Ocular toxoplasmosis: a global reassessment: part II: disease manifestations and management

Recurrent toxoplasmic retinochoroiditis in an immunocompetent adult patient. There is a “satellite lesion” associated with pre-existing retinochoroidal scars and a mild overlying vitreous inflammatory reaction.

The right fundus of a severely immunocompromised patient with AIDS, showing two large foci of extensive retinal necrosis. The inferior focus was complicated by an exudative retinal detachment. There were no pre-existing retinochoroidal scars.

The same fundus shown in Figure 1, photographed 4 months later. The patient was initially treated with pyrimethamine and sulfadiazine; no corticosteroids were given. Inflammatory signs improved rapidly, and there was no enlargement of lesions after the start of therapy. At this point in time, pyrimethamine alone was being given as long-term “maintenance therapy.” All retinochoroidal scars appear to be inactive.

The left optic disk of a 17-year-old girl with recurrent parapapillary toxoplasmic retinochoroiditis with exudation and optic disk swelling. A pre-existing hyperpigmented retinochoroidal scar is present at the inferonasal optic disk margin. The patient was treated with a 4-week course of pyrimethamine, sulfadiazine, and prednisone, with complete resolution of the optic disk swelling and retinochoroiditis. Vision improved to 20/20 in the eye.

Extensive toxoplasmic retinochoroiditis involving the macula and superior retina in a 77-year-old man. There were also two isolated foci of active retinochoroiditis inferiorly. The presence of Toxoplasma gondii DNA in a vitreous humor specimen was confirmed by polymerase chain reaction technique. Despite 4 months of therapy with pyrimethamine, sulfadiazine, clindamycin, and prednisone, disease remained active. (Photographs courtesy of Emilio M. Dodds, MD).

A large retinochoroidal lesion in the left macula of an immunocompetent adult with postnatally acquired Toxoplasma gondii infection.

Extensive scarring of the retina following resolution of an episode of presumed toxoplasmic retinochoroiditis in a 75-year-old man. Despite extensive retinal infection, severe, excavated retinochoroidal scarring did not occur. (Photograph courtesy of Allan E. Kreiger, MD). A similar case is illustrated in Figure 5 of the following publication: Johnson MW, Greven GM, Jaffe GJ, et al. Atypical, severe toxoplasmic retinochoroiditis in elderly patients. Ophthalmology 1997;104:48–57.

Ocular toxoplasmosis at a tertiary referral center in Maryland. The open and cross-hatched bars correspond to data presented in Figure 5 of the following publication: Friedmann CT, Knox DL. Variations in recurrent active toxoplasