TREATMENT OF REFRACTORY TUBERCULAR SERPIGINOUS-LIKE CHOROIDITIS WITH INTRAVITREAL METHOTREXATE

PURPOSE

To describe a case of tubercular serpiginous-like choroiditis that progressed, despite antitubercular medication, corticosteroids, and immunomodulatory treatment, which ultimately quieted after two intravitreal methotrexate injections.

METHODS

Case report.

RESULTS

A 35-year-old woman reported a shadow in the left eye for 2 weeks. She presented with tubercular serpiginous-like choroiditis in the right eye 2 years prior. At that time, she was started on antituberculosis therapy but was noncompliant and lost to follow-up. On re-presentation, there was a new active left-eye serpiginous lesion, with repeat positive QuantiFERON gold testing. Four antituberculosis drugs were started, followed by corticosteroids and azathioprine, with continued progression despite aggressive treatment. She was finally given 2 intravitreal methotrexate injections (400 μg/0.1 cc) 1 month apart, with final arrest of lesion extension. The uveitis remained quiet for over 24 months, and the patient was able to discontinue all systemic therapy.

CONCLUSION

Intravitreal methotrexate injections halted progression of treatment-refractory tubercular serpiginous-like choroiditis.

SOLITARY IDIOPATHIC CHOROIDITIS IN THE SETTING OF EXTENSIVE ANIMAL EXPOSURE

PURPOSE

To describe solitary idiopathic choroiditis in the setting of extensive animal exposure.

METHODS

A 56-year-old asymptomatic female equestrian with an extensive history of exposure to horses and dogs and a trapper of wild animals and rodents was discovered to have an amelanotic choroidal mass in the macular region and referred for suspicious atypical nevus.

RESULTS

Funduscopy revealed a deep yellow mass with overlying retinal pigment epithelial thinning and without visible subretinal fluid or lipofuscin. Mild hyperautofluorescence represented unmasking of scleral autofluorescence. Ultrasonography showed a 1.8-mm-thick echodense lesion. Enhanced depth imaging-optical coherence tomography disclosed a dense, elevated scleral mass with "volcanic" configuration, demonstrating choroidal compression and trace overlying subretinal fluid. These features were consistent with solitary idiopathic choroiditis/scleritis. Systemic evaluation for standard cat-related bartonellosis, tuberculosis, sarcoidosis, and syphilis were negative. Horse-, dog-, and rodent-related bartonellosis testing was not available. Observation was advised, and the findings remained stable at 6 months.

CONCLUSION

Solitary idiopathic choroiditis is best imaged on enhanced depth imaging-optical coherence tomography as a scleral lesion with "volcanic" configuration and often secondary to previous Bartonella infection. Serologic positivity for cat-related Bartonella decays over time, and testing for horse-, dog-, or rodent-related Bartonella is not commonly used.

A case of multifocal choroiditis secondary to Candida albicans infection in a leukemic child

Acute leukemia commonly renders a child immunocompromised, making them susceptible to opportunistic microorganism infection.We report an interesting case that presented to us with multifocal choroiditis secondary to Candida albicans infection in a Leukemic child. Appropriate management was undertaken and the infection subsided.

Serpiginous choroiditis and infectious multifocal serpiginoid choroiditis

Serpiginous choroiditis (SC) is a posterior uveitis displaying a geographic pattern of choroiditis, extending from the juxtapapillary choroid and intermittently spreading centrifugally. The choroiditis involves the overlying retinal pigment epithelium, and the outer retina. This intraocular inflammation typically involves both eyes in otherwise healthy, middle-aged individuals with no familial or ethnic predilection. Pathogenesis is unclear; based on limited histopathologic studies, however, favorable response to immunosuppressive agents, and the absence of association with systemic or local infectious or noninfectious diseases, an organ-specific autoimmune inflammation seems likely to be the underlying process. Patients, particularly from tuberculosis-endemic regions, may present with fundus changes simulating SC, but show evidence of active tuberculosis and/or the presence of mycobacterial DNA in the aqueous humor. This has been referred to as serpiginous-like choroiditis, but we prefer the description multifocal serpiginoid choroiditis (MSC). We present the distinguishing features of SC and infectious multifocal serpiginoid choroiditis simulating SC. The distinction is crucial to avoid unnecessarily treating SC with antimicrobial agents. Advances in diagnostic and imaging modalities can help differentiate SC from MSC. Novel local and systemic treatment approaches improve the outcome and preserve vision in SC.

