Photo Quiz

Visual Disturbance and Skin Rash


Am Fam Physician. 2021 Mar 15;103(6):373-374.

A 35-year-old patient presented with a two-month history of progressive bilateral blurry vision and a rash on the trunk that developed two weeks before presentation. He was not taking any medications. The patient had a few days of flulike symptoms about four months earlier.

On examination, the patient appeared healthy and was in no distress. His visual acuity was 20/30 in each eye without a relative afferent pupillary defect. Ophthalmoscopy demonstrated bilateral asymmetric optic nerve head swelling and scattered tiny white spots in the retinas (Figure 1). There was an erythematous, maculopapular eruption on the trunk and left arm (Figure 2).






Based on the patient's history, physical examination, and test findings, which one of the following is the most likely diagnosis?

  • A. Idiopathic intracranial hypertension.

  • B. Malignant hypertension.

  • C. Optic neuritis.

  • D. Secondary syphilis.


The answer is D: secondary syphilis. Secondary syphilis often involves the eye and can cause optic nerve head edema and chorioretinitis, which manifested as small white dots in the retinas of this patient.1,2

Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum. Secondary syphilis occurs approximately two months after the initial infection and is typically associated with lymphadenopathy and a maculopapular rash.2 Ocular syphilis can occur at any stage of the disease but is most common in secondary syphilis. Inflammation results in swelling of the optic nerve head and retrobulbar optic neuropathy. Symptoms may include decreased visual acuity, decreased color perception, and pain with extraocular movements. Uveitis occurs in approximately 10% of cases and presents as red eye with pain and photo-phobia.1,2 An ophthalmologic evaluation is recommended

Author disclosure: No relevant financial affiliations.

Address correspondence to Edward Margolin, MD, at Reprints are not available from the authors.


show all references

1. Woolston SL, Dhanireddy S, Marrazzo J. Ocular syphilis: a clinical review. Curr Infect Dis Rep. 2016;18(11):36....

2. Kiss S, Damico FM, Young LH. Ocular manifestations and treatment of syphilis. Semin Ophthalmol. 2005;20(3):161–167.

3. Bidot S, Bruce BB. Update on the diagnosis and treatment of idiopathic intracranial hypertension. Semin Neurol. 2015;35(5):527–538.

4. Hammond S, Wells JR, Marcus DM, et al. Ophthalmoscopic findings in malignant hypertension. J Clin Hypertens (Greenwich). 2006;8(3):221–223.

5. Balcer LJ. Clinical practice. Optic neuritis. N Engl J Med. 2006;354(12):1273–1280.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

A collection of Photo Quiz published in AFP is available at

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at To be considered for publication, submissions must meet these guidelines. E-mail submissions to



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