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PubMed2001

[Ocular parasitoses and mycoses: cases diagnosed in the Central University Hospital of Sfax between 1996 and 1999].

Parasitical and fungal ophthalmic infections are polymorphic and variably severe. They are rarely reported in publications. The aim of our study has been to specify the parasitic and fungal agents isolated from the ocular samples in our district (Sfax-Tunisia). We surveyed retrospectively the different ocular parasitosis and mycosis diagnosed in our laboratory (Sfax hospital) over a 4 year-period (1996-1999). Fungal ophthalmic infections were dominated by corneal localisations: 20 cases of keratomycosis secondary to: Fusarium solani (8 cases), Aspergillus fumigatus (3 cases); Aspergillus flavus (2 cases); Alternaria sp (2 cases), Candida albicans (2 cases); Fusarium dimerium (1 case); Fusarium oxysporum (1 case) and Scedosporium sp (1 case). A prolonged treatment by ketoconazole had a successful resolution in 70% of cases; 1 case of ciliar tinea caused by Trichophyton violaceum. Parasitic agents were dominated by Demodex folliculorum (32 cases), Phthirius inguinalis (6 cases) and Oestrus ovis (2 cases). Two cases of orbital hydatidosis and 2 cases of palpebral cutaneous leishmania were noted; 21 cases of ocular toxoplasmosis were treated by clindamycine. Our survey concerned not only cosmopolite parasitosis and fungi, but also some affections endemic to our district (hydatidosis and leishmaniasis) with manifestations in isolated ophthalmic localisation. Our research has underscored the need to specify types of infection by way of adequate sampling so as to treat early and then improve prognosis.

Adolescent↗

PubMed2001

[Ophthalmic complications in the course of opportunistic infections--part I].

One of the most important problem of contemporary medicine appears to be constantly increasing number of patients with opportunistic infections. The situation is mainly due to world epidemic of AIDS. The progress in transplantology, huge number of immunocompromised patients during oncological and hematological treatment as well as prolongation of life time in children with congenital immunodeficiencies are successive conditions for the development of opportunistic infection. Pathogens infecting immunocompromised individuals have very low virulence, but in these persons disease is often very severe and potentially lethal. Main agents responsible for opportunistic infections are: Toxoplasma gondii, Cytomegalovirus hominis, Herpes simplex virus, Varicella-zoster virus and fungi. In the paper we describe clinical symptoms, diagnostic methods and therapies of ocular toxoplasmosis and viral infections. Knowledge of diagnosing methods and treatment of opportunistic infections which, when untreated, may quickly lead to vision loss, is necessary in contemporary ophthalmological practice.

Blindness↗

PubMed2003

[Extensive toxoplasmic retinochoroiditis. Diagnostic and therapeutic management].

INTRODUCTION: To assess the diagnostic and therapeutic management of extensive toxoplasmic retinochoroiditis. PATIENTS AND METHODS: The files of all patients referred between December 1999 and December 2001 for the management of a severe, potentially sight-threatening toxoplasmic retinochoroiditis were retrospectively analyzed. The therapeutic strategy and the progression of intraocular inflammation are reported. RESULTS: Thirteen eyes of seven patients were finally included in the study. The sex ratio (F/M) and the mean age were respectively 4/3 and 44.5 years. Most of the patients were immunocompromised. Both eyes were initially affected in five cases. The diagnosis was confirmed by polymerase chain reaction (PCR) after anterior chamber paracentesis in six cases. Retinal detachment was observed in three cases, initially or during follow-up. All patients were treated with a combination of sulfadiazine and pyrimethamine, but azithromycin was necessary in two cases. Clindamycin was used in two cases of allergy to sulfadiazine. Corticosteroids were associated in five cases. For all patients, infection and inflammation were finally controlled. The visual acuity improved more than two lines in four eyes and remained stable in seven other eyes. DISCUSSION: Clinical diagnosis is still a challenge in severe cases of extensive toxoplasmic retinochoroiditis. PCR is helpful in identifying Toxoplasma gondii DNA. A systemic immunosuppression is frequently associated with a positive PCR. Treatment is based on a standard antiparasitic association and steroids must be discussed for each case according to the intensity of inflammation and the degree of immunosuppression. CONCLUSION: Extensive ocular toxoplasmosis is a serious condition. The final prognosis depends on the location of the necrotic lesions, rapid diagnosis, and efficient treatment.

Adolescent↗

PubMed1990

[Arterial occlusion associated with toxoplasmic chorioretinitis].

The authors report a case of unusual toxoplasma chorioretinitis presenting a branch retinal occlusion of an artery passing through the acute necrotic focus. This complications has been very rarely described previously and may have been caused by the acute retinal necrosis. Arterial inflammatory phenomena constitute another etiologic hypothesis. As this branch vascular obstruction may change the appearance of the fundus and obscure the initial inflammatory focus, ocular toxoplasmosis should be included in the differential diagnosis of branch retinal vascular occlusion associated with posterior uveitis, particularly in young patients.

Adult↗

PubMed1987

[Efficacy of specific chemotherapy in the prevention of recurrences of toxoplasmic chorioretinitis during the 4 years following the treatment].

The effectiveness of a curative or preventive therapy in toxoplasmic retinochoroiditis is difficult to evaluate clinically. The goal of the present paper was to study the recurrence rate of ocular toxoplasmosis during a four years period following a Pyrimethamine-sulfadiazine therapy. Some case had received previous therapy (systemic steroids alone or in combination with Spiramycin) which had not effected a lasting cure. In this series of 54 patients diagnosed as having active toxoplasmosis chorioretinitis, the combination of Pyrimethamine and Sulfadiazine seems statistically more effective than other reported treatments. The recurrence rate in a four years follow up study was 40 percent. The benefit of the therapy is more obvious in severe toxoplasmosis uveitis (with severe vitreous reaction, high recurrence rate, macular lesions). The treatment was less effective when indicated after an ineffective previous therapy. The dosage and the duration of the therapy must be adapted to each case. No complication was experienced during the treatment. In order to prevent recurrent toxoplasmosis uveitis Pyrimethamine-Sulfadiazine therapy appears to be the only effective synergistic therapy.

Adolescent↗

PubMed1993

[The clinical significance of culturing Toxoplasma gondii on blood and other organic media].

BACKGROUND: The aim of this study was to determine the value of the Toxoplasma gondii culture in blood and in other organic fluids in HIV positive and negative patients. METHODS: Retrospective analysis (October 1990-May 1992) was carried out including all patients with positive cultures for T. gondii admitted to the Hospital Central of Asturias. The parasite was identified by monoclonal antibodies against the tachyzoite membrane. All patients with positive cultures were treated with pyrimethamine and sulphadiazine. RESULTS: Three hundred two samples from 256 patients, seropositive and seronegative for HIV, were analyzed. Of the seropositive group 8/45 (18%) had positive cultures for T. gondii versus 9/211 (4.3%) of the seronegative group (p = 0.002). Of the 19 positive samples, 15 were from blood, 3 from bronchoalveolar lavage and one from the vitreous fluid. Four out of 9 patients (44%) with AIDS and encephalic toxoplasmosis (ET) had blood cultures positive for T. gondii. Another 4 patients with AIDS presented toxoplasmenia without visceral involvement. Of the 9 HIV seronegative patients (3 immunodepressed patients), 4 had pulmonary toxoplasmosis, one ocular toxoplasmosis, and other clinical forms of toxoplasmosis were seen in the remaining 4. All the patients evolved to cure except 2 cases coinfected by cytomegalovirus who died. CONCLUSIONS: The identification of Toxoplasma gondii may be performed by blood cultures in half of the patients with AIDS and encephalic toxoplasmosis and in an undetermined percentage of the other clinical forms both in immunocompetent and immunodepressed subjects. In addition, toxoplasmemia has been registered in AIDS patients preceding any other organic seating of the parasite. Early antitoxoplasma therapy may, therefore, be effective.

AIDS-Related Opportunistic Infections↗

PubMed1995

[AIDS: infections of the retina and choroid].

Various viral, bacterial, parasitic and fungal agents have been found to cause infections of retina and choroidea in HIV-infected patients. Usually these infections are opportunistic infections caused by the profound immunodeficiency, which is a result of the decay of lymphocytes by HIV. Before the HIV epidemic only rare cases of cytomegalovirus (CMV) retinitis were known in the literature. Now CMV retinitis has become the most common infection of the eye in AIDS patients. Ocular toxoplasmosis in HIV-infected patients can have a severe clinical appearance without treatment. Spontaneous recovery, as it usually occurs in otherwise healthy patients, does not take place in HIV-infected patients, so that a lifelong maintenance therapy is mandatory. Pneumocystis carinii chorioiditis was unknown before the HIV epidemic. In 1987 Pneumocystis carinii were found in the choroidea and two years later the clinical appearance could be described. Infections of choroidea and retina associated with AIDS may not be seen as isolated diseases. Commonly other organs are infected by the same or another organism. In case of AIDS-associated eye infections other organs should be checked for opportunistic disease. Diagnosis can be difficult. Because most of all intraocular infections associated with AIDS are CMV retinitis, an effective therapy can be initiated in most cases and in the follow-up a diagnosis can finally be made. Serological testing may be inconclusive because of occasional false-negative findings. Treatment often only suppresses the infections and so ongoing maintenance therapy may be necessary, as in the cases of CMV retinitis and Toxoplasma retinochorioiditis. A variety of different diseases, which can be treated by a multitude of different substances with a lot of adverse effects and contraindications, can complicate the therapeutic modalities used for the management of each individual disorder. Additionally HIV-infected patients suffer from at least two or three different diseases and must be treated lifelong with plenty of substances, which often are given with higher doses than usual. Only by cooperation of HIV-experienced doctors of different specialities in hospitals and offices the complex subject of HIV infection can be managed.

AIDS-Related Opportunistic Infections↗

PubMed1996

Polymerase chain reaction for the detection of Toxoplasma gondii in aqueous humor of cats.

OBJECTIVES: To develop Toxoplasma gondii B1 gene polymerase chain reaction (PCR) for use with aqueous humor of cats, and to report PCR and antibody detection results in naturally exposed cats with and without uveitis. SAMPLE POPULATION: Serum and aqueous humor samples from client-owned, healthy cats (n = 23) and client-owned cats with uveitis (n = 43). PROCEDURE: T gondii-specific IgM and IgG were measured in serum and aqueous humor from all cats. The Goldman-Witmer coefficient for ocular antibody production was calculated for cats positive for T gondii-specific IgM or IgG in aqueous humor. Aqueous humor from all cats was assessed by the B1 gene PCR. RESULTS: T gondii was detected in aqueous humor by PCR from 2 of 23 (8.7%) healthy cats and 8 of 43 (18.6%) cats with uveitis. T gondii-specific IgM in either serum or aqueous humor was detected in 5 of 8 (62.5%) cats with uveitis and T gondii in aqueous humor. All cats with uveitis and T gondii in aqueous humor had anterior segment disease. In 5 of 8 (62.5%) cats with uveitis and T gondii in aqueous humor, ocular production of T gondii antibodies was not detected. T gondii was not detected in aqueous humor from 14 of 17 (82.4%) cats with ocular production of T gondii-specific antibody. CONCLUSIONS: The presence of T gondii in aqueous humor may correlate to clinical disease in some, but not all, cats. CLINICAL RELEVANCE: T gondii-specific aqueous humor antibody tests and PCR should be used together to aid in the diagnosis of ocular toxoplasmosis in cats.

Animals↗

PubMed2004

[Ophthalmological findings in HIV infected patients in the post-HAART (Highly Active Anti-retroviral Therapy) era, compared to the pre-HAART era].

BACKGROUND: To determine the frequency of the ophthalmological findings in Human Immunodeficience Virus (HIV) infected patients in the post-HAART (Highly Active Anti-retroviral Therapy) era and to compare it to data from the Federal University of São Paulo in the pre-HAART era10,11. METHODS: Charts from 200 consecutive patients examined from May 2000 to February 2001 were reviewed. RESULTS: From the total of 200 patients, 84 (42%) presented ophthalmological findings related to HIV infection in the first ocular examination: 36 (18%) with Cytomegalovirus retinitis (9 active and 27 inactive), 22 (11%) with ocular toxoplasmosis, (9 active and 13 inactive), 15 (7.5%) with retinal detachment (10 secondary to CMV retinitis, 3 to ocular toxoplasmosis and 2 not determined), 8 (4%) with cataract (5 secondary to CMV retinitis, 1 to ocular toxoplasmosis and 2 not determined), 8 (4%) with cotton wool spots, 6 (3%) with acute retinal necrosis (4 active and 2 inactive) and 3 (1.5%) with intersticial keratitis. All patients with acute retinal necrosis showed T CD4 cells under 100 cells/microL. CONCLUSION: The authors identified in the post-HAART era, rise on number of patients with normal ophthalmologic exam and decreased number of cases of CMV retinitis and ocular toxoplasmosis when compared to the pre-HAART era.

Acquired Immunodeficiency Syndrome↗

PubMed1997

Right active retinitis and left focal retinochoroidal scar in a girl with congenital toxoplasmosis.

In congenital cases, ocular toxoplasmosis often presents as a focal whitish fluffy lesion in the retina adjacent to an inactive chorioretinal scar. We examined a girl who has visible floaters in the right eye. The patient had focal active retinitis in the right fundus, a focal chorioretinal scar in the left fundus, a positive enzyme-linked immunosorbent assay (ELISA) for IgG anti-Toxoplasma antibodies and a negative ELISA for IgM antibodies. We believe that active focal retinitis in one eye and a focal chorioretinal scar in the fellow eye in congenital toxoplasmosis, as demonstrated in our patient, may be rare.

Adolescent↗

PubMed2006

Toxoplasmic chorioretinitis and antitumor necrosis factor treatment in rheumatoid arthritis.

OBJECTIVES: To present the data supporting the possible relationship of ocular toxoplasmosis to antitumor necrosis factor-alpha (TNF-alpha) therapy in patients with rheumatoid arthritis (RA). METHODS: A Medline search was performed using the words "toxoplasmosis, anti-TNF-alpha antagonists, chorioretinitis." We report 2 RA patients who developed ocular toxoplasmosis while receiving anti-TNF-alpha therapy. RESULTS: In addition to our patients with toxoplasmic chorioretinitis, there are 2 published cases of cerebral toxoplasmosis during treatment with anti-TNF-alpha agents. CONCLUSION: The risk of serious toxoplasmic infection during anti-TNF-alpha therapy for RA should be recognized.

Adult↗

PubMed1995

Acquired retinochoroiditis in hamsters inoculated with ME 49 strain Toxoplasma.

PURPOSE: These studies were undertaken to establish an animal model for use in studies of ocular toxoplasmosis. An animal model is needed to examine the development, progression, and resolution of ocular Toxoplasma infections and to study the effects on the disease of currently used and experimental therapies. METHODS: Cysts of the ME 49 strain of Toxoplasma gondii were injected intraperitoneally into each of 60 golden hamsters. The hamsters' eyes were examined before inoculation and at intervals after inoculation, and fundus photographs were taken. Histologic sections were analyzed and photographed to document the ocular effects of the infection. RESULTS: Retinochoroiditis was found in both eyes of all hamsters within 2 to 3 weeks of inoculation. The disease resolved spontaneously without treatment and was quiescent in most cases at 12 weeks after inoculation. The animals remained in good general health, and those tested had high antibody titers to Toxoplasma (1:256 to 1:32,000) at 6 months after the infection. The discovery of cysts and lesions in the retina confirmed the diagnosis. CONCLUSIONS: Although the lesions were not identical to those of human disease, this animal model of ocular toxoplasmosis offers several advantages: reproducibility, short incubation time, spontaneous resolution without treatment, consistent production of cysts, and ease of inoculation intraperitoneally without intraocular injection.

Animals↗

PubMed2002

Toxoplasmosis, an overview with emphasis on ocular involvement.

Toxoplasmosis is a common parasitic zoonosis and an important cause of abortions, mental retardation, encephalitis, blindness, and death worldwide. Although a large body of literature has emerged on the subject in the past decades, many questions about the pathogenesis and treatment of the disease remain unanswered. This review aims to provide an overview of the current insights regarding the causative parasite and the mechanisms leading to symptomatic infection with emphasis on ocular toxoplasmosis.

Acute Disease↗

PubMed2002

Diagnosis of toxoplasmic retinochoroiditis with atypical clinical features.

PURPOSE: To determine the value of aqueous humor analysis for confirming the diagnosis of ocular toxoplasmosis in patients who present with atypical clinical features and to relate the results of local antibody production and polymerase chain reaction (PCR) with the extent of active retinitis and the immune status of the patient. DESIGN: Retrospective case series. METHODS: Sixty-seven consecutive patients with retinitis or retinochoroiditis that was clinically consistent with atypical ocular toxoplasmosis underwent diagnostic anterior chamber paracentesis and serological studies. The aqueous humor was analyzed both by PCR to detect Toxoplasma gondii B1 gene and by the Goldman-Witmer coefficient to determine levels of local anti-T. gondii antibody production. RESULTS: In nine of the 67 cases, PCR was positive for T. gondii; seven of these were negative for local antibody production. All nine patients had illnesses associated with immunosuppression or advanced old age and all had active retinitis with a mean area of 11.5 disk areas (DA). Twenty-five of the remaining 58 cases were positive for local antibody production. These 25 had a mean area of active retinitis measuring 2.6 DA, and 24 of these patients were immunocompetent. All 34 cases with laboratory evidence of ocular toxoplasmosis diagnosed by either method responded to anti-T. gondii agents. The remaining 33 were negative for T. gondii infection by these two methods; some had laboratory evidence of other infections. CONCLUSIONS: Although in the present study, the sensitivity and specificity of the aqueous humor PCR and Goldman-Witmer coefficient could not be ascertained in the laboratory diagnosis of toxoplasmic retinochoroiditis, the PCR method appears to confirm the diagnosis in immunocompromised individuals with large atypical foci of retinitis. Conversely, determination of local antibody production may be appropriate for proper diagnosis in immunocompetent individuals presenting with small foci of retinitis.

Adult↗

PubMed1995

Reactivation toxoplasmic retinochoroiditis in patients undergoing bone marrow transplantation: is there a role for chemoprophylaxis?

The objective of this study was to report the occurrence of reactivation ocular toxoplasmosis in bone marrow transplant (BMT) recipients and to propose guidelines for identification and chemoprophylaxis of high-risk patients. The study design was a series of cases from the tertiary care university hospital which has an active BMT program. The patients were two recipients of autologous BMTs with past histories of toxoplasma retinochoroiditis who developed symptomatic reactivation of ocular toxoplasmosis as documented by formal opthalmologic examination in the early post-transplant period. Opthalmoscopic examinations in the two patients with non-Hodgkin's lymphoma who received autologous transplants and then developed decreased visual acuity in the first week after transplant revealed recurrent retinochoroiditis adjacent to old toxoplasma lesions. Pre-transplant eye examinations in both patients had demonstrated only inactive chorioretinal scars. Therapy with sulfadiazine, pyrimethamine and prednisone ultimately led to resolution of retinitis in both patients. BMT recipients who are seropositive for antibody to T. gondii and have findings consistent with previous toxoplasma retinochoroiditis on pre-transplant ophthalmologic examination appear to be at risk for reactivation of ocular toxoplasmosis in the early post-transplant period and may warrant preventive chemoprophylaxis for toxoplasmosis.

Animals↗

PubMed1996

[Treatment of toxoplasmosis retinochoroiditis with atovaquone in an immunocompetent patient].

BACKGROUND: In Central Europe ocular toxoplasmosis is the leading cause of posterior uveitis. It is a major cause of severe visual loss and blindness in young people. Drugs for treatment of active lesions (tachyzoites) have been available for decades but are seen controversial especially because of sometimes serious side effects. These drugs don't seem to shorten the active inflammation nor the recurrence rate, in particular because of the poor effect on the cystic form (bradyzoites). Atovaquone (hydroxynaphthoquinone) is well tolerated systemically and is effective against tachyzoites and bradyzoites of Toxoplasma gondii so that we hope to reduce the recurrence rate. PATIENT HISTORY AND CLINICAL FINDINGS: Two immunocompetent patients with the first and respective second symptomatic recurrence of unilateral active toxoplasmic retinochorioiditis located within the major temporal vascular arcades were treated with Atovaquone and Fluorocortolone because of an impending loss of central visual function. THERAPY AND CLINICAL COURSE: Under the treatment with Atovaquone (3 x 750 mg/day) for three weeks and tapering of the Fluorocortolone the active lesions healed quickly. After a few weeks, atrophic and remarkably little pigmented scars remained. No side effects were observed. After a period of 7 and respective 11 months no recurrence occurred. CONCLUSIONS: Atovaquone is an effective and well tolerated drug for the treatment of active ocular toxoplasmosis in immunocompetent patients. Its efficacy against tachyzoites and cysts of Toxoplasma gondii relative to other drugs remains to be determined by further clinical trials.

Adult↗

PubMed2001

[Analysis of the local synthesis of Toxoplasma gondii-specific immunoglobulins in the anterior eye chamber fluid. Report of two cases].

We reported two cases strongly suspected of ocular toxoplasmosis, in which a puncture of anterior eye chamber was performed for a final verification of clinical diagnosis. In both patients, fresh focal lesions of retinochoroiditis associated with old pigmented retinal scars were diagnosed. The 62-year-old women had a serological evidence of recently acquired T. gondii infection with an increasing IgG titre of a low avidity and a presence of specific IgM and IgA antibodies. In the 13-year-old girl, an immunological profile of the chronic infection was shown, confirmed by a high IgG avidity value. In the patient with a clinical picture of recurrent congenital toxoplasmosis, intraocular production of T. gondii-specific IgG was found in anterior eye chamber. The analysis of the specific antibodies synthesis in ocular fluid by the Western blot seems to be a valuable immunodiagnostic method for a final diagnosis of ocular toxoplasmosis.

Adolescent↗

PubMed1995

Ocular manifestations of HIV infection.

OBJECTIVE: To evaluate the frequency of ocular complications and the clinical outcomes of these complications in patients with various stages of HIV infection. METHODS: Retrospective review of all HIV-infected patients seen in an AIDS ophthalmology clinic from November 1983 through December 31, 1992. RESULTS: Eleven-hundred sixty-three patients were seen for ophthalmologic evaluation. Of these, 781 had the acquired immune deficiency syndrome (AIDS), 226 had symptomatic HIV infection (AIDs-related complex [ARC]), and 156 had asymptomatic HIV infection. Non-infectious HIV retinopathy was the most common ocular complication, affecting 50% of the patients with AIDS, 34% of the patients with ARC, and 3% of the patients with asymptomatic HIV infection. Cytomegalovirus (CMV) retinitis was the most common opportunistic ocular infection, affecting 37% of the patients with AIDS. Other opportunistic ocular infections, including ocular toxoplasmosis, varicella zoster virus retinitis, and Pneumocystis choroidopathy were all much less common, each occurring in < or = 1% of the patients with AIDS. Treatment of CMV retinitis with either foscarnet or ganciclovir was successful in initially controlling the retinitis. However, relapse represented a significant problem and required frequent re-inductions. As a consequence of the retinal damage associated with relapse, loss of visual acuity occurred. The median time to a visual acuity of 20/200 or worse for all eyes with CMV retinitis was 13.4 months, and the median time to a visual acuity of 20/200 or worse in the better eye was 21.1 months. At last follow-up, 75% of the patients had a final visual acuity of 20/40 or better in at least one eye. Retinal detachments were a frequent ophthalmologic complication of CMV retinitis with a cumulative probability of a retinal detachment in at least one eye of 57% at 12 months after the diagnosis of CMV retinitis. Herpes zoster ophthalmicus developed in 3% of the overall series and was seen in all stages of HIV infection. Fifty-six percent of the cases of ocular toxoplasmosis had simultaneous toxoplasmic cerebritis. Ocular toxoplasmosis responded to standard anti-microbial therapy. Varicella zoster virus retinitis, when manifested by the acute retinal necrosis (ARN) syndrome, responded to intravenous acyclovir therapy. Conversely, in a limited number of patients with the progressive outer retinal necrosis syndrome, the disease responded poorly to intravenous acyclovir therapy, but appeared to respond to combination foscarnet and acyclovir therapy. Neuro-ophthalmic lesions were present in 6% of the patients with AIDS. The most common cause of a neuro-ophthalmic lesion was cryptococcal meningitis, and 25% of the patients with cryptococcal meningitis developed a neuro-ophthalmic complication. CONCLUSIONS: Ocular manifestations are common in patients with AIDS. CMV retinitis represented a major vision-threatening problem in these patients. While available therapy was successful in initially controlling the retinitis, the phenomenon of relapse resulted in some degree of long-term visual loss. Preservation of the patient's visual acuity in at least one eye was generally successful. Other opportunistic ocular infections were substantially less common than CMV retinitis but require aggressive therapy.

AIDS-Related Opportunistic Infections↗