Continuous progression of tubercular serpiginous-like choroiditis after initiating antituberculosis treatment

PURPOSE

To describe the frequency, risk factors, management, and outcome of eyes with tubercular serpiginous-like choroiditis showing continued progression following initiation of antituberculosis treatment.

DESIGN

Retrospective, comparative, interventional case series.

METHODS

SETTING

Institutional.

PATIENT POPULATION

One hundred ten patients of serpiginous-like choroiditis with 1) complete records, 2) tuberculin skin test, 3) active lesions in at least 1 eye, and 4) minimum 18 months follow-up.

INTERVENTION

Based on the positivity of tuberculin skin test, the patients were categorized in Group A (84 patients with positive tuberculin test) and Group B (26 patients with negative tuberculin test). Of the 84 patients in Group A, 19 received systemic corticosteroids while 65 also received 4-drug antituberculosis treatment in addition. All patients in Group B received corticosteroids. Patients with continued progression received an increased dose of corticosteroids with or without immunosuppressive agents.

MAIN OUTCOME MEASURE

Development of continued progression.

RESULTS

There were 61 men and 23 women in Group A and 19 men and 7 women in Group B. Continued progression was observed in 12 patients (14.28%) in Group A and none in Group B (P = .04). Of the 12 patients in Group A showing progression, 11 (16.9%) were receiving antituberculosis treatment and corticosteroids. The lesions responded in all eyes, and final visual acuity of 20/40 or better could be achieved in 10 eyes (75%).

CONCLUSION

Continued progression of choroiditis lesions occurs in 14% of patients after initiating antituberculosis treatment in tubercular serpiginous-like choroiditis. Increased immunosuppression with continuation of antituberculosis treatment resulted in good outcome.

Bilateral multifocal choroiditis and optic neuropathy in a patient with AIDS: a diagnostic dilemma

A rare case of bilateral multifocal choroiditis and optic neuropathy as the result of disseminated cryptococcal infection in a person with AIDS is described. A 30-year-old HIV-positive man presented with fever, headache, vomiting, and altered sensorium Ophthalmological examination revealed bilateral multifocal choroiditis and optic neuropathy. Laboratory examination and imaging suggested a presumptive diagnosis of disseminated Cryptococcus neoformans infection. Therapeutic response confirmed the diagnosis.

Ocular tuberculosis

We present an article on asymptomatic tuberculous choroiditis on screening. Discussions also include the manifestations, relevant investigations and management of ocular tuberculosis. Clinicians should be aware of these findings when treating such patients.

Multifocal choroiditis in disseminated Cryptococcus neoformans infection

PURPOSE

To report an uncommon case of multifocal choroiditis as the result of disseminated Cryptococcus neoformans infection in a patient who is HIV-positive.

DESIGN

Interventional case report.

METHODS

A 27-year-old HIV-positive woman with fever, headache, and vomiting was examined. Lumbar puncture was performed and revealed C neoformans infection. Her condition evolved with sudden bilateral blindness and deafness. Ophthalmologic examination revealed multiple yellowish choroidal lesions in the posterior pole of both eyes.

RESULTS

Postmortem examination showed disseminated C neoformans infection. Histologic examination of the eyes confirmed the presence of C neoformans in the choroiditis.

CONCLUSION

Multifocal choroiditis in C neoformans infection is a rare ophthalmic manifestation. The recognition of this condition by ophthalmologists can help physicians to diagnose a disseminated and fatal disease.

Poststreptococcal syndrome uveitis: a descriptive case series and literature review

PURPOSE

To describe the clinical features in a series of patients with poststreptococcal uveitis and to review literature on the pathophysiology and management.

DESIGN

Retrospective and descriptive case series.

PARTICIPANTS

Ten consecutive cases of poststreptococcal syndrome uveitis diagnosed between 1996 and 2003.

METHODS

Review of patient case notes.

MAIN OUTCOME MEASURES

Age, laterality, clinical features, and anti-streptococcal lysin O titers.

RESULTS

Ten consecutive cases of poststreptococcal syndrome uveitis were identified. All our cases had bilateral nongranulomatous inflammation and raised anti-streptococcal lysin O titers. Collating data from previous reports and this series showed that 96% of the patients were below 40 years of age, and 87.5% had evidence of previous streptococcal infection. One third of the patients had posterior segment involvement. In our patients, this was in the form of vitritis, focal retinitis, optic disc swelling, and multifocal choroiditis.

CONCLUSIONS

Poststreptococcal syndrome uveitis should be considered in the etiology of acute bilateral nongranulomatous uveitis in children and young patients.

Tuberculosis: an under-diagnosed aetiological agent in uveitis with an effective treatment

PURPOSE

To highlight the diversity of clinical presentations with tubercular uveitis in a nonendemic setting, and discuss the diagnostic approach and an effective treatment.

METHOD

Descriptive case series.

RESULTS

A total of 12 cases of varied presentations of tubercular uveitis diagnosed over a period of 1 year of which six cases are described in detail. Presentations included choroidal tuberculomas, multifocal choroiditis, recurrent granulomatous uveitis, panuveitis with cystoid macular oedema, and serpiginous choroiditis. All cases had a chronic or recurrent course and responded very well to antitubercular treatment. Diagnosis was mainly assisted by positive tuberculin testing.

CONCLUSION

A high index of suspicion helps diagnose ocular tuberculosis in areas of low prevalence of the disease. It forms part of the differential diagnosis of any chronic or recurrent uveitis, especially in an at-risk patient. Antitubercular treatment seems highly effective.

Multifocal choroiditis: ocular TB or side-effects of anti-TB therapy?

A patient with end-stage renal failure secondary to polycystic kidney disease was seen in the Eye Clinic for a corneal abrasion. Incidental fundal examination revealed bilateral multiple, small, raised, pale yellow sub-retinal nodules. Past medical history of inadequately treated pulmonary tuberculosis was obtained. Following initiation of anti-tuberculous therapy, the choroidal lesions resolved.

Presumed tubercular serpiginouslike choroiditis: clinical presentations and management

PURPOSE

Choroiditis, choroidal tubercles, and tuberculomas are well known ocular manifestations of systemic tuberculosis. The present series aimed to report the occurrence of serpiginouslike choroiditis of presumed tubercular origin.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

Eleven eyes in seven consecutive patients with a diagnosis of choroidal tuberculosis simulating serpiginous choroiditis were studied between 1997 and 2000. TESTING AND INTERVENTION: All patients had their fundus photographs taken at the time of initial presentation as well as during follow-up. All patients underwent a Mantoux skin test and chest radiography. In addition, five patients had their aqueous or vitreous humor subjected to polymerase chain reaction (PCR) for Mycobacterium tuberculosis. Sputum examination, biopsy, or both were carried out whenever recommended by the pulmonologist. Systemic antituberculosis chemotherapy was instituted in combination with treatment for ocular inflammation.

MAIN OUTCOME MEASURE

Therapeutic response and visual improvement.

RESULTS

There were five men and two women ranging in age from 17 to 32 years. Clinical presentations included three morphologic variants; multifocal progressive choroiditis showing wavelike progression to confluent, diffuse lesions resembling serpiginous choroiditis (three eyes); diffuse choroiditis characterized by diffuse plaquelike choroiditis with an amoeboid pattern suggestive of serpiginous choroiditis at initial presentation (four eyes); and mixed variety where opposite eyes had mixed features (four eyes). All patients had strongly positive Mantoux skin test results and positive chest radiograph results. The PCR results from aqueous and vitreous humor in four samples was positive for Mycobacterium tuberculosis; one had sputum positive for acid-fast bacilli, whereas two had histopathologic evidence of tuberculosis from cervical or parahilar lymph nodes. Treatment was associated with resolution of choroidal lesions and visual improvement. Final visual acuity of 20/30 or better was achieved in five eyes.

