Toxoplasmosis chorioretinitis mimicking acute retinal necrosis associated with local corticosteroid

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Abstract

Background

The cases discussed highlight the atypical presentation and diagnostic dilemmas of toxoplasmosis with fulminant retinal necrosis and the potentially devastating visual outcomes of toxoplasma chorioretinitis following local corticosteroid exposure.

Case presentation

We report a series of three patients who presented with toxoplasmosis mimicking severe acute retinal necrosis. Patients were between 59 and 77 years old and had been exposed to local corticosteroids preceding our evaluation. All patients demonstrated diffuse retinal whitening with severe vision loss on presentation. Polymerase chain reaction testing (PCR) was diagnostic in two patients, and histopathologic examination of a vitrectomy specimen was diagnostic in one patient. All cases of retinitis resolved with anti-parasitic medication; however, visual acuity failed to improve in all patients due to disease severity and presentation.

Conclusions

Local corticosteroid injection may trigger or exacerbate toxoplasmosis chorioretinitis, leading to fulminant retinal necrosis and severe vision loss. Toxoplasma chorioretinitis should be considered in the differential diagnosis of patients presenting with clinical features of acute retinal necrosis, particularly following local corticosteroid injection regardless of their baseline systemic immune status. Diagnostic vitrectomy may be helpful in patients in whom PCR testing is negative and ocular toxoplasmosis is suspected.

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Most cited references 5

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Polymerase chain reaction analysis of aqueous and vitreous specimens in the diagnosis of posterior segment infectious uveitis.

Darlene Miller, Gary W Harper, Joyce C Schiffman … (2008)

To assess polymerase chain reaction (PCR) analysis of intraocular fluid as a test for infectious uveitis of the posterior segment in a representative patient population. Retrospective, interventional case series. One hundred and thirty-three patients with possible infectious chorioretinitis underwent PCR testing of aqueous or vitreous in a university setting. Baseline characteristics predictive of test positivity were identified. Positive and negative predictive values were calculated. Four hundred and thirty-three PCR tests of 105 aqueous and 38 vitreous specimens (mean, 3.3 tests per patient) identified 77 of the 95 patients with a final clinical diagnosis of infectious uveitis (81%). Herpes simplex virus, varicella zoster virus, and cytomegalovirus PCR analysis were performed in almost all cases, with fewer tests for toxoplasmosis or Epstein-Barr virus. Clinical features associated with positive PCR results were retinal vascular inflammation (P < .001), optic nerve involvement (P = .008), immunocompromised state (P = .039), and extensive retinitis (P = .002). Cases sampled within one week of presentation were more likely to have positive PCR results than those sampled later (P = .071). The predictive value of positive and negative tests was 98.7% and 67.9%, respectively, in this patient group. Alteration in treatment based on PCR and syphilis serologic results led to resolution in 25 of 26 patients after treatment was changed. PCR testing is a useful adjunct in the diagnosis of infectious causes of posterior uveitis. Cases with vascular or optic nerve inflammation, extensive retinitis, or immunocompromise are more likely to have positive PCR results and may benefit from PCR testing of aqueous humor.

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Diagnosis of toxoplasmic retinochoroiditis with atypical clinical features.

Christine Fardeau, Stéphane Romand, Narsing Rao … (2002)

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. Retrospective case series. 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. 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. 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.

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

D Moshfeghi, Susana I C O Santos, Careen Y. Lowder … (2004)

To describe the means of diagnosis and clinical features of atypical toxoplasmic chorioretinitis mimicking acute retinal necrosis. Observational case series. Twenty-two patients (25 eyes) with widespread chorioretinitis resulting from toxoplasmosis examined between 1990 and 2001. 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. 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. 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. 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.

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Author and article information

Contributors

Steven Yeh: steven.yeh@emory.edu

Journal

Journal ID (nlm-ta): Int J Retina Vitreous

Journal ID (iso-abbrev): Int J Retina Vitreous

Title: International Journal of Retina and Vitreous

Publisher: BioMed Central (London )

ISSN (Electronic): 2056-9920

Publication date (Electronic): 3 June 2020

Publication date PMC-release: 3 June 2020

Publication date Collection: 2020

Volume: 6

Electronic Location Identifier: 21

Affiliations

Emory Eye Center, Emory University School of Medicine, 1365 Clifton Rd, Atlanta, GA 30322 USA

Article

Publisher ID: 225

DOI: 10.1186/s40942-020-00225-0

PMC ID: 7268411

PubMed ID: 32514378

SO-VID: 7947dd03-5ad5-4be3-9b9a-89b14956cd95

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 26 February 2020

Date accepted : 27 May 2020

Funding

Funded by: National Institutes of Health (US)

Award ID: P30EY006360

Award ID: RO1 EY029594

Award ID: K23EY030158

Award Recipient : Jessica G. Shantha Steven Yeh

Funded by: Research to Prevent Blindness (US)

Award ID: Unrestricted Grant to Emory Eye Center

Award ID: Emory University School of Medicine

Funded by: FundRef http://dx.doi.org/10.13039/100005426, Association for Research in Vision and Ophthalmology;

Award ID: Mallinckrodt Research Fellowship

Award Recipient : Steven Yeh

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Keywords: toxoplasmosis,acute retinal necrosis,corticosteroids

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Keywords: toxoplasmosis, acute retinal necrosis, corticosteroids

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Toxoplasmosis chorioretinitis mimicking acute retinal necrosis associated with local corticosteroid

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Abstract

Background

Case presentation

Conclusions

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PLOS Global Public Health

Most cited references 5

Polymerase chain reaction analysis of aqueous and vitreous specimens in the diagnosis of posterior segment infectious uveitis.

Diagnosis of toxoplasmic retinochoroiditis with atypical clinical features.

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

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Cited by 5

Most referenced authors 51