Intrauterine herpes simplex virus infections

Neonatal herpes simplex virus (HSV) infection is usually acquired at birth, although a few infants have had findings suggestive of intrauterine infection. We describe 13 babies who had clinical manifestations of intrauterine HSV infection, including skin lesions and scars at birth (12), chorioretinitis (eight), microcephaly (seven), hydranencephaly (five), and microphthalmia (two). All infants had combinations of these defects. Infection was proved by viral isolation in each case; all isolates were HSV-2. Two infants died during the first week of life; 10 of the surviving infants had severe neurologic sequelae, and one infant was blind. Four mothers experienced an apparent primary genital HSV infection, and one had recurrent infection, at varying times during gestation. The remaining women denied a history of symptoms of genital HSV infection. These findings indicate that intrauterine HSV infection can occur as a consequence of either primary or recurrent maternal infection and has severe consequences for the fetus.

Acute syphilitic posterior placoid chorioretinitis

Six patients with evidence of secondary syphilis presented with visual loss in both eyes caused by large, placoid, yellowish lesions with faded centers at the level of the pigment epithelium in the macula and juxtapapillary areas. All eyes had vitreitis. All of the lesions showed a similar fluorescein angiographic pattern of early hypofluorescence and late staining. Five patients had mucocutaneous lesions typical of secondary syphilis. All five patients treated with antibiotics had prompt improvement in visual function and resolution of the fundus lesions. The ophthalmoscopic and angiographic appearance of these posterior fundus lesions was sufficiently characteristic to suggest a diagnosis of secondary syphilis. Modification of the host response to syphilis by human immune deficiency virus (HIV) infection may be partly responsible for this peculiar fundus picture. Three of the four patients tested positive for HIV.

Toxocariasis

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Chorioretinal involvement in patients with West Nile virus infection☆

PURPOSE

To characterize and analyze the chorioretinal manifestations of West Nile virus (WNV) infection.

DESIGN

Prospective, noncomparative case series.

PARTICIPANTS

Twenty-nine consecutive patients with serologically confirmed WNV infection in the setting of an outbreak of the disease.

METHODS

The average duration of systemic symptoms before ophthalmic examination was 10 days (range, 2-30 days). All participants underwent a detailed ophthalmic examination at presentation and regularly throughout follow-up, including dilated biomicroscopic fundus examination, fundus photography, and fluorescein angiography.

RESULTS

A typical multifocal chorioretinitis was observed in 20 of 29 patients (69%) bilaterally at presentation and developed later during follow-up in 3 patients (10.3%), bilaterally (n = 1) or unilaterally (n = 2). Multifocal chorioretinitis was associated with mild vitreous inflammatory reaction in all cases. Other findings included intraretinal hemorrhages (21 patients [72.4%]), white-centered retinal hemorrhages (7 patients [24.1%]), focal retinal vascular sheathing (3 patients [10.4%]), marked diffuse retinal arterial sheathing (1 patient [3.4%]), retinal vascular leakage (5 patients [17.2%]), optic disc swelling (2 patients [6.9%]), optic disc staining (6 patients [20.7%]), segmental zones of retinal pigment epithelium changes (1 patient [3.4%]), and nonproliferative diabetic retinopathy (7 patients [24.1%]). The posterior segment findings related to WNV disease had a self-limited course in all patients.

CONCLUSIONS

Chorioretinal involvement, frequently asymptomatic and self-limited, is common in patients with acute WNV infection. The unique pattern of multifocal chorioretinitis in patients with systemic symptoms suggestive of WNV can help to establish the diagnosis while serologic testing is pending. Therefore, a systematic ocular evaluation, including dilated fundus examination and fluorescein angiography in selected cases, is recommended in patients with clinically suspected WNV infection.

Choroidopathy of systemic lupus erythematosus

PURPOSE

To describe the ocular and systemic manifestations associated with systemic lupus erythematosus (SLE) choroidopathy.

METHODS

Three new cases of choroidopathy in patients with active SLE were described. Twenty-five published cases of lupus choroidopathy were summarized.

RESULTS

There have been 28 cases of lupus choroidopathy (47 involved eyes) that have been reported in the English literature since 1968, including the three current cases. Only two of the patients were male. The choroidopathy was bilateral in 19 patients (68%). All 28 patients (100%) had active systemic vascular disease at the onset of their choroidopathy; 18 (64%) had nephropathy and 10 (36%) had central nervous system (CNS) lupus vasculitis. All but one of the patients had a known diagnosis of SLE at the onset of choroidopathy. 30 of the 47 involved eyes had presenting visual acuity of 20/40 or better; 14 eyes showed improvement in visual acuity with therapy. 23 patients (82%) had resolution of their choroidopathy when their systemic disease was brought under control. Despite treatment, 4 of the 28 patients (14%) died from complications of SLE.

CONCLUSIONS

Although less known than retinopathy, lupus choroidopathy may be more common than generally appreciated. It usually serves as a sensitive indicator of lupus activity. The presence of SLE choroidopathy is generally indicative of coexistent (although sometimes occult) nephropathy, CNS vasculitis, and other SLE visceral lesions. Immunomodulation of the systemic disease can lead to improvement and resolution of the systemic vasculitis as well as the choroidopathy.

Population based assessment of uveitis in an urban population in southern India

AIM

To assess the prevalence of active and inactive uveitis unrelated to previous surgery or trauma in an urban population in southern India.

METHODS

As part of the Andhra Pradesh Eye Disease Study, 2522 subjects (85.4% of those eligible), a sample representative of the population of Hyderabad city in southern India, underwent interview and detailed dilated eye examination. Presence of sequelae of uveitis without current active inflammation was defined as inactive uveitis.

RESULTS

Unequivocal evidence of active or inactive uveitis unrelated to previous surgery or trauma was present in 21 subjects, an age-sex adjusted prevalence of 0.73% (95% confidence interval (CI) 0.44-1.14%). Active uveitis was present in eight subjects, an age-sex adjusted prevalence of 0.37% (95% CI 0. 19-0.70), of which 0.06% was anterior, 0.25% intermediate, and 0.06% posterior. The 0.36% (95% CI 0.17-0.68%) prevalence of inactive uveitis included macular chorioretinitis scars (0.26%), anterior (0. 07%) and previous vasculitis involving the whole eye (0.03%). The prevalence of visual impairment due to uveitis of less than 6/18 in at least one eye was 0.27%, less than 6/60 in at least one eye was 0. 16%, and less than 6/60 in both eyes was 0.03%.

CONCLUSION

These population based cross sectional data give an estimate of the prevalence of various types of uveitis in this urban population in India. Active or past uveitis that might need treatment at some stage was present in one of every 140 people in this population.

Syphilitic uveitis in patients infected with human immunodeficiency virus

BACKGROUND

This work investigates the incidence and clinical features of syphilitic uveitis in patients infected with human immunodeficiency virus (HIV).

MATERIAL AND METHODS

We retrospectively reviewed syphilitic uveitis in patients coinfected with HIV that presented at a referral center between July 2001 and November 2003.

RESULTS

Twelve patients (20 eyes) were included. The ocular manifestations of syphilis led to the discovery of HIV-1 seropositivity in three patients. All patients were male and homosexual. One patient has been previously treated for syphilis with benzathine penicillin G. One patient presented with anterior uveitis and 11 patients had panuveitis or posterior uveitis. Necrotizing retinitis was noted in seven eyes (35%), posterior placoid chorioretinitis in six eyes (30%) and optic nerve involvement in five eyes (25%). Of nine patients with available cerebrospinal fluid (CSF) studies, seven (77.8%) had CSF abnormalities. Eleven patients were treated with intravenous penicillin G and one with intravenous ceftriaxone sodium. One patient required a second course of antibiotics to control uveitis. Ocular inflammation decreased and visual acuity improved in all nine patients for whom follow-up was available after treatment.

CONCLUSION

Manifestations of syphilitic uveitis in HIV-infected patients are multiple, with high frequencies of posterior uveitis, posterior placoid chorioretinitis, necrotizing retinitis and optic nerve involvement. Syphilitic uveitis in HIV-infected patients seems to have a more severe course and may relapse despite high-dose intravenous penicillin therapy.

