This document describes a case of toxoplasmosis retinochoroiditis in a 26-year-old male who presented with sudden loss of vision in his left eye. Examination found inflammation and a white lesion in the left eye along with old scarring. Tests supported a diagnosis of toxoplasmosis. The patient was treated with systemic antiparasitic medications and steroids, along with topical steroids and cycloplegics. Toxoplasmosis results from infection by the protozoan Toxoplasma gondii and commonly causes posterior uveitis, with retinitis developing near old scars when immunity is suppressed.
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Toxoplasma
1. I see too many flies…….
DR.GAYATREE MOHANTY
SR, DEPT. OF OPHTHALMOLOGY
KIIMS
2. HISTORY
A 26 year-old male presented on Aug 27th, 2014
C/o Sudden Diminution of Vision of Left Eye
since past 6 days associated with photophobia &
floaters.
No h/o fever, night sweats, wt.loss, loss of appetite,
rashes, skin ulcers
No h/o trauma
No exposure to pets
No h/o breathlessness or convulsion
3. ON EXAMINATION
The right eye had a
BCVA 6/6 ,normal
anterior segment &
normal fundus.
4. ON EXAMINATION OF THE LEFT EYE
BCVA: CF close
Anterior segment:
Ciliary congestion,
Keratic precipitates : Medium size,
Homogeneous scattered on corneal
endothelium.
Anterior chamber: Cells +++ Flare +
Pupil sluggishly reacting to light
Posterior synechiae
Pigments on lens
5. POSTERIOR SEGMENT:
Vitreous condensations
Grade 2 Vitreous haze.
Hazy media clouding
details of optic disc &
vessels
Retinitis: Solitary white
fluffy lesion near an old
scar in
macula overshadowing
underlying vessels.
6. ON FFA:
Staining of the
scar
Leakage at the site
of retinitis.
No s/o vasculitis
11. PATHOGENESIS
Toxoplasma gondii
Obligate intracellular protozoa
Definite host: Cat
Infectious agent: Sporozoites
Intermediate host: Human
Proliferative form: Tachyzoites
Mode of Transmission:
1.Undercooked meat,
2.Contamination with cat litter
3.Transplacental transfer
12. PATHOGENESIS
Acute systemic toxoplasmosis in
immunocompetent patient induce immune
response (T-cell response) Flu like illness.
If reaches retina Tachyzoites convert into
Bradyzoites and when immunity
suppressed the Cyst ruptures
14. CONGENITAL TOXOPLASMOSIS
Transmitted transplacentally
Severity of disease depends on time of
maternal infestation
1st Trimester:15% cases. Severe disease
leading to spontaneous abortion
3rd Trimester: 40% cases. Subclinical disease
leading to Congenital toxoplasmosis
15. CONGENITAL TOXOPLASMOSIS
Cerebral calcification
leading to convulsion
Bilateral healed
chorioretinal scars:
central vision jeopardized
Hydrocephalus
Microcephaly
Psychomotor retardation
Organomegaly
Jaundice
Rashes and fever
17. TOXOPLASMA
RETINOCHOROIDITIS
Reactivation of previously encysted cyst
containing scars
Cysts rupture to release several tachyzoites
into retinal cells and induce inflammation.
Common age group: 10-35yrs.
18. TOXOPLASMA RETINITIS
Unilateral sudden diminution of
vision, photophobia and floaters
Spill over granulomatous ant.
uvietis
Vitritis: Headlight in fog
Retinitis: Unilateral central
solitary punched out lesion near
an old macular scar
In immunocompromised:
Bilateral multiple foci of extensive
inflamm with no pre-existing scar
19. COMPLICATIONS
Direct involvement of macula
Involvement of Optic n. head
with juxtapapillary lesion
Papillitis: Rare
Occlusion of major blood
vessel
Choroidal neovascularization
Serous detachment
Tractional RD: Vitreous
condensation
Macular edema
20. DIAGNOSIS
Clinical diagnosis
Serological tests for Toxoplasma
Sabin Feldman Test
Immunofluorescent test
Hemagglutination test
Enzyme Linked Immunosorbent
Assay(ELISA)
22. TREATMENT
Self limiting disease
Indications for T/t (American Uveitis
Society)
Lesion involving Macula, Papillomacular
bundle, Optic n. head or Major blood
vessel
Severe vitritis: Risk of tractional RD
Immunocompromised
23. TREATMENT REGIMEN
Systemic Prednisolone 1mg/kgbdwt/d
Pyrimethamine (50mg/d loading dose, 25mg/d
maintainance x 4 wks) along with
Sulfadiazine( 2gm loading dose, 1gm qid x 4wks)
Folinic acid 3-5mg/d
Other systemic options: Clindamycin,
Cotrimoxazole, Azithromycin, Atovaquone
Topical Prednisolone Acetate for anterior uveitis
Cycloplegic
24. CONCLUSION
Ocular toxoplasmosis is a common cause of
infectious posterior uveitis.
Easily diagnosed clinically and lab. diagnosis
e.g ELISA for Toxoplasma Ab.
Treatment is accompanied by resolution of
active infection in the majority of cases