Toxoplasmosis Presentation

7/24/2019 Toxoplasmosis Presentation

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Toxoplasmosis GondiiHelena Wang


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Chief Complaint 67 year old male presents for pressure

check Also complains of oating spots O

starting ! "eek agoOccasional infre#uent photopsias $ut

una$le to determine "hich eye


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Case History %&&' ()!*)!+ at the ,A "ith r- Chini"alla

in Ophthalmology

.OHx' .OAG O/0 Cataracts O/0 1Toxocara2scar O3

4OHx' 5onearried

uit smoking 89 years agorinks :eer and oonshine occasionallyari;uana occasionally :.' !


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.ro$lem %ist Chronic yeloid %eukemia &sophageal =eux &rectile ysfunction Hearing %oss Chronic O$structi>e %ung isease %o"er :ack .ain .T3 History of .olyp of Colon .OAG


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eds .otassium Cl 3ildena?l @matini$ esylate

Arti?cial tears %atanoprost Cosopt :udesonide)4ormoterTiotropium :romideOmepraole Al$uterol Aspirin


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&xam 4indings :C,A' O ac O/ All other structures normal

@O.s' !+0 !8 "ith GAT F !9'99am4&' see photos O/


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O .hotos


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O .hotos


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O3 .hotos


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&xam 4indings ,essels' A, crossing changes O/ .eriphery' 8 circular C= scars 3T to macular

scar os BDholes)tears)detachements O/ ") scleral

depression ED., O3 EDoater O near macula impending .,


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Toxoplasmosis Gondiiost common cause of posterior u>eitisToxoplasmosis Gondii is an o$ligatory

intracellular parasite 4indings common in ne"$orns and

immunocompromised patients 3exual reproduction of the parasite

occurs in the small intestinal epithelialcells of cats 4ecal elimination of oocytes


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Toxoplasmosis GondiiOnce the parasite reaches the retina0 it

proliferates "ithin host cells follo"ed $y

rupture of the host cells and in>adingneigh$oring cells to make primary lesions 3ometimes the restricted parasite $y the host

immunity in the ?rst scar is acti>ated to infectanother lesion near$y the scar

Originally thought that an acti>e ocular toxo isa reacti>ation of a congenital toxo scar

ore recent studies sho" that ac#uiredinfections are much more common thanpre>iously thought


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Toxoplasmosis GondiiTypically asymptomatic in

immunocompetent patients :enign and selfBlimiting

3e>ere in fetus andimmunocompromised patients


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3igns and 3ymptomsild fe>eralaiseuscle and)or;oint painHeadache 3ore throat 3kin rash

4loaters :lurred >ision

4rom macularin>ol>ement or se>ere>itreal inammation


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Acti>e Toxo =etinochoroiditis

=ecurrence in e itWhite and exudati>e "ith illBde?ned

$orders @n>ol>es the macula in a ma;ority of

patientsild to moderate anterior segment

inammation ,itreous inammation is >irtually al"ays

presentay see retinal >asculitis


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Optic neuritis5euroretinitis .apillitis .seudoretinitisuring healing' =etinochoroidal shunt >essels C5, Gliosis ,itreal tractional $ands


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@n immunocompromised pts' ay sho" atypical features %arge conuent areas of necrosis :ilateral lesions


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aking the diagnosisainly $y clinical o$ser>ation of a focal necrotiing

retinochoroiditisTest such as serum antiBToxoplasma titers of @g and

@gG can support the dx .C= of a#ueous and >itreous sample ha>e high sensiti>ity

and high speci?city

4luorescein angiography and indoBcyanine greenangiography

5onspeci?c =ecent nonBin>asi>e photography techni#ues @nfrared and autouorescence0 can help determine the

extent of retinochoroiditis


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x 3erpiginous choroiditis C,

H3,0 HI, 4ungal retinitis 3eptic retinitisOcular toxocariasis

3arcoidosis 3yphilisTu$erculosis


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Toxocariasis


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3erpiginous choroiditis


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C,


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4ungal &ndophthalmitis


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Tx ToxoplasmosisGoal is to stop the multiplication of

the parasite during the acti>eperiod of retinochoroiditis and to

minimie further damageCandidates for Tx


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Tx Classic Therapy' .yrimethamine and

3ulfadiaine plus corticosteroids

7+B!99 mg of pyrimethamine daily for t"odays follo"ed $y a


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5e"er Tx intra>itreal in;ection of clindamycin and

dexamethasone

Higher intracellular penetration compared toother A$s like erythromycin and le>ooxacin

3tudies sho" that its ;ust as eJecti>e asolder txs

Gi>en the "idespread use of intra>itreal

dexamethasone0 it has also gainedacceptance as an ad;unct treatment forocular toxoplasmosis


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5e"er Tx Can add clindamycin "ith classic tx %aser photocoagulation and >itrectomy

has also $een used


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Tx in .regnancyuring pregnancy0 acti>e recurrent

lesions usually do not pose a threat tothe fetus

The mother should $e treated $utkeeping in mind the teratogenicpotential of the antimicro$ial agents0especially during the early stages of

pregnancy Com$ined intra>itreal in;ection of

clindamycin and dexamethasone may$e a $etter alternati>e in this case


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Tx in

@mmunocompromised =isk of dissemination and related

complications is high

.yrimethamine has an antagonistic acti>ityagainst idu>udine may $e a>oided or used in lo"er dosage in the

treatment regimen of patients "ith H@,)A@3"ho recei>e HAA=T

%ifetime maintenance therapy includingeither a lo"er dosage of pyrimethaminecom$ined "ith sulfadiaine or clindamycinor trimethoprim)sulfamethoxaole


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=ecurrence =ecurrence rate correlates in>ersely "ith the

period of follo"Bup

Other host factors and the particular strain of T-gondii may also play a roleOne study sho"ed that longBterm intermittent

treatment "ith trimethoprim)sulfamethoxBaolee>ery three days reduced the recurrence rate

@n t"o separate studies0 the recurrence rates"ithin t"o years "ere determined to $e $et"een+-KLB!9-(L


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Conclusions


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=eferences http'))"""-re>ie"ofophthalmology-com)co

ntent)d)retinalMinsider)c)ie"Pid!9-+8!+)apallergy-mode./:=

&A&= http'))"""-aapos-org)terms)conditions)!96

http'))"""-nc$i-nlm-nih-go>)pmc)articles).C(779*6K

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Toxoplasmosis Presentation

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