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Optic neuritis due to acquired toxoplasmosis.

A pediatric patient with well documented acquired toxoplasmic optic neuritis is presented. Use of immunoglobulin M immunofluorescent antibody studies allow easier identification of recently acquired toxoplasmosis. Toxoplasmic optic neuritis and retinitis should be considered along with toxoplasmic meningitis or encephalitis as complications of acquired toxoplasmosis. Therapy is available which may decrease the duration of visual symptomatology and reduce residual visual impairment.

Adolescent↗
PubMed2004

Acute acquired toxoplasma retinitis may present similarly to unilateral acute idiopathic maculopathy.

PURPOSE: To describe a patient with acquired toxoplasma retinitis that shared similarities with unilateral acute idiopathic maculopathy. DESIGN: Interventional case report. METHODS: Interventional case report. RESULTS: A 39-year-old woman presented with sudden unilateral vision loss in the right eye after a flu-like illness. She had retinitis involving the fovea, subretinal fluid, thickening of the retinal pigment epithelium, and a few vitreous cells; the retinitis resolved with antitoxoplasma antibiotic treatment. CONCLUSIONS: Acute acquired toxoplasma retinitis may present similarly to unilateral acute idiopathic maculopathy.

Acute Disease↗
PubMed2006

Rapid progression of diabetic retinopathy in eyes with posterior uveitis.

PURPOSE: To report on two patients who developed rapid progression of asymmetric diabetic retinopathy (DRP) in eyes affected by posterior uveitis in contrast to their fellow eyes not affected by uveitis. DESIGN: Observational case report. METHODS: Two patients with diabetes mellitus (DM) and unilateral uveitis underwent repeated ophthalmologic examinations and fluorescein angiography. RESULTS: Two patients with DM and unilateral posterior uveitis developed proliferative DRP in eyes with previous uveitis within 3 months after the uveitis subsided. In contrast, the retinal findings of nonuveitic eyes remained unchanged on follow-up of several years. CONCLUSIONS: Since the pathogenesis of intraocular inflammation and diabetic retinopathy acts through similar biochemical mediators and pathways, it is feasible that posterior uveitis accelerates the progression of diabetic retinopathy. Our results support this hypothesis and point out a risk for rapid retinopathy development in eyes affected with posterior uveitis.

Adult↗
PubMed2006

Correlation between clinical suspicion and polymerase chain reaction verification of infectious vitritis.

PURPOSE: To compare polymerase chain reaction (PCR) results to presumptive clinical diagnosis in patients with vitritis. DESIGN: Retrospective review of PCR laboratory records from vitreous samples. METHODS: Fifty consecutive laboratory records of vitreous samples sent for PCR testing were reviewed. Three reviewers with uveitis training ranked the clinical suspicion of a specific diagnosis using a classification system (scale of 1 to 4) and were masked to the PCR results. RESULTS: The degree of clinical suspicion of a particular diagnosis was significantly associated with a positive PCR result (P = .048). Higher clinical suspicion was significantly more associated with a positive PCR result compared with cases with lower clinical suspicion (P = .01). CONCLUSIONS: If the clinical suspicion of a specific diagnosis is low, the PCR for any infectious etiology is unlikely to be positive.

Adult↗
PubMed2006

Third-generation optical coherence tomography findings in punctate retinal toxoplasmosis.

PURPOSE: To investigate optical coherence tomography (OCT) findings in patients with punctate retinal toxoplasmosis (PRT). DESIGN: Observational case series. METHODS SETTING: Tertiary ophthalmic referral center. STUDY POPULATION: Four patients with PRT consecutively evaluated between July 2004 and June 2005. OBSERVATION PROCEDURES: Clinical examination and OCT. MAIN OUTCOME MEASURES: Morphologic features at baseline and changes within a 24-week follow-up interval. RESULTS: Retinal layers were abnormally hyperreflective at the active lesion site and associated with some degree of retinal pigment epithelium-choriocapillaris/choroidal optical shadowing in all patients. The posterior hyaloid was thickened and focally detached (over the lesion). Additional findings include tractional maculopathy (n = 2) and diffuse macular edema (n = 1). During follow-up, focal choriocapillaris/choroidal relative hyperreflectivity was observed at the former lesion site, and posterior vitreous detachment progressed in all patients. CONCLUSIONS: Our findings suggest that OCT may enable identification of subtle morphologic features previously underappreciated in patients with PRT, which may provide new insights about the disease pathophysiologic mechanisms.

Antiprotozoal Agents↗
PubMed2005

Evaluation of a Real-time PCR-based assay using the lightcycler system for detection of Toxoplasma gondii bradyzoite genes in blood specimens from patients with toxoplasmic retinochoroiditis.

PCR based methods have advantages over traditional methods for the diagnosis of toxoplasmosis, especially when serology fails and clinical symptoms are not evident. However, current PCR-based assays are often labour-intensive and not readily quantifiable and have the potential for contamination due to a requirement for postamplification sample handling. Real-time PCR can address these limitations. We have developed and evaluated a highly sensitive Real-time PCR (Light-cycler, LC-PCR) to detect and quantify Toxoplasma gondii B1 and bradyzoite specific genes (SAG-4, MAG-1) in serum and peripheral blood mononuclear cells (PBMC) specimens, from five immunocompetent subjects with clinically suspected toxoplasmic retinochoroiditis (TRC) or without a suspected T. gondii infection. A standard curve for quantitation of parasitic load was generated using SYBR Green I fluorescent detection. The results were compared with those obtained with a nested PCR (n-PCR). In TRC patients, both PCR methods confirmed ophtalmoscopy and fluorangiographic findings. Among the TRC patients, the use of LC-PCR was more sensitive than n-PCR for detection and quantification of either B1 gene (P<0.001) or SAG-4/MAG-1 gene (P<0.05). LC-PCR has been shown particularly useful to accurately determine the parasite DNA load in follow-up specimens in whom the performance of either B1 or SAG-4 and MAG-1 in detecting T. gondii loads, varied with respect to specific antitoxoplasmic treatment.

Adult↗
PubMed2004

Retinal and choroidal biopsies are helpful in unclear uveitis of suspected infectious or malignant origin.

OBJECTIVES: To assess the clinical value of retinal or choroidal biopsy in establishing a definitive diagnosis directing subsequent management and to assess the risk involved in such surgery. DESIGN: Retrospective noncomparative interventional case series. PARTICIPANTS: Thirteen patients with uveitis of suspected malignant or infectious origin. One patient had 2 consecutive biopsies on the same eye. METHODS: A retrospective review of a 4-year period was undertaken of all those cases in which the biopsy was taken for diagnostic purposes at a single institution. MAIN OUTCOME MEASURES: Ability of biopsy to establish a pathologic diagnosis and guide treatment and surgical complications. RESULTS: A transscleral approach was used in 4 and a pars plana vitrectomy approach in 10 of the biopsies. The only operative complication was a retinal break in 1 case. Postoperative events that might be related to the surgery included 1 localized retinal detachment, 2 cataracts, and 1 phthisical eye. The pathologic diagnosis differed from the initial clinical diagnosis in 5 of the 13 cases. The biopsy result directed specific appropriate treatment in 7 of the 13 cases. In the 6 remaining cases, no specific diagnosis was confirmed, but the results of the biopsy were useful in excluding malignancy and in some cases allowing a therapeutic trial. CONCLUSIONS: Retinal or choroidal biopsy is a valuable investigation that often changes clinical management when carried out for specific indications in patients with uveitis of suspected malignant or infectious origin. Although it is likely to remain an investigation of last resort, it should be considered at an earlier stage when there is diagnostic uncertainty if severe visual loss is to be prevented.

Adult↗
PubMed2004

Diagnostic approaches to severe, atypical toxoplasmosis mimicking acute retinal necrosis.

PURPOSE: To describe the means of diagnosis and clinical features of atypical toxoplasmic chorioretinitis mimicking acute retinal necrosis. DESIGN: Observational case series. PARTICIPANTS: Twenty-two patients (25 eyes) with widespread chorioretinitis resulting from toxoplasmosis examined between 1990 and 2001. TESTING: Patients were diagnosed by various techniques, including polymerase chain reaction (PCR) of aqueous and vitreous, serum and intraocular antibody determination, culture of intraocular fluid, retinal biopsy, histopathologic examination, therapeutic trial of antibiotics active against toxoplasmosis, or a combination thereof. MAIN OUTCOME MEASURES: The primary outcome measure was diagnosis of disseminated toxoplasmic chorioretinitis by any combination of tests or by empiric use of specific antibiotics. The secondary outcome measure was visual and anatomic outcome of treatment. RESULTS: Mean age was 53.5 years (range, 19-77 years), with a median of 59.5 years. There were 9 women and 13 men. Six patients were infected with HIV, and 3 patients, 1 with HIV, had bilateral disease. Mean initial vision was 20/110 (median, 20/400; range, 20/20 to no light perception [NLP]). Sixteen patients (73%) had received oral or injectable corticosteroids and 11 (50%) had received antiviral therapy before the diagnosis of toxoplasmosis. Diagnosis was made solely by clinical response to antitoxoplasmosis medications in 4 patients. Sixteen patients were diagnosed based on evaluation of intraocular fluids and tissue by antibody determinations, culture, PCR, histopathologic examination, or a combination thereof. Visual acuity improved after treatment in 7 of 25 eyes (28%). Mean final visual acuity was 20/156 (median, 20/2500; range, 20/30 to NLP). Anatomically, 18 of 23 eyes with follow-up had healed or improved chorioretinitis. Retinitis was progressive in 1 eye, 2 eyes were enucleated, and 2 were phthisical. CONCLUSIONS: Diagnosis of atypical toxoplasmic chorioretinitis that mimics viral retinitis can be accomplished by several means. Prompt diagnosis may help avoid poor visual and anatomic outcomes after prolonged initial treatment with oral prednisone or antiviral medications.