Assessment and classification of choroidal vasculitis in posterior uveitis using indocyanine green angiography

BACKGROUND

By allowing one to detect fluorescence beyond the retinal pigment epithelium, indocyanine green angiography (ICGA) has made it possible to analyse the choroidal vessels. Our aim was to characterize choroidal vasculitis in posterior uveitis using ICGA.

METHODS

Charts of active posterior uveitis patients with a specific diagnosis seen in the different centers participating in the study who had undergone dual fluorescein and ICG angiography were reviewed. The type of inflammatory involvement of the choroidal circulation at entry and the treatment response on follow-up angiograms were analysed.

RESULTS

A total of 129 patients were analysed. Choroidal vasculitis could be subdivided into two main patterns: (1) primary inflammatory choriocapillaropathy and (2) stromal inflammatory vasculopathy. The first pattern consisted of hypofluorescent areas up to the late phase of angiography characteristic for choriocapillaris non-perfusion and included entities such as multiple evanescent white dot syndrome (MEWDS), acute posterior multifocal placoid pigment epitheliopathy (APMPPE), multifocal choroiditis (MC), ampiginous choroidopathy and serpiginous choroidopathy. The second pattern consisted of fuzzy indistinct appearance of vessels in the intermediate angiographic phase and diffuse choroidal hyperfluorescence in the late phase indicating inflammatory vasculopathy of larger choroidal vessels. This pattern was found in all cases of active Vogt-Koyanagi-Harada disease, ocular sarcoidosis and tuberculosis and birdshot chorioretinopathy. In Behçet's uveitis of recent onset, choriocapillaris perfusion delay and fuzzy choroidal vessels without diffuse late choroidal hyperfluorescence was found. In posterior scleritis, enlargement of vorticous veins was an additionnal ICGA sign. Stromal inflammatory vasculopathy always responded to anti-inflammatory therapy. A third group of patients with severe retinal or choroidal inflammation presented with associated secondary inflammatory choriocapillaropathy angiographically identical to the primary involvement.

CONCLUSIONS

ICGA allowed the hitherto impossible characterization of inflammatory involvement of the choroidal vessels, showing either predominant inflammation of the choriocapillaris or predominant inflammation of the stromal choroidal vessels with or without secondary choriocapillaritis. ICGA will be indispensable for the correct evaluation and follow-up of posterior inflammation with suspected choroidal involvement.

Pyrimethamine-sulfadoxine treatment of congenital toxoplasmosis: follow-up of 78 cases between 1980 and 1997. Reims Toxoplasmosis Group

The purpose of this study was to determine the clinical and immunological outcome of 78 children with congenital toxoplasmosis treated with the pyrimethamine-sulfadoxine combination between 1980 and 1997.

METHODS

Children were divided into 3 groups according to the initial duration of treatment (always including folinic acid, 5 mg/week by mouth), as follows: pyrimethamine (1.25 mg/kg every 15 d) + sulfadoxine (25 mg/kg every 15 d) for 12 months (Group 1, 47 children), or for 24 months, with or without prenatal therapy (respectively, Group 2, 19 children, and Group 3, 12 children).

RESULTS

Chorioretinitis occurred in 23% of these 78 children. Four children had unilateral blindness, 1 had mild epileptic fits and 1 had psychomotor retardation. The lowest rate of sequelae were in Groups 2 and 3. Immunological rebounds, generally without clinical repercussions, occurred frequently (90% of cases on average) during, or more often after therapy, regardless of the treatment duration. Treatment was always well tolerated.

CONCLUSIONS

Our current treatment strategy for congenital toxoplasmosis consists of a 24-month course of pyrimethamine-sulfadoxine (Fansidar) combined with folinic acid (Lederfoline). If the prenatal diagnosis is positive, we also prescribe this treatment to the mother until delivery. This combination offers satisfactory compliance, adequate serum concentrations, and good preventive efficacy.

