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Laviers H, Petzold A, Braithwaite T. How far should I manage acute optic neuritis as an ophthalmologist? A United Kingdom perspective. Eye (Lond) 2024; 38:2238-2245. [PMID: 38867071 PMCID: PMC11306244 DOI: 10.1038/s41433-024-03164-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 05/07/2024] [Accepted: 06/04/2024] [Indexed: 06/14/2024] Open
Abstract
Optic neuritis (ON) is an inflammation of or around the optic nerve, frequently caused by infectious or immune-mediated inflammatory disorders. In the UK, its strongest association is with Multiple Sclerosis (MS), though the combined prevalence of other associated infectious and immune-mediated inflammatory diseases (I-IMID) is similar to that of MS-ON. Prompt identification and understanding of ON's underlying cause informs tailored management and prognosis. Several IMIDs linked to ON, such as aquaporin-4 antibody-associated optic neuritis (AQP4-ON), myelin oligodendrocyte glycoprotein antibody-associated optic neuritis (MOG-ON), and neuro-sarcoidosis, show remarkable response to corticosteroid treatment. Therefore, urgent investigation and treatment are crucial in cases 'atypical' for MS-ON. Following the 1992 Optic Neuritis Treatment Trial, clinical practice has evolved, with short-course high-dose corticosteroids considered safe and effective for most people. Timely recognition of patients who could benefit is critical to avoid irreversible vision loss. This review provides a practical guide and a summary of evidence on the investigation and management of acute optic neuritis. It reflects the knowledge and limitations of current evidence, framed through the neuro-ophthalmic perspective of clinical practice at multiple UK academic centres.
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Affiliation(s)
- Heidi Laviers
- The Medical Eye Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Ophthalmology, King's College Hospital, London, UK
| | - Axel Petzold
- Neuro-ophthalmology Service, Moorfields Eye Hospital, London, UK
- Neuro-ophthalmology Service, The National Hospital for Neurology and Neurosurgery, London, UK
- Amsterdam University Medical Center (AUMC), Amsterdam, Netherlands
| | - Tasanee Braithwaite
- The Medical Eye Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK.
- The School of Immunology and Microbial Science and The School of Life Course and Population Sciences, King's College London, London, UK.
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2
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Amaral DC, Lane M, Aguiar EHC, Marques GN, Cavassani LV, Rodrigues MPM, Alves MR, Manso JEF, Monteiro MLR, Louzada RN. Surgical management of retinal detachment and macular holes secondary to ocular toxoplasmosis: a systematic review and meta-analysis. Int J Retina Vitreous 2024; 10:23. [PMID: 38424638 PMCID: PMC10903043 DOI: 10.1186/s40942-024-00540-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/03/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Toxoplasma gondii causes ocular toxoplasmosis (OT), involving inflammation, scarring, and retinal complications. The OT complications were retinal detachment (RD), and retinal breakage (RB). Surgical interventions like scleral buckling (SB) and vitrectomy are common. Limited understanding exists of the safety and efficacy of surgical management of RD/RB secondary to OT. Another complication is toxoplasmosis-related macular holes (tMH), with sparse evidence on surgical outcomes. This meta-analysis aims to clarify clinical characteristics, and surgical results, and enhance understanding of RD, RB, and MH secondary to OT. METHODS PubMed, Cochrane, Embase and Web of Science database were queried for retrospective studies, case series and case reports that provided information on RD, RB and MH associated with OT and reported the outcomes of: (1) Retinal reattachment of RD/RB and tMH closure; (2) Best-corrected visual acuity (BCVA) improvement; and (3) Complications. Heterogeneity was examined with I2 statistics. A random-effects model was used for outcomes with high heterogeneity. Statistical analysis was performed using the software R (version 4.2.3, R Foundation for Statistical Computing, Vienna, Austria). RESULTS Fourteen final studies, comprising a total of 96 patients were analyzed, 81 with RD or RB and 15 with tMH. Overall, surgical management was associated with several advantages: a high rate of retinal reattachment of RD/RB of 97% (95% Confidence Interval [CI] 92-100%; I2 = 0%), retinal reattachment of just RD of 96% (95% CI 89-100%; I2 = 30%) and tMH closure 97% (95% CI 87-100; I2 = 12%). There were significant differences in BCVA after surgeries in studies of RD/RB (MD 0.60; 95% CI 0.35-0.65; I2 = 20%) and MH (MD 0.67; 95% CI 0.50-0.84; I2 = 0%). The overall complication rate associated with surgical procedures in RD/RB secondary to OT was confirmed to be 25%. CONCLUSIONS The systematic review and meta-analysis showed that the treatment approaches currently in use are effective, with a remarkable rate of retinal reattachment of RD/RB, tMH closure, and substantial improvements in visual acuity. More randomized, long-term studies on disease and surgical factors can provide valuable insights into their impact on anatomical and visual outcomes.
