|Year : 2019 | Volume
| Issue : 1 | Page : 4
Unusual associations with toxoplasmosis: Report of two cases
Denis Anaya, Alberto Castro
Retina and Vitreous Department, Pontificia Universidad Javeriana, Cali, Colombia
|Date of Submission||10-Jul-2019|
|Date of Acceptance||10-Jul-2019|
|Date of Web Publication||08-Aug-2019|
Dr. Denis Anaya
Cra 47, No. 8C-94, Clínica de Oftalmología de Cali, Office 301, Cali
Source of Support: None, Conflict of Interest: None
Toxoplasma retinochoroiditis is an entity of variable incidence according to the country and it is prevalent in Colombia and Latin America. The purpose of this report is to present two cases of toxoplasma retinochoroiditis with unusual associations with other retinal diseases. The first case corresponds to a young immunocompetent patient who developed toxoplasma retinochoroiditis in one eye and was treated. Six years later, he presented a similar picture in the contralateral eye and the same diagnostic was done. But the evolution was torpid and finally an herpetic acute retinal necrosis was confirmed. The second case corresponds to a healthy young patient, who developed toxoplasma retinochoroiditis and at the time of diagnosis he had exudative lesions in the same eye, that difficulted the diagnosis and were due to adult Coats´ disease.
Keywords: Acute retinal necrosis, Coats disease, ocular toxoplasmosis
|How to cite this article:|
Anaya D, Castro A. Unusual associations with toxoplasmosis: Report of two cases. Pan Am J Ophthalmol 2019;1:4
| Introduction|| |
Toxoplasmosis is the most frequent cause of blindness secondary to retinal inflammatory disease and a significant cause of posterior uveitis in the world. The prevalence, severity, and risk of ocular involvement are higher in Latin America than in the United States and some European countries.
It is caused by the intracellular parasite Toxoplasma gondii and usually presents with necrotizing retinochoroiditis, vitreitis, and vasculitis. The diagnosis is clinical; however, serological tests and more recently, the polymerase chain reaction test in vitreous or aqueous humor samples can support the diagnosis with high sensitivity and specificity.
In the differential diagnosis of toxoplasmosis retinochoroiditis, it is crucial to take into account other necrotizing infectious diseases of the retina such as acute retinal necrosis, a rapidly progressive, rare, and devastating entity caused by herpes virus type 1, type 2, or varicella zoster. It is characterized by usually glaucomatous panuveitis with high vitreous turbidity, occlusive retinal vasculitis with an arterial, venous, and choroidal compromise that leads to diffuse peripheral necrotizing retinitis and generally to retinal detachment.
There are other noninfectious diseases that, depending on the context, could simulate Toxoplasma retinochoroiditis, such as Coats disease. This is a nonhereditary sporadic disease that mainly affects young males, has a broad clinical spectrum, but is generally characterized by telangiectasias in the periphery of the retina with intra- and sub-retinal exudation in different degrees, being less aggressive when it is initiated in adulthood.
We herein presented two cases of patients with Toxoplasma retinochoroiditis with significant associations with other diseases of the retina.
| Case Reports|| |
Case report 1
A 33-year-old male consulted for 15 days with a history of blurred vision in his right eye. We found visual acuity of 20/300, inflammatory deposits in the endothelium, anterior chamber cellularity, severe vitreitis, two focus of retinochoroiditis compatible with toxoplasmosis and elevated IgM, and IgG antibodies serum to T. gondii. Treatment was started with oral trimethoprim/sulfamethoxazole and clindamycin, topical steroid, and mydriatic eye drops. In the same day, intravitreal clindamycin was applied, which was repeated 5 days later, associated with intravitreal triamcinolone. He had improvement of the inflammation; nevertheless, to the 15th day, he presented a retinal tear with localized retinal detachment and required surgery with retinopexy with a scleral band, posterior vitrectomy, endolaser, and gas. In the early postoperative period, he presented redetachment of the retina and was submitted to vitrectomy with silicone oil. Four months after the initial surgery, the retina was attached, but with a sizeable epiretinal membrane; so, silicone extraction and peeling of the epiretinal membrane were performed. The patient had a good evolution, with improvement of the infectious and inflammatory process with visual acuity of 20/80 after two years of follow-up.
Six years later, the patient consulted for pain in the other eye. Visual acuity of 20/40, keratic precipitates, cellularity in the anterior chamber was found, and although there was no evident focus on the retina, from the antecedent of the right eye, it was decided to start systemic treatment for toxoplasmosis. The visual acuity deteriorated, and 10 days later, a plate-like necrotic lesion appeared in the temporal periphery, which complemented the management with the injection of intravitreal clindamycin. Despite this, there was no improvement, and the lesion was extended circumferentially [Figure 1]; so, it was considered a probable acute retinal necrosis, and intravenous acyclovir was started. The response was still poor after 1 week of treatment, with visual acuity of count fingers at 1 m; therefore, a dose of intravitreal ganciclovir was applied. Finally, the lesion was inactivated [Figure 2], and maintenance therapy with oral valacyclovir was continued. One month later, he developed retinal detachment that required lensectomy, posterior vitrectomy, and silicone injection, with good evolution. After 3 months, the silicone was removed, and an intraocular lens was implanted in capsular remnants. Visual acuity improved to 20/20 at 2 years.
|Figure 2: The retinal zone corresponding to [Figure 1], with pigmented scar and laser fingerprints|
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Case report 2
A 30-year-old male consulted with a history of 8 years of blurred vision in the left eye that worsened in the last 3 days associated with floaters. He had visual acuity of 20/50, cellularity which was found in the anterior chamber and eye fundus with peripheral vasculitis, a scar of temporal retinochoroiditis with active satellite lesions, and a nearby area with exudates, elevated retina, and vascular anomalies.
With these findings, it was considered that they were two entities of different etiology – an old chronic lesion with exudation corresponding to adult Coats disease and another active retinal toxoplasmosis lesion. Treatment was started with oral trimethoprim/sulfamethoxazole and azithromycin, which improved the infectious process, but the area with exudation was not under control, leading to retinal detachment [Figure 3]. He was submitted to retinopexy surgery with a scleral band, lensectomy, posterior vitrectomy, and silicone oil injection. At 3 months, he developed corneal opacity due to the presence of silicon oil in the anterior chamber and secondary intraocular hypertension, which led to silicone oil removal. Ten months after that, he was submitted to intraocular lens implant with retropupillary iris fixation with visual acuity of 20/80. After 1 year, retina was applied, and proper healing of the peripheral lesions was noted [Figure 4].
|Figure 4: Mosaic showing the attached retina, with good peripheral healing without signs of activity|
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| Discussion|| |
Toxoplasma retinochoroiditis is an entity of variable incidence according to the country or location. In Colombia and Latin America, it is relatively frequent; however, in other regions, it can become very unusual. Some diseases can simulate a similar clinical presentation and make diagnosis difficult such as acute retinal necrosis due to herpes, presented in case 1, in which the history of retinochoroiditis due to Toxoplasma in the other eye was a confounding factor. It is crucial to make the diagnosis promptly since acute retinal necrosis can be devastating if it is not treated in early stages. Furthermore, some entities can occur in the same eye of retinochoroiditis due to Toxoplasma, without being related to each other, generating doubts when making the diagnosis, like the case 2 in which the infection was incidentally developed in an eye that already had manifestations of adult Coats disease.
In both cases, diagnosis and timely treatment were achieved, although these associations were infrequent, finally leaving to good functional and anatomical results.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]