Evidence for associations between the purinergic receptor P2X(7) (P2RX7) and toxoplasmosis

Congenital Toxoplasma gondii infection can result in intracranial calcification, hydrocephalus and retinochoroiditis. Acquired infection is commonly associated with ocular disease. Pathology is characterized by strong proinflammatory responses. Ligation of ATP by purinergic receptor P2X(7), encoded by P2RX7, stimulates proinflammatory cytokines and can lead directly to killing of intracellular pathogens. To determine whether P2X(7) has a role in susceptibility to congenital toxoplasmosis, we examined polymorphisms at P2RX7 in 149 child/parent trios from North America. We found association (FBAT Z-scores +/-2.429; P=0.015) between the derived C(+)G(-) allele (f=0.68; OR=2.06; 95% CI: 1.14-3.75) at single-nucleotide polymorphism (SNP) rs1718119 (1068T>C; Thr-348-Ala), and a second synonymous variant rs1621388 in linkage disequilibrium with it, and clinical signs of disease per se. Analysis of clinical subgroups showed no association with hydrocephalus, with effect sizes for associations with retinal disease and brain calcifications enhanced (OR=3.0-4.25; 0.004 Collapse

Key Words

• toxoplasmosis
• genetic polymorphisms
• purinergic receptor p2x₇
• north america
• brazil

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MESH Headings

• Adult
• Brazil
• Child, Preschool
• Chorioretinitis/etiology
• Chorioretinitis/genetics
• Female
• Genetic Predisposition to Disease/genetics
• Genome-Wide Association Study
• Haplotypes/genetics
• Humans
• Inheritance Patterns/genetics
• Linkage Disequilibrium
• Logistic Models
• Male
• North America
• Polymorphism, Single Nucleotide/genetics
• Receptors, Purinergic P2/genetics
• Receptors, Purinergic P2X7
• Toxoplasmosis, Congenital/complications
• Toxoplasmosis, Congenital/genetics

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Grants

• 16945 01-20 PHS HHS
• 27530 01-20 PHS HHS
• 4328 01-11 PHS HHS
• 071319-01 PHS HHS
• R01 AI027530 NIAID NIH HHS
• R01 AI043228 NIAID NIH HHS
• R01 AI071319 NIAID NIH HHS
• R01 AI016945 NIAID NIH HHS

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Collaborators Collapse

Outbreak of toxoplasmosis in a family and documentation of acquired retinochoroiditis

An outbreak of toxoplasmosis in one household is described. It demonstrates the potential for a common source infection with Toxoplasma gondii to cause multiple cases. Six of seven members of a household investigated for toxoplasmosis demonstrated high antibody titers consistent with recent infection; five of these members (83%) were symptomatic. The most common manifestations were fever and lymphadenopathy, which developed from seven to 18 days (mean 11 days) after a common source ingestion of infected meat. Since inadequately cooked lamb, pork and beef are probably the most common sources of infection in the United States, outbreaks of multiple cases may occur more frequently than is generally appreciated. As more outbreaks of febrile illnesses are examined, especially in families and closed communities, it is likely that more common source epidemics of toxoplasmosis will be recognized. Retinochoroiditis is an unusual manifestation of adult acquired toxoplasmosis. In the index case in this epidemic the patient manifested vision threatening retinochoroiditis 129 days after infection with toxoplasmosis. He represents the ninth well-documented case of toxoplasma retinochoroiditis associated with adult acquired disease.

Experimental Trichosporon infection in persistently granulocytopenic rabbits: implications for pathogenesis, diagnosis, and treatment of an emerging opportunistic mycosis

Disseminated Trichosporon infection, an uncommon but emerging opportunistic mycosis due to Trichosporon beigelii, is frequently difficult to diagnose, refractory to treatment, and associated with a high attributable mortality. Models of disseminated and gastrointestinal Trichosporon infection were developed in persistently granulocytopenic rabbits. The patterns of infection resembled those of clinical disease, including cutaneous lesions, chorioretinitis, renal infection, pulmonary infection, and antigenemia cross-reactive with cryptococcal capsular polysaccharide. Antigenemia, an early manifestation of disseminated Trichosporon infection, originated in vivo from a fibrillar extracellular matrix. Trichosporon organisms disseminated from the gastrointestinal tract to visceral tissue in colonized immunosuppressed rabbits, whereas there was no dissemination from the gastrointestinal tract of otherwise normal rabbits. The antifungal triazoles, fluconazole and SCH 39304, were most active; maximum tolerated doses of amphotericin B and liposomal amphotericin B were ineffective. Trichosporon antigenemia declined in response to antifungal therapy. These findings contribute to improved understanding of the pathogenesis, diagnosis, and treatment of disseminated Trichosporon infection.