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Affiliation(s)
- Dillan Cunha Amaral
- Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | | | | | | | | | | | | | - Ricardo Noguera Louzada
- Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
- Instituto de Olhos São Sebastião, Largo Do Machado 54, 1208, Rio de Janeiro, 22221-020, Brazil.
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Akhavanrezayat A, Uludag Kirimli G, Matsumiya W, Khojasteh H, Or C, Karaca I, Pham B, Ongpalakorn P, Lajevardi S, Lam B, Hwang JJ, Than NTT, Park S, Yavari N, Bazojoo V, Mobasserian A, Khatri A, Halim MS, Thng ZX, Ghoraba H, Do DV, Tugal-Tutkun I, Gupta V, de Smet M, Nguyen QD. The Role of Corticosteroids and Immunomodulatory Therapy in the Management of Infectious Uveitis. Ocul Immunol Inflamm 2024:1-12. [PMID: 38330155 DOI: 10.1080/09273948.2023.2296032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/11/2023] [Indexed: 02/10/2024]
Abstract
PURPOSE The index review aims to provide an update on the role of corticosteroids and steroid-sparing immunomodulatory therapy (IMT) in managing patients with infectious uveitis. METHOD Narrative literature review. RESULTS Corticosteroids and immunomodulatory therapy (IMT) focus on the host defense system instead of the pathogen, adjusting exaggerated inflammatory reactions to reduce potential harm to ocular tissues. Systemic or local corticosteroids are primarily selected as adjunctive medication for infectious uveitis. Concomitant corticosteroids have also been used in cases of paradoxical worsening in ocular tuberculosis and immune recovery uveitis in cytomegalovirus (CMV) retinitis. While there is no well-established evidence to support the use of IMT in infectious uveitis, it is occasionally used in clinical settings to treat persistent inflammation following resolution of infection such as cases of ocular tuberculosis and ocular syphilis where an insufficient response is observed with corticosteroids. CONCLUSION There is no consensus on the position of immunomodulatory therapy in the management of infectious uveitis with different etiologies. The index review provides an overview of available adjunctive corticosteroids and IMT options to assist clinicians in managing such disease entities more efficiently.
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Affiliation(s)
- Amir Akhavanrezayat
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Gunay Uludag Kirimli
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Wataru Matsumiya
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hassan Khojasteh
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Christopher Or
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Irmak Karaca
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Brandon Pham
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | | | - Sherin Lajevardi
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Brandon Lam
- Department of Ophthalmology, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Jaclyn Joyce Hwang
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ngoc Trong Tuong Than
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - SungWho Park
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Negin Yavari
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Vahid Bazojoo
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Azadeh Mobasserian
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Anadi Khatri
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Muhammad Sohail Halim
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Zheng Xian Thng
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Hashem Ghoraba
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Diana V Do
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
- Bayrampasa Eye Hospital, Eye Protection Foundation, Istanbul, Turkey
| | - Vishali Gupta
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Marc de Smet
- Department of Ophthalmology, MicroInvasive Ocular Surgery Clinic (MIOS), Lausanne, Switzerland
| | - Quan Dong Nguyen
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
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Yogeswaran K, Furtado JM, Bodaghi B, Matthews JM, Smith JR. Current practice in the management of ocular toxoplasmosis. Br J Ophthalmol 2023; 107:973-979. [PMID: 35197262 DOI: 10.1136/bjophthalmol-2022-321091] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/08/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Ocular toxoplasmosis is common across all regions of the world. Understanding of the epidemiology and approach to diagnosis and treatment have evolved recently. In November 2020, an international group of uveitis-specialised ophthalmologists formed the International Ocular Toxoplasmosis Study Group to define current practice. METHODS 192 Study Group members from 48 countries completed a 36-item survey on clinical features, use of investigations, indications for treatment, systemic and intravitreal treatment with antiparasitic drugs and corticosteroids, and approach to follow-up and preventive therapy. RESULTS For 77.1% of members, unilateral retinochoroiditis adjacent to a pigmented scar accounted for over 60% of presentations, but diverse atypical presentations were also reported. Common complications included persistent vitreous opacities, epiretinal membrane, cataract, and ocular hypertension or glaucoma. Most members used clinical examination with (56.8%) or without (35.9%) serology to diagnose typical disease but relied on intraocular fluid testing-usually PCR-in atypical cases (68.8%). 66.1% of members treated all non-pregnant patients, while 33.9% treated selected patients. Oral trimethoprim-sulfamethoxazole was first-line therapy for 66.7% of members, and 60.9% had experience using intravitreal clindamycin. Corticosteroid drugs were administered systemically by 97.4%; 24.7% also injected corticosteroid intravitreally, almost always in combination with an antimicrobial drug (72.3%). The majority of members followed up all (60.4%) or selected (35.9%) patients after resolution of acute disease, and prophylaxis against recurrence with trimethoprim-sulfamethoxazole was prescribed to selected patients by 69.8%. CONCLUSION Our report presents a current management approach for ocular toxoplasmosis, as practised by a large international group of uveitis-specialised ophthalmologists.
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Affiliation(s)
- Kengadhevi Yogeswaran
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - João M Furtado
- Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Janet M Matthews
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Justine R Smith
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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Castaño BL, Silva AA, Hernandez-Velasco LL, Pinheiro APDS, Gibaldi D, Mineo JR, Silva NM, Lannes-Vieira J. Sulfadiazine Plus Pyrimethamine Therapy Reversed Multiple Behavioral and Neurocognitive Changes in Long-Term Chronic Toxoplasmosis by Reducing Brain Cyst Load and Inflammation-Related Alterations. Front Immunol 2022; 13:822567. [PMID: 35572567 PMCID: PMC9091718 DOI: 10.3389/fimmu.2022.822567] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Toxoplasma gondii infects one-third of the world population. For decades, it has been considered a silent lifelong infection. However, chronically T. gondii-infected persons may present psychiatric and neurocognitive changes as anxiety, depression, and memory loss. In a model of long-term chronic infection, behavioral alterations parallel neuroinflammation and systemic high cytokine levels, and may reflect brain cyst load. Recent findings support that in chronic infection an active parasite-host interplay involves an immune-mediated control of tissue cysts. Here, we tested the idea that etiological treatment in chronic phase may add advantage to intrinsic immune-mediated cyst control and impact behavioral changes. Thus, we combined sulfadiazine-plus-pyrimethamine (S+P), the first-choice therapy for toxoplasmosis, to study the association of brain cyst load and biological processes related to the immune response (neuroinflammation, blood-brain barrier -BBB- disruption and serum cytokine levels), with behavioral and neurocognitive changes of long-term chronic infection. Female C57BL/6 mice (H-2b) were infected (5 cysts, ME-49 strain) and treated with S+P from 30 to 60 days postinfection (dpi), compared with vehicle (Veh)-treated and noninfected controls. At endpoints (pre-therapy, 30 dpi; S+P therapy, 60 dpi; after ceased therapy, 90 dpi), independent groups were subjected to behavioral tests, and brain tissues and sera were collected. Multiple behavioral and neurocognitive changes were detected in the early (30 dpi) and long-term (60 and 90 dpi) chronic infection. S+P therapy resolved locomotor alterations, anxiety, and depressive-like behavior, partially or transiently ameliorated hyperactivity and habituation memory loss. Analysis after therapy cessation showed that S+P therapy reduced the number of stimuli required for aversive memory consolidation. S+P therapy resulted in reduced brain cyst load, neuroinflammation and BBB disruption, and lowered systemic Th1-cytokine levels. Correlation analysis revealed association between IFNγ, TNF and MCP-1/CCL2 serum levels, brain cyst load and behavioral and neurocognitive alterations. Moreover, principal-component analysis (PCA-2D and 3D projections) highlighted distinction between clusters (noninfected; Veh-treated and S+P-treated infected). Thus, our data suggest that S+P therapy added gain to intrinsic brain cyst control and, direct or indirectly, ameliorated inflammation-related alterations, traits associated with behavioral and neurocognitive alterations.
