Secondary Syphilis with Ocular Neurosyphilis and a Jarisch–Herxheimer Reaction to Treatment: A Case Report

A 33-year-old man was admitted to the hospital with a two-week history of fever, chills, arthralgias, malaise, anorexia, and a generalized non-pruritic erythematous rash. He also noted several days of blurring of vision in his right eye. Pertinent findings on physical examination included a temperature of 38° C, generalized lymphadenopathy, hepatosplenomegaly, and a maculopapular rash involving his face, trunk, and extremities, including his palms and soles. Ophthalmologic examination of his right eye revealed a posterior placoid chorioretinitis. Laboratory findings were notable for a lymphocytosis with increased Th17 and Th22 cells and markedly elevated liver enzymes. A liver biopsy showed bile canaliculi heavily colonized by spirochetes. Cerebrospinal fluid analysis revealed a mononuclear pleocytosis and a positive FTA-ABS test. Dark-field microscopy of a skin scaping was positive for Treponema pallidum. The patient was diagnosed with secondary syphilis with neurological involvement. He was treated with intravenous penicillin G for 14 days, during which he experienced a transient Jarisch–Herxheimer reaction. The patient was discharged in stable condition with plans for long-term serologic monitoring.