Hematogenous candida endophthalmitis in patients receiving parenteral hyperalimentation fluids

To determine the incidence of hematogenous candida endophthalmitis in seriously ill patients given parenteral hyperalimentation fluids, 131 hyperalimented postoperative patients were prospectively evaluated. All patients were screened weekly for the development of chorioretinal lesions, blood cultures positive for Candida albicans, and signs and symptoms of candida infection. Thirteen (9.9%) of 131 patients developed chorioretinal lesions compatible with hematogenous candida endophthalmitis. Seven of the 13 patients with eye lesions had blood cultures positive for yeast, whereas only two of 118 without eye lesions had blood cultures positive for yeast (P less than 0.0005). Thus, the occurrence of eye lesions consistent with hematogenous candida endophthalmitis correlated with positive blood cultures for yeast and strongly suggested invasive candidiasis.

Diffuse toxoplasmic retinochoroiditis in a patient with AIDS

Ocular toxoplasmosis typically presents as a focal necrotizing retinochoroiditis. We report a case of diffuse necrotizing retinochoroiditis due to toxoplasmosis in a patient with the acquired immunodeficiency syndrome (AIDS). The appearance at initial presentation was similar to the acute retinal necrosis syndrome. We recommend that toxoplasmosis be considered in the differential diagnosis of diffuse retinal necrosis in patients with AIDS. Although systemic disseminated toxoplasmosis is not rare in AIDS, this is, to our knowledge, the first reported case of diffuse ocular involvement.

Unusual central chorioretinitis as the first manifestation of early secondary syphilis

Three young, otherwise healthy patients had a similar picture of unilateral central chorioretinitis associated with severe visual loss. Fluorescein angiography disclosed diffuse leakage under the neurosensory retina in the posterior pole, associated with multifocal areas of staining along the retinal vessels. Systemic examination showed a positive fluorescent treponemal antibody absorption test and a sharp increase in VDRL titers, indicative of active secondary syphilis. The patients responded dramatically to penicillin treatment, with visual recovery and resolution of the fundus lesions.

Fuchs' heterochromic cyclitis and ocular toxoplasmosis

Ocular toxoplasmosis and Fuchs' heterochromic cyclitis are well-defined diseases that have completely different clinical courses. We studied 13 patients (seven men and six women, ranging in age from 18 to 73 years) who had Fuchs' heterochromic cyclitis and the focal necrotizing chorioretinal lesions characteristic of ocular toxoplasmosis. The reason for this association is still unknown, as is the pathogenesis of Fuchs' heterochromic cyclitis. None of the patients had ciliary injection or posterior synechiae, but 11 of the 13 (84.6%) had keratic precipitates, anterior chamber reaction, and cataracts. Six patients (38.4%) had iris transillumination, two (15.3%) had glaucoma, and four (30.7%) had lesions in the fellow eyes.

Long-term outcome of children with congenital toxoplasmosis

OBJECTIVE

Maternal toxoplasmosis infection acquired during pregnancy carries significant risk of fetal damage. We aimed to assess the long-term outcome of children and young adults with congenital toxoplasmosis diagnosed and treated in utero.

STUDY DESIGN

This was a 20 year prospective study (1985-2005). All mothers received spiramycin, alone or associated with pyrimethamine-sulfadoxine, and underwent amniocentesis and monthly ultrasound screening. Infected children were followed every 3-6 months.

RESULTS

Of 666 liveborn children (676 mothers), 112 (17%) had congenital toxoplasmosis. Among these, 107 were followed up for 12-250 months: 79 were asymptomatic (74%) and 28 had chorioretinitis (26%). Only 1 child had a serious neurological involvement.

CONCLUSION

The percentage of chorioretinitis in treated children depends on length of follow-up, but this complication occurs mainly before the age of 5 years and almost always before the age of 10 years. Visual impairment was infrequently severe, and outcome appears consistently good. Long-term follow-up is recommended to monitor ocular and neurological prognosis, whatever the practical difficulties.