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Affiliation(s)
- Barrios Leda Castaño
- Laboratory of Biology of the Interactions, Oswaldo Cruz Institute/Fiocruz, Rio de Janeiro, Brazil
| | - Andrea Alice Silva
- Multiuser Laboratory for Research Support in Nephrology and Medical Sciences, Federal University Fluminense, Niterói, Brazil
| | | | | | - Daniel Gibaldi
- Laboratory of Biology of the Interactions, Oswaldo Cruz Institute/Fiocruz, Rio de Janeiro, Brazil
| | - José Roberto Mineo
- Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, Brazil
| | - Neide Maria Silva
- Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, Brazil
| | - Joseli Lannes-Vieira
- Laboratory of Biology of the Interactions, Oswaldo Cruz Institute/Fiocruz, Rio de Janeiro, Brazil
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Schaeffer M, Ballonzoli L, Gaucher D, Arndt C, Angioi-Duprez K, Baudonnet R, Bodaghi B, Bron A, Chiambaretta F, Cimon B, Chiquet C, Creuzot-Garcher C, Daien V, Deleplanque AS, Fricker-Hidalgo H, Hadjadj E, Houze S, Ifrah T, Korobelnik JF, Labalette P, Le Lez ML, L’Ollivier C, Mercie M, Mouriaux F, Paris L, Pelloux H, Pomares C, Quintyn JC, Rougier MB, Rousseau A, Soler V, Talmud M, Villena I, Villard O, Speeg-Schatz C, Bourcier T, Sauer A. Prise en charge de la toxoplasmose oculaire en France : résultats d’une étude Delphi modifiée. J Fr Ophtalmol 2022; 45:413-422. [DOI: 10.1016/j.jfo.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/08/2021] [Accepted: 11/08/2021] [Indexed: 11/29/2022]
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7
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Duraffour P, Mehanna C, Hoogewoud F, Touboul A, Monnet D, Brézin AP. Comparison between the areas of scarred and active toxoplasmic retinochoroiditis. Eye (Lond) 2021; 35:2733-2739. [PMID: 33235345 PMCID: PMC8452670 DOI: 10.1038/s41433-020-01290-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND/OBJECTIVES To assess the ratio of scarred/active areas of fundus lesions in patients with presumed ocular toxoplasmosis. SUBJECTS/METHODS Retrospective monocentric study of patients with presumed ocular toxoplasmosis seen between May 2004 and February 2018. Patients with a positive anti-Toxoplasma serology presenting characteristic fundus lesions. Cases with images of both baseline active and scarred lesions of the fundus were included. The borders of each active or scarred lesion were delineated on colour photographs by two independent observers and the area of the lesions was calculated using Digimizer 4.2.2 (MedCalc Software, Ostend, Belgium). The interobserver variability of the measures was recorded and their means were used for further calculations. To study the ratio of the area of scarred retinochoroiditis over the area of the baseline active lesion (R). RESULTS A total of 171 cases (83 males, 88 females) with a mean age of 31.6 ± 13.8 years were included. The average areas of active and scarred retinochoroiditis were, respectively, 1.32 ± 1.59 and 1.79 ± 2.36 optic disc area. The average ratio between scarred and active areas of retinochoroiditis was 1.36 [range 0.54-2.18]. The administration of a systemic treatment [R = 1.25, p = 0.003], the absence of a pre-existing scar [R = 1.05, p < 0.001] and a peripapillary location of the lesion [R = 0.85, p < 0.001] were each significantly associated with smaller scarred/active area ratios. CONCLUSIONS We assessed in a standardized manner the ratio of scarred/active areas of toxoplasmic lesions and showed that the area of scarred lesions was on average slightly larger than the area of active retinochoroiditis.