Adult↗
PubMed2006

[Interest of an internist's consultation in uveitis. Comparative study in 66 cases].

BACKGROUND: After exclusion of a masquerade syndrome, uveitis may be associated with infection, systemic diseases, specific ocular diseases, or may be drug-induced. In order to improve diagnostic strategy in uveitis, we performed a comparative study to assess the importance of internist and ophtalmologist's collaboration and we proposed a well-adapted diagnostic procedure. MATERIAL AND METHODS: A comparative study was performed in a tertiary centre. The population was divided in two groups. The first one was retrospective and consisted of patients treated at the Ophthalmology department of Croix Rousse Hospital from 1991 to 2002 without internist's collaboration. The second one was prospective and consisted of patients referred in the same centre in 2003 and 2004 with intervention of an internist. Patients of less than 18 years of age with pre-existent diagnosis, specific ocular diseases, toxoplasmosis infection, or with human immunodeficiency virus infection were excluded. RESULTS: Sixty-six patients were included. Anterior uveitis was the most frequent form (25 cases), followed by panuveitis (20 cases), posterior uveitis (14) and intermediate uveitis (7). The most frequent cause of uveitis was systemic disease (19 cases) followed by infection (7 cases) and neurological entities (4 cases). The rate of diagnosis was 30.3% without internist's intervention and 60.6% when patients were referred to an internist (P=0,01). The internist intervention was contributive in 75% of diagnoses. CONCLUSIONS: The internist intervention significantly enhances the rate of etiological diagnoses in uveitis. These results should further strengthen the internist/ophthalmologist collaboration for patients with uveitis.

Adult↗
PubMed2002

Atypical anterior optic neuropathy caused by toxoplasmosis.

PURPOSE: To report atypical anterior optic neuropathy due to toxoplasmosis. METHODS: Interventional case report. A 33-year-old male presented with sudden painless loss of vision and floaters in the right eye. Examination demonstrated a best-corrected visual acuity of 20/200, optic nerve head edema, retinal hemorrhages, and vitreous opacities. RESULTS: Nine days later, a granuloma at the optic nerve head was apparent, and the patient was treated with pyrimethamine, sulfadiazine, folinic acid, and prednisone. Six weeks after initiating therapy, best-corrected visual acuity had improved to 20/25. CONCLUSION: Optic nerve involvement in toxoplasmosis is uncommon and, when it occurs, usually presents with a white inflammatory mass on the optic disk. The current case demonstrates the importance of including toxoplasmosis in the differential diagnosis of unilateral anterior optic neuropathy, even if a focal inflammatory mass is not apparent.

Adult↗
PubMed2002

The effect of long-term intermittent trimethoprim/sulfamethoxazole treatment on recurrences of toxoplasmic retinochoroiditis.

PURPOSE: To determine the effect of long-term intermittent trimethoprim/sulfamethoxazole treatment on recurrences of toxoplasmic retinochoroiditis. DESIGN: Prospective randomized open-labeled interventional clinical trial. METHODS: A total of 124 patients with a history of recurrent toxoplasmic retinochoroiditis were randomized to treatment with one tablet of trimethoprim (160 mg)/sulfamethoxazole (800 mg) (Bactrim F; Roche Pharmaceuticals, Rio de Janeiro, Brazil) every 3 days (61 patients) or to observation without treatment (63 patients) and were followed monthly for up to 20 consecutive months for clinical signs of disease recurrence. A recurrence was defined as a new focus of necrotizing retinochoroiditis with active inflammation either adjacent to or remote from preexisting retinochoroidal scars. RESULTS: Recurrences developed in four (6.6%) treated patients and in 15 (23.8%) controls (P =.01). Treatment was discontinued prematurely in four patients because of mild drug reactions. CONCLUSION: Long-term intermittent treatment with trimethoprim/sulfamethoxazole can reduce the rate of recurrent toxoplasmic retinochoroiditis.

Adolescent↗