Toxoplasma gondii infection induces gene expression and secretion of interleukin 1 (IL-1), IL-6, granulocyte-macrophage colony-stimulating factor, and intercellular adhesion molecule 1 by human retinal pigment epithelial cells

We have used human retinal pigment epithelial (HRPE) cultures to investigate the primary cellular responses of retinal resident cells to intracellular Toxoplasma gondii replication. At 4 days postinoculation, when all of the cells were infected, the secretion of interleukin 1beta (IL-1beta), IL-6, granulocyte-macrophage colony-stimulating factor (GM-CSF), and intercellular adhesion molecule 1 (ICAM-1) was augmented by 23-, 10-, 8-, and 5-fold, respectively, over the control. Northern and reverse transcriptase PCR analyses showed significant upregulation of steady-state levels of mRNA for IL-1beta, IL-6, GM-CSF, and ICAM-1. The secretion of these molecules by HRPE cells may play a critical immunoregulatory role in the pathophysiological processes associated with T. gondii-induced retinochoroiditis.

Retinal Complications in Patients With Solid Organ or Bone Marrow Transplantations

BACKGROUND

The administration of systemic immunosuppressive agents to recipients of solid organ or bone marrow transplants results in an immunocompromised status. As the number of organ recipients and their life span increase with recent progress in organ transplantation, ocular complications tend to become more diverse and serious.

METHODS

From 1995 to 2005, 3656 cases of organ transplantations were performed at Asan Medical Center. The medical records of 1198 of these patients who had been examined at the Department of Ophthalmology were reviewed.

RESULTS

Retinal complications were diagnosed in 33 of the transplant recipients; five with bone marrow transplantation, 16 with kidney transplantation, seven with liver transplantation (LT), and five with heart transplantation. Diagnoses included 11 cases of CMV (cytomegalovirus) retinitis, three of acute retinal necrosis, one of progressive outer retinal necrosis, five of fungal chorioretinitis, one of toxoplasmic retinochoroiditis, three of central retinal vein occlusion, and nine of central serous chorioretinopathy. While CMV, fungal, or toxoplasmic chorioretinitis developed frequently in association with extraocular infection or organ rejection, herpetic infection manifested only in the eye without any rejection. Most infectious cases responded well to the standard therapeutic regimen. Interestingly, central retinal vein occlusion developed exclusively following LT, possibly in relation to coagulation cascade abnormality.

CONCLUSIONS

To our best knowledge, this comprehensive review presents the largest series of ocular complication in organ transplant recipients. Familiarity with the potential ocular complications as well as a high index of suspicion is warranted to the practicing ophthalmologists.

Ocular toxoplasmosis in the immunocompromised host

Disseminated toxoplasmosis is a well-known complication of immunodeficiency states, including those induced by malignancies, steroid and cytotoxic drug therapy, and AIDS. In immunodeficient patients, toxoplasmic infections of the eye are less common than toxoplasmic infections of other organs for unknown reasons. When ocular toxoplasmosis does occur in the immunodeficient host, or if immunosuppressive therapy is administered to patients with active disease, widespread tissue destruction by proliferating organisms may result. Immunodeficiency alone may not be sufficient, however, to cause reactivation of encysted organisms in retinochoroidal scars. Ocular toxoplasmosis in the immunocompromised host presents difficult problems in diagnosis and management. There may be a variety of clinical lesions, including single foci of retinochoroiditis in one or both eyes, multifocal lesions, or diffuse areas of retinal necrosis. The majority of lesions do not arise from the borders of preexisting scars, which suggests that they result from acquired infection or dissemination of organisms from nonocular sites of disease. Toxoplasma gondii may infect iris, choroid, and vitreous-tissues that are not usually infected in the immunocompetent host. Ocular lesions appear to respond to standard antiparasitic drug therapies, but continued treatment is probably necessary to prevent reactivation of disease in the most immunocompromised patients. The best treatment regimens have yet to be determined. Histopathologic studies show little retinal inflammation; therefore anti-inflammatory drugs, such as oral steroids, probably have no role in the management of infection.