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Affiliation(s)
- Pierre Duraffour
- grid.411784.f0000 0001 0274 3893Service d’ophtalmologie, Hôpital Cochin, Assistance Publique – Hôpitaux de Paris, Paris, France ,grid.508487.60000 0004 7885 7602Université de Paris, Paris, France
| | - Chadi Mehanna
- grid.411784.f0000 0001 0274 3893Service d’ophtalmologie, Hôpital Cochin, Assistance Publique – Hôpitaux de Paris, Paris, France ,grid.412134.10000 0004 0593 9113Département de biostatistiques, Hôpital Necker-Enfants Malades, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Florence Hoogewoud
- grid.411784.f0000 0001 0274 3893Service d’ophtalmologie, Hôpital Cochin, Assistance Publique – Hôpitaux de Paris, Paris, France ,grid.508487.60000 0004 7885 7602Université de Paris, Paris, France
| | - Arnaud Touboul
- grid.411784.f0000 0001 0274 3893Service d’ophtalmologie, Hôpital Cochin, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Dominique Monnet
- grid.411784.f0000 0001 0274 3893Service d’ophtalmologie, Hôpital Cochin, Assistance Publique – Hôpitaux de Paris, Paris, France ,grid.508487.60000 0004 7885 7602Université de Paris, Paris, France
| | - Antoine P. Brézin
- grid.411784.f0000 0001 0274 3893Service d’ophtalmologie, Hôpital Cochin, Assistance Publique – Hôpitaux de Paris, Paris, France ,grid.508487.60000 0004 7885 7602Université de Paris, Paris, France
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Treatment Strategy in Human Ocular Toxoplasmosis: Why Antibiotics Have Failed. J Clin Med 2021; 10:jcm10051090. [PMID: 33807871 PMCID: PMC7961948 DOI: 10.3390/jcm10051090] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Background: There is currently no clear evidence of the effectiveness of antibiotic therapy in acute ocular toxoplasmosis (OT), but its effect as a secondary prophylaxis is undisputed. The majority of uveitis specialists advocate treatment. This meta-analytic review aims to critically analyze determinants of treatment success and to update current treatment strategies for OT in order to explain this discrepancy. Methods: A systematic literature search was performed in NCBI/PubMed, Clinical Trials, Google Scholar and ScienceDirect to retrieve pro- and retrospective studies using the key terms “ocular toxoplasmosis” or “retinochoroiditis” and “immunocompetent” and “treatment” or “therapy” and “human.” Of these, larger case series and prospective clinical studies and cross references identified from meta-analyses were selected by a manual search, and primary and secondary outcome parameters were extracted. Results: Ten case series and clinical trials reported success parameters for treatment outcomes, and four additional for recurrence prophylaxis. Five treatment studies were randomized clinical trials, three comparative and two noncomparative case series. Though several outcome parameters were reported, five of them defined time to healing, four visual gain and one lesion size as primary and secondary outcome parameters, recurrence rate as a secondary outcome parameter was reported once. No conclusive evidence was found for an antibiotic treatment effect. Four prophylaxis studies addressed the prevention of recurrences after treatment. The primary outcome in all studies was the effect of treatment and prophylaxis on recurrences, and all four found a significant effect on the risk of and time to recurrences. Conclusions: Antibiotic treatment of OT aims at controlling parasite proliferation. The absence of an effect on visual acuity and time to healing is thus not surprising. The fact that time to and number of recurrences respond to recurrence of prophylaxis proves the antibiotic effect on parasite activity.
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Yazdanpanah O, Monday LM, Surapaneni S, Singh V, Chi J. Ocular Toxoplasmosis Mimicking Lymphoma: Exploring the Correlation and Distinction. Cureus 2021; 13:e13014. [PMID: 33659144 PMCID: PMC7920518 DOI: 10.7759/cureus.13014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We present a case of a 74-year-old woman with chronic lymphocytic leukemia (CLL) who presented with unilateral blurry vision that had progressively worsened over a few weeks. Ophthalmic examination revealed unilateral anterior chamber, vitreous body inflammation along with retinal infiltration which was initially diagnosed with posterior uveitis. Analysis of vitreous fluid aspiration was negative for bacteria, fungal and viral etiologies. Despite the broad-spectrum intraocular antibiotics, her vision continued to decline, and she later developed retinal detachment. Cytology for lymphoma was negative. However, polymerase chain reaction (PCR) with internal transcribed spacer-specific (ITS) primer set detected Toxoplasma gondii, and the patient was diagnosed with intraocular toxoplasmosis. Treatment with systemic clindamycin, pyrimethamine, leucovorin, prednisone, and topical clindamycin for four weeks successfully prevented further ocular damage.
