pallidum</i> infection that can occur at any stage of syphilis and affect any eye structure. It remains unknown if certain <i>T. pallidum</i> strains are associated with ocular infections; therefore, we performed genotyping and whole genome sequencing (WGS) to characterize strains from patients with ocular syphilis. Seventy-five ocular or non-ocular specimens from 55 ocular syphilis patients in 14 states within the United States were collected between February 2016 and November 2020. Sufficient <i>T. pallidum</i> DNA was available from nine patients for genotyping and three for WGS. Genotyping was done using the augmented Centers for Disease Control and Prevention typing scheme, and WGS was performed on Illumina platforms. Multilocus sequence typing allelic profiles were predicted from whole genome sequence data. <i>T. pallidum</i> DNA was detected in various specimens from 17 (30.9%) of the 55 patients, and typing was done on samples from 9 patients. Four complete strain types (14d10/g, 14b9/g, 14d9/g, and 14e9/f) and five partial types were identified. WGS was successful on samples from three patients and all three strains belonged to the SS14 clade of <i>T. pallidum</i>. Our data reveal that multiple strain types are associated with ocular manifestations of syphilis. While genotyping and WGS were challenging due to low amounts of <i>T. pallidum</i> DNA in specimens, we successfully performed WGS on cerebrospinal fluid, vitreous fluid, and whole blood.IMPORTANCESyphilis is caused by the spirochete <i>Treponema pallidum</i>. Total syphilis rates have increased significantly over the past two decades in the United States, and the disease remains a public health concern. In addition, ocular syphilis cases has also been on the rise, coinciding with the overall increase in syphilis rates. We conducted a molecular investigation utilizing traditional genotyping and whole genome sequencing over a 5-year period to ascertain if specific <i>T. pallidum</i> strains are associated with ocular syphilis. Genotyping and phylogenetic analysis show that multiple <i>T. pallidum</i> strain types are associated with ocular syphilis in the United States.