Bilateral hypopyon in syphilitic uveitis

PURPOSE: To report an atypical bilateral hypopyon presentation of syphilitic uveitis. OBSERVATIONS: A 38-year-old male presented with a 2-day history of bilateral progressive visual loss, conjunctival hyperemia, and photophobia. Initial ophthalmologic examination revealed bilateral hypopyon and vitritis that limited the examination of the posterior segment. The physical exam revealed cervical lymphadenopathy, glossal leukoplakia, erythematous maculae on the hard palate, erythematous macular lesions on both palms, onychodystrophy, onycholysis, and psoriasiform plaques on both plantar surfaces, testicular tenderness, and hypopigmented patches on the scrotal and perianal skin. A therapeutic and diagnostic vitrectomy was performed on the right eye, and the intraoperative findings were consistent with severe vitritis and pre-retinal precipitates. The cytopathologic analysis of the right vitreous revealed a mixed inflammatory process composed of lymphocytes, histiocytes, and neutrophils in a proteinaceous background. Laboratory testing revealed positive serum RPR, CSF FTA-Abs and VDRL, and HIV serology. Treatment with a 2-week course of intravenous penicillin G 4 million units every 4 hours and topical corticosteroids resulted in complete resolution of the uveitis. CONCLUSIONS AND IMPORTANCE: Bilateral hypopyon uveitis may be a rare presentation of syphilitic uveitis. As with most forms of uveitis, syphilis should be considered in the differential diagnosis of patients presenting with bilateral hypopyon.