Answer: E. Intravenous penicillin G
This patient has acute syphilitic posterior placoid chorioretinitis (ASPPC), a distinctive manifestation of ocular syphilis. The clues that separate this from acute retinal necrosis are subtle: the relatively indolent, weeks-long course rather than days; the notable absence of significant ocular pain; the characteristic placoid, yellowish macular lesion rather than peripheral necrotizing patches; and the lack of occlusive retinal vasculitis. The systemic history of resolved palmar rash, night sweats, and unprotected sexual contact points toward secondary syphilis.
Any patient with ocular syphilis is treated as having neurosyphilis, regardless of cerebrospinal fluid findings, and requires intravenous penicillin G per the neurosyphilis treatment protocol. All patients with ocular syphilis should also be tested for HIV, since co-infection is common and can alter the clinical course.
A. High-dose systemic antiviral therapy: This is the correct treatment for acute retinal necrosis, the diagnosis that this vignette is designed to resemble. The absence of pain, the placoid (rather than necrotizing) macular lesion, and the lack of occlusive vasculitis argue against ARN.
B. Intravitreal ganciclovir: This targets CMV retinitis, which typically occurs in significantly immunocompromised patients such as those with untreated advanced HIV and produces a granular, hemorrhagic ("pizza-pie") retinitis rather than a placoid lesion.
C. Oral doxycycline: Doxycycline is an acceptable alternative for early syphilis in penicillin-allergic, non-pregnant patients without neurologic or ocular involvement — but ocular syphilis specifically requires treatment as neurosyphilis, which mandates IV penicillin G (or penicillin desensitization if allergic).
D. Systemic corticosteroids alone: Steroids without antimicrobial coverage will not treat the underlying infection and can worsen outcomes; steroids may be added as adjunctive therapy only after antitreponemal treatment has been initiated.