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Affiliation(s)
- Omid Yazdanpanah
- Internal Medicine, Wayne State University School of Medicine, Detroit, USA.,Internal Medicine, Wayne State University Detroit Medical Center, Detroit, USA
| | - Lea M Monday
- Internal Medicine, John D. Dingell VA Medical Center, Detroit, USA.,Internal Medicine, Wayne State University Detroit Medical Center, Detroit, USA
| | - Sarvani Surapaneni
- Internal Medicine, Wayne State University School of Medicine, Detroit, USA.,Internal Medicine, Wayne State University Detroit Medical Center, Detroit, USA
| | - Vijendra Singh
- Hematology and Oncology, Karmanos Cancer Institute, Detroit, USA
| | - Jie Chi
- Internal Medicine, Wayne State University Detroit Medical Center, Detroit, USA
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10
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Mobini M, Ahmadzade-Amiri A, Ghasemian R, Torabizadeh Z, Fakhar M. Heerfordt-Waldenström syndrome, a rare presentation of sarcoidosis in a patient with old ocular toxoplasmosis. Infect Disord Drug Targets 2020; 21:629-633. [PMID: 32901589 DOI: 10.2174/1871526520666200909094500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 06/19/2020] [Accepted: 07/27/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND There are similarities between ophthalmic presentation of toxoplasmosis and sarcoidosis and there are some concerns of immunosuppressive treatments for sarcoidosis may lead to T. gondii reactivation. We report a rare case with acute sarcoidosis (Heerfordt-Waldenström syndrome) and past history of ocular toxoplasmosis from the North of Iran. CASE PRESENTATION The patient was a 36-year-old woman, with left painful eye and swollen parotid, right facial paresis, maculopapular rash in left eyebrow and erythema nodosa on both legs. Anti-Toxoplasma IgG antibody was positive and IgM was not detectable. Radiographic findings on chest revealed bilateral hilar lymphadenopathy. The initial treatment was sulfamethoxazole-trimethoprim to prevent recurrence of retinal toxoplasmosis and corticosteroid and mycophenolate mofetil for sarcoidosis. The patient showed clinical and vision improvement without recurrences during three months follow-up. DISCUSSION Ophthalmological examinations and laboratory test to rule out toxoplasmosis could be considered in known cases of sarcoidosis particularly in ocular sarcoidosis status. To the best of our knowledge this is first report of co-morbidity of ocular toxoplasmosis / sarcoidosis from Iran and possibly the world.
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Affiliation(s)
- Maryam Mobini
- Department of Internal Medicine, Diabetes Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari. Iran
| | - Ahmad Ahmadzade-Amiri
- Department of Ophthalmology, Diabetes Research Center, Mazandaran University of Medical Sciences, Sari. Iran
| | - Roya Ghasemian
- Department of Infectious Diseases, Antimicrobial Resistance Research Center, Mazandaran University of Medical Sciences, Mazandaran. Iran
| | - Zhila Torabizadeh
- Department of Pathology, Mazandaran University of Medical Sciences, Mazandaran. Iran
| | - Mahdi Fakhar
- Toxoplasmosis Research Center, Iranian National Registry Center for Toxoplasmosis (INRCT), Department of Parasitology, Mazandaran University of Medical Sciences, Sari. Iran
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11
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Zhang Y, He J, Zheng H, Huang S, Lu F. Association of TREM-1, IL-1β, IL-33/ST2, and TLR Expressions With the Pathogenesis of Ocular Toxoplasmosis in Mouse Models on Different Genetic Backgrounds. Front Microbiol 2019; 10:2264. [PMID: 31649630 PMCID: PMC6794992 DOI: 10.3389/fmicb.2019.02264] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 09/17/2019] [Indexed: 12/11/2022] Open
Abstract
Ocular toxoplasmosis (OT) is one of the most common causes of posterior uveitis. The signaling of triggering receptor expressed on myeloid cells (TREM)-1 amplifies inflammation, whereas TREM-2 signaling is anti-inflammatory. IL-1β is a major driver of inflammation during infection. Toll-like receptors (TLRs) play important roles in protective immune response during Toxoplasma gondii infection, and interleukin (IL)-33 receptor (T1/ST2) signaling prevents toxoplasmic encephalitis in mice. However, the pathogenic mechanisms of OT are not yet well elucidated. To investigate the role of TREM-1, TREM-2, IL-1β, IL-33/ST2, and TLRs in OT of susceptible C57BL/6 (B6) and resistant BALB/c mice, both strains of mice were intravitreally infected with 500 tachyzoites of the RH strain of T. gondii. Histopathological analysis showed that