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Grand Ward Round 2 nd August 2007

Grand Ward Round 2 nd August 2007. Francine Yang Medical Officer. History. Mdm HS 51 year old Indian female Past medical history: Diabetes mellitus – on Metformin Hypertension – on Nifedipine Hyperlipidemia – on Simvastatin Manic depression – on Lithium, Benil & Haloperidol.

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Grand Ward Round 2 nd August 2007

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  1. Grand Ward Round2nd August 2007 Francine Yang Medical Officer

  2. History Mdm HS 51 year old Indian female Past medical history: • Diabetes mellitus – on Metformin • Hypertension – on Nifedipine • Hyperlipidemia – on Simvastatin • Manic depression – on Lithium, Benil & Haloperidol

  3. Presented on 5th July 2007: • Left eye floaters for 2 weeks • Photopsia for past 1 year

  4. On examination…

  5. Left Fundus (Superior temporal region): Lesion, vitritis, vascular sheating Right fundus was normal

  6. Differential diagnoses Posterior uveitis: Yellowish-white retinal lesion with surrounding vasculitis Causes to Consider • Infective: • Parasitic Uveitis • Toxoplasma retinitis • Toxocariasis • Bacterial • Tuberculosis • Syphilis • Viral Uveitis • Non-infective: • Sarcoidosis • Bechet’s disease

  7. Investigations • FBC • ESR, CRP • RPR, TPPA • Toxoplasma IgM & IgG • Mantoux test • AC tap for Tetraplex PCR & TB PCR • Heptatits B screen • LFT

  8. Results • TWC 9.9 • ESR 19, CRP 2.1 • RPR & TPPA non-reactive • Toxoplasma IgM reactive, IgG >300 • Mantoux test: negative at 72 hours • AC tap: CMV DNA – not detected HSV PCR – not detected VZV DNA – not detected T. gondii – detected Mycobacterium TB – negative • LFT normal • Hepatitis B screen negative

  9. Toxoplasmosis • Causative agent: Toxoplasma gondii • Obligate intra-cellular protozoan • Host: domestic cat • Transmission: ingestion, transplacental • Life cycle: oocysts, trophozoites, bradyzoites (within cysts) • Pathogenesis • Ingestion of cysts in undercooked meat or contact with cat faeces • Small intestine: cysts rupture, trophozoites rapidly multiply and invade the intestinal wall • Spread and enter host cells • Develop into cysts in which the parasites multiply slowly (bradyzoites) • Cell mediated immunity limits spread and when contained, organisms persist as cysts within tissues • No inflammation • Asymptomatic unless immunosuppression allows activation of the organisms within the cysts

  10. Clinical Manifestations • Most primary infections in immunocompetent adults are asymptomatic • Immunocompromised Life-threatening disseminated disease, encephalitis • Congenital infection: still birth, neonatal disease with encephalitis and chorioretinitis

  11. Toxoplasma Retinitis • Most frequent cause of infectious retinitis in immunocompetent individuals • Majority are acquired postnatally • Reactivation: recurrent episodes of inflammation when cysts rupture • Symptoms • Unilateral, sudden onset of floaters, visual loss and photophobia • Clinical features • White-yellow retinal lesion: usually solitary, multiple foci uncommon • Old pigmented chorioretinal scar • Severe vitritis, focal, “headlight in the fog” • Optic nerve or macular involvement • AC inflammation • IOP may be increased in 10-20% • Immunocompromised patients: Atypical features • Extensive confluent areas of retinitis • Absence of pre-existing scar suggesting that the infestation is newly acquired or disseminated from extra-ocular sources • Minimal/ No vitritis

  12. Course • Immunocompetent patients: healing occurs within 6-8 weeks • Inflammatory focus replaced by a sharply demarcated atrophic scar with a hyperpigmented border • Vitreous opacities take longer to resolve • Resolution of anterior uveitis is a reliable sign of posterior segment healing • Complications: serious visual loss • Macula involvement • Optic nerve head involvement • Occlusion of major blood vessel

  13. Management • Aims • Reduce duration and severity of acute inflammation • Lessen risk of permanent visual loss • Reduce risk of recurrence

  14. Treatment Regime • Pyrimethamine + Folinic acid + Sulfadiazine • Prednisolone • Clindamycin • Alternative therapies: Atovaquone, Trimethroprim/ Sulfamethoxazole • Adjuncts: Laser photocoagulation, cryotherapy, vitrectomy • Maintenance therapy for immunosuppressed patients

  15. Progress • 5th July 4007 • G. Pred Forte 2 hourly • G. Atropine BD • 9th July: improvement in symptoms, decrease in floaters • Lab results available • Examination findings similar to at presentation • IOP: 23 in both eyes • Continued on G. Pred Forte and Atropine • Started on Clindamycin 300mg QDS • Prednisolone 40mg OM x 1 week, then 35mg OM LE

  16. 12th July • OS: edges of the lesion more well-defined • OD: ? New focus of chorioretinitis, no vitritis, no vasculitis • 16th July: decrease in left eye floaters • OS: edge of lesion drying up, residual vasculitis • OD: no change in size of suspect lesion • 23rd July • FFA done • OS: lesion improving morphologically • On third week of oral Clindamycin • Weekly review

  17. 23rd July 2007

  18. Literature Review • Ocular Toxoplasmosis: Clinical features and prognosis of 154 patients Lotje E H, Bosch-Driessen, Tos T J, M Berendschot, J V Ongkosuwito, A Rothova. Ophthalmology 2002; 109: 869-878 • Observational case series of 154 patients with active lesions of ocular toxoplasma • 28% presenting with primary retinal lesions, 72% with a combination of active lesions and old scars • Primary ocular toxoplasmosis was noted clinically in 82% of the patients with confirmed serologic characteristics of acute phase infection (IgM +) • 2 peaks in presenting age: • 15-35 years for active OT during the chronic phase of systemic infection • 50-70 years for active OT during the acute stage of systemic infection

  19. Clinical features • Macular lesions were more common in patients with congenital infection • Peripheral lesions more common in post-natally acquired toxoplasmosis • Retinal lesions adjacent to the optic nerve manifested in 21% of patients in the chronic phase of infection; absent in patient’s in the acute phase Prognosis and course • Recurrence occurred in 60% • Manifested in 49% of previously affected eyes and 3% of initially healthy eyes • 24% developed blindness in 1 eye, 1% bilaterally • Factors: macular location of retinal lesion, retinal detachment, optic nerve atrophy, corticostoids without anti-parasitic drugs, congenital toxoplasmosis

  20. Antibiotics for Toxoplasmic Retinochoroiditis: An evidence-based systemic review. Miles R, Stanford, Sarah E See, Leanne V Jones, Ruth E Gilbert. Ophthalmology 2003; 110: 926-932

  21. Effects of reatment on recurrence • Belfore et al. • Patients treated for 14 months were less likely to have recurrent lesions than untreated patients • Effects of treatment on short term changes in visual acuity and acute chorioretinitis • Inconsistent Prospective, randomised trial of pyrimethamine and azithromycin vs pyrimethamine and sulfadiazine for the treatment of ocular toxoplasmosis Prospective randomized trial of trimethoprim/ sulfamethoxazole versus pyrimethamine and sulfadiazine in the treatment of ocular toxoplasmosis Atovaquone for the treatment of toxoplasma retinochoroiditis in immunocompetent patients

  22. Thank you

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