Syphilitic Panuveitis Presenting as Bilateral Granulomatous Uveitis in an Immunocompetent Patient: A Case Report

Ocular syphilis is a re-emerging, sight-threatening manifestation of Treponema pallidum infection that can mimic a wide range of inflammatory eye diseases. We report the case of a 31-year-old immunocompetent woman who presented with a two-month history of progressive bilateral blurred vision, ocular pain, redness, photophobia, and floaters. Ophthalmic examination revealed bilateral granulomatous panuveitis with mutton-fat keratic precipitates, anterior chamber inflammation, vitritis, optic disc hyperemia, and multifocal chorioretinal lesions. Dermatologic examination demonstrated non-pruritic maculopapular eruptions on both palms and the right sole, raising suspicion for secondary syphilis. Serologic testing showed a rapid plasma reagin (RPR) titer of 1:320 and a positive Treponema pallidum hemagglutination assay (TPHA), while human immunodeficiency virus (HIV) and tuberculosis screening were negative. Optical coherence tomography (OCT) demonstrated preserved foveal architecture without cystoid macular edema. Due to the unavailability of standard intravenous therapy in the local clinical setting, the patient was treated with a locally adapted, non-standard regimen of intramuscular benzathine penicillin G 2.4 million units at seven-day intervals for three doses, along with topical and systemic corticosteroids. By day 28, best-corrected visual acuity improved to 20/20 in both eyes, with marked resolution of inflammation. At three months, the RPR titer declined fourfold, indicating an adequate serologic response. This case highlights the importance of considering syphilis in the differential diagnosis of bilateral granulomatous panuveitis, particularly when accompanied by a palmoplantar rash. It underscores the value of prompt serologic testing and timely treatment to preserve vision, while also acknowledging the challenges of adhering to standard treatment protocols in resource-limited settings.