T. gondii-infected B6 mice had more severe ocular damage observed by light microscopy, higher number of neutrophil elastase-positive cells in the eyes detected by immunohistochemical staining, more T. gondii tachyzoites in the eyes observed by transmission electron microscopy, and higher mRNA expression levels of tachyzoite-specific surface antigen 1 detected by quantitative real-time reverse transcription-polymerase chain reaction (qRT-PCR) in comparison of T. gondii-infected BALB/c mice. Detected by using qRT-PCR, the mRNA expression levels of TREM-1, IL-1β, IL-33, ST2, TLR11, TLR12, and TLR13 were significantly higher in the eyes of T. gondii-infected B6 mice than those of T. gondii-infected BALB/c mice, whereas the mRNA expression levels of TLR3 and TLR9 were significantly higher in the eyes of T. gondii-infected BALB/c mice than those of T. gondii-infected B6 mice. Correlation analysis showed that significant positive correlations existed between TREM-1 and IL-1β/IL-33/ST2/TLR9/TLR11 in the eyes of B6 mice and existed between TREM-1 and IL-33/ST2/TLR3/TLR9/TLR13 in the eyes of BALB/c mice after ocular T. gondii infection. Our data revealed that, compared with T. gondii-resistant BALB/c mice, ocular T. gondii infection can stimulate higher production of TREM-1, IL-33, ST2, TLR11, TLR12, and TLR13 in the eyes of T. gondii-susceptible B6 mice, however, whether those lead to more severe ocular pathology in the susceptible B6 mice remain to be further studied.
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Affiliation(s)
- Yanxia Zhang
- Department of Parasitology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Tropical Disease Control of Ministry of Education, Sun Yat-sen University, Guangzhou, China
| | - Jian He
- Department of Parasitology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Tropical Disease Control of Ministry of Education, Sun Yat-sen University, Guangzhou, China.,Public Experimental Teaching Center, Sun Yat-sen University, Guangzhou, China
| | - Huanqin Zheng
- Department of Parasitology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Tropical Disease Control of Ministry of Education, Sun Yat-sen University, Guangzhou, China
| | - Shiguang Huang
- School of Stomatology, Jinan University, Guangzhou, China
| | - Fangli Lu
- Department of Parasitology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Tropical Disease Control of Ministry of Education, Sun Yat-sen University, Guangzhou, China
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Treatment of Toxoplasmosis: Historical Perspective, Animal Models, and Current Clinical Practice. Clin Microbiol Rev 2018; 31:31/4/e00057-17. [PMID: 30209035 DOI: 10.1128/cmr.00057-17] [Citation(s) in RCA: 251] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Primary Toxoplasma gondii infection is usually subclinical, but cervical lymphadenopathy or ocular disease can be present in some patients. Active infection is characterized by tachyzoites, while tissue cysts characterize latent disease. Infection in the fetus and in immunocompromised patients can cause devastating disease. The combination of pyrimethamine and sulfadiazine (pyr-sulf), targeting the active stage of the infection, is the current gold standard for treating toxoplasmosis, but failure rates remain significant. Although other regimens are available, including pyrimethamine in combination with clindamycin, atovaquone, clarithromycin, or azithromycin or monotherapy with trimethoprim-sulfamethoxazole (TMP-SMX) or atovaquone, none have been found to be superior to pyr-sulf, and no regimen is active against the latent stage of the infection. Furthermore, the efficacy of these regimens against ocular disease remains uncertain. In multiple studies, systematic screening for Toxoplasma infection during gestation, followed by treatment with spiramycin for acute maternal infections and with pyr-sulf for those with established fetal infection, has been shown to be effective at preventing vertical transmission and minimizing the severity of congenital toxoplasmosis (CT). Despite significant progress in treating human disease, there is a strong impetus to develop novel therapeutics for both the acute and latent forms of the infection. Here we present an overview of toxoplasmosis treatment in humans and in animal models. Additional research is needed to identify novel drugs by use of innovative high-throughput screening technologies and to improve experimental models to reflect human disease. Such advances will pave the way for lead candidates to be tested in thoroughly designed clinical trials in defined patient populations.
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