CONCLUSIONS

Choroidal tuberculosis may present as multifocal progressive or diffuse choroiditis resembling serpiginous choroiditis. It is important to recognize these presentations because these eyes show good response to systemic antituberculosis chemotherapy.

[Cryptococcal choroiditis in a patient with acquired immunodeficiency syndrome]

PURPOSE/METHODS

We report the case of a 31 year old male with presumed cryptococcal choroiditis associated with cryptococcal meningitis and AIDS. Multiple yellowish-whitish small choroidal lesions, retinal hemorrhages and cotton-wool spots appeared in the posterior pole associated with vision loss. We also carried out differential diagnosis with other frequent diseases and a review of the treatments.

RESULTS/CONCLUSIONS

Cryptococcus neoformans is an opportunistic fungus with a predilection for infecting the meninges in patients with Acquired Immunodeficiency Syndrome AIDS (10%). Ocular manifestation usually includes cranial nerve palsies or papilledema secondary to increased intracranial pressure. Cryptococcal choroiditis is less frequent (5% of patients with meningitis).

Massive mycobacterial choroiditis during highly active antiretroviral therapy: another immune-recovery uveitis?

PURPOSE

To describe the ocular presentation of disseminated mycobacterial disease occurring during immune-recovery in a patient with acquired immune deficiency syndrome (AIDS).

STUDY DESIGN

Case report and literature review.

PARTICIPANTS

A 41-year-old AIDS patient with a prior diagnosis of cytomegalovirus retinitis.

METHODS

The patient developed progressive, bilateral multifocal choroiditis with panuveitis 2 months after beginning and responding to highly active antiretroviral therapy. His left eye became blind and painful and was enucleated. Pathologic examination revealed massive choroiditis with well-formed, discrete granulomas and multiple intracellular and extracellular acid-fast organisms within the choroidal granulomas. Culture and polymerase chain reaction of vitreous specimens revealed Mycobacterium avium complex (MAC).

RESULTS

Empiric, and later sensitivity-guided, local and systemic antibiotic therapy was used to treat the remaining right eye, but it continued to deteriorate. Despite medical therapy, three vitrectomies and repeated intravitreal injections of amikacin, a total retinal detachment ensued. One week after the third vitrectomy, the patient died from mesenteric artery thrombosis in the setting of disseminated mycobacterial disease.

CONCLUSIONS

This is the first report of ocular inflammation as the presenting finding in the recently recognized syndrome of immune-recovery MAC disease. Pathogenesis of this entity is related to an enhanced immune response to a prior, subclinical, disseminated infection. The formation of discrete granulomas, normally absent in MAC infections in AIDS, reflects this mechanism.

[Surgical treatment of retrofoveal choroid neovascularization in multifocal choroiditis]

BACKGROUND

Surgical removal of subfoveal choroidal neovascularization allows visual improvement, especially in young patients.

METHODS

Three eyes of 3 patients were prospectively studied. Subfoveal choroidal neovascularization was related to presumed ocular histoplasmosis syndrome. The surgical procedure included vitrectomy, surgical excision of the neovascular membrane, and air tamponnade.

RESULTS

Follow-up was 6, 12 and 20 months. Vision improved in 2 eyes. In one case, recurrent extrafoveal neovascularization was treated with laser photocoagulation.

DISCUSSION

Surgery seems to be an alternative to photocoagulation in subfoveal choroidal neovascularization in presumed ocular histoplasmosis.

Presumed multifocal cryptococcol choroidopathy prior to specific systemic manifestation

PURPOSE

Disseminated cryptococcosis is a major cause of morbidity and mortality in immunocompromised individuals, especially those with the acquired immunodeficiency syndrome (AIDS). Early diagnosis and treatment greatly improves the outcome, so clinical clues that lead to prompt diagnosis are important.

METHODS

Three patients with AIDS in whom multifocal choroiditis and choroidal lesions were the initial signs of disseminated cryptococcosis were treated with systemic amphotericin B and flucytosine. All of the patients had a systemic work-up that included evaluation of the cerebral spinal fluid (CSF).

RESULTS

All three patients who were seen with the choroidal lesions as the presenting sign were noted to have either positive titers for cryptococcus or cultures that grew cryptococcus in the CSF. The choroidal lesions are presumed to be due to cryptococcus as no histopathologic or microscopic studies were available for ocular tissues. The choroidal lesions started to resolve one to three months after systemic treatment with amphotericin B and flucytosine.

CONCLUSION

Primary choroidal lesions in patients with AIDS may herald severe systemic disseminated disease. Funduscopic examination, however, may detect disseminated cryptococcal disease before other overt clinical manifestations, thereby allowing prompt institution of effective therapy.

Ocular tuberculosis. A prospective study in a general hospital

Ocular tuberculosis has traditionally been considered uncommon or anecdotal. Imprecise and variable diagnostic criteria have contributed to the confusion surrounding this topic. The increase in extrapulmonary manifestations of tuberculosis during the AIDS era established the need for a prospective study of ocular involvement in patients with all types of tuberculosis using well-defined criteria. During a 15-month period, 300 cases had culture-proven tuberculosis at our institution. We randomly selected 100 for systematic ophthalmologic evaluation. Our criteria for ocular tuberculosis were divided as follows: certainty (isolation of Mycobacterium tuberculosis from ocular specimens), probability (patients with isolation of M. tuberculosis from extraocular samples, with ocular lesions not attributable to other causes that respond to anti-tuberculous treatment), and possibility (same as probability but follow-up impossible). Ocular tuberculosis was present in 18 patients (18%) of which 10 patients fulfilled probability and 8 patients fulfilled possibility criteria. Eleven of 18 patients had HIV infection. In 11 patients, ocular involvement was asymptomatic. Almost all patients (17/18) had choroiditis, and other ocular lesions included papillitis, retinitis, vitritis, vasculitis, dacryoadenitis, and scleritis. Multivariate analysis showed as risk factors independently predicting ocular involvement in patients with ocular tuberculosis the presence of miliary disease (odd ratio 43.92, p = 0.002), ocular symptoms (odds ratio 6.35, p = 0.0143), and decreased visual acuity (odds ratio 0.04, p = 0.012). We observed an unexpectedly high (18%) incidence of ocular involvement, frequently asymptomatic, in patients with tuberculosis. Miliary disease is a clear predisposing factor in both HIV-infected and noninfected populations. Ocular examination should be routinely considered in patients with proven or suspected tuberculosis.

Retinal vascular nonperfusion and retinal neovascularization as a consequence of cytomegalovirus retinitis and cryptococcal choroiditis

BACKGROUND

Cytomegalovirus retinitis and cryptococcal choroiditis are opportunistic infections in patients with acquired immune deficiency syndrome. These infections are associated with a retinal vasculitis and vascular attenuation.

METHODS

We present a case of retinal vascular nonperfusion and retinal neovascularization in a patient with acquired immune deficiency syndrome.

RESULTS

Retinal vascular nonperfusion and retinal neovascularization were confirmed by fluorescein angiography.

CONCLUSIONS

This is the first reported case of retinal neovascularization in a patient with acquired immune deficiency syndrome, ocular cytomegalovirus retinitis, and cryptococcal infection.

[Tuberculous choroiditis]

Tuberculosis is a rare cause of choroiditis. In most cases there is only a presumptive diagnosis based on a history of TB, its clinical picture, and a positive skin test. A 79-year-o;d man complained of acute, right visual loss. On examination, choroiditis was found. During his 20s he had had pulmonary tuberculosis; his Mantoux test was positive.

Tuberculous choroiditis and acquired immunodeficiency syndrome

Tuberculosis is a common illness among patients with acquired immunodeficiency syndrome (AIDS), and therefore, choroidal tubercles are expected to be found in these patients. Nevertheless, this association (AIDS-induced choroidal tuberculosis) is infrequently reported in the literature. We report four cases of patients with AIDS and tuberculosis who did not have any visual complaints and in whom a routine funduscopic examination disclosed the presence of choroidal nodules. These lesions were not accompanied by vitritis, iridocyclitis, or any sign of uveitis as has been reported in cases of tuberculous choroiditis in patients with AIDS by others in the literature.

Cytologically proven seronegative Lyme choroiditis and vitritis

PURPOSE

To report on a vitreous specimen in a 53-year-old patient with unilateral choroiditis and vitritis of unknown cause.

METHODS

Cytologic examination of a vitreous aspirate stained by the Papanicolaou method.

RESULTS

Intravitreal spirochetes consistent with Borrelia burgdorferi were found in this seronegative patient.

CONCLUSION

Vitreous specimens of patients with choroiditis and vitritis of unknown cause should be examined cytologically, particularly when serologic results do not corroborate the clinical findings of Lyme disease.

Infectious multifocal choroiditis in patients with acquired immune deficiency syndrome

PURPOSE

The purposes of this study are to determine the incidence of infectious opportunistic choroiditis in patients with the acquired immune deficiency syndrome (AIDS), to study the association of these choroidal infections with systemic dissemination, and to investigate the life expectancy and cause of death in patients with infectious opportunistic choroiditis.

METHODS

A total of 470 eyes of 235 consecutive autopsies of patients with AIDS were examined by histopathologic methods. The clinical charts and autopsy reports of these patients were subsequently reviewed for presence of systemic dissemination of various infectious agents.

RESULTS

Of the 235 patients, 18 were found to have infectious choroiditis. The etiologic agents found were: Cryptococcus neoformans, Pneumocystis carinii, Mycobacterium tuberculosis, Histoplasma capsulatum, Candida, Aspergillus fumigatus, Toxoplasma gondii, and Mycobacterium avium-intracellulare. In 15 of these 18 patients, the cause of death was considered to be due to systemic dissemination of the organism causing the choroiditis. Only 4 of the 18 cases of infectious choroiditis were diagnosed during life, and the survival time of these patients after diagnosis was only 25 days. Five of the 18 patients also were found to have cytomegalovirus (CMV) infection of the retina.

CONCLUSION

Multifocal choroiditis due to endogenous infectious emboli in patients with AIDS reflects systemic dissemination and localization of infectious agents predominantly in the choriocapillaris. Early diagnosis and treatment are imperative and may be life-saving.

Systemic viral infections and their retinal and choroidal manifestations

Viruses are one of the most common causes of infections involving the posterior segment of the eye. Such infections can occur either on a congenital or an acquired basis, and may affect primarily the retina or the choroid. Congenital cytomegalovirus (CMV) and rubella infections may result in retinitis. CMV retinitis is also the most common cause of acquired viral retinitis, primarily because of the acquired immunodeficiency syndrome (AIDS). Other types of viral retinitis, such as those caused by herpes simplex or herpes zoster, can occur in immunocompromised or immunocompetent individuals. Retinitis or choroiditis caused by viruses such as measles, influenza, Epstein-Barr virus, and Rift Valley fever virus, typically occurs subsequent to an acute viral systemic illness. The systemic and ocular manifestations, as well as the histopathology, laboratory tests, differential diagnoses, and treatment regimens for each of the individual viruses are discussed in detail.

Multifocal choroiditis with evidence of Lyme disease

A 32-year-old man had multifocal choroiditis without vitreous involvement. The diagnosis of Lyme disease was suggested by serial enzyme-linked immunosorbent assays of his serum and a cerebrospinal fluid specimen. The ocular findings resembled those seen in patients with acute posterior multifocal placoid pigment epitheliopathy (APMPPE). The active lesions resolved after administration of a two-week course of intravenous ceftriaxone. This case suggests that some cases of APMPPE actually may be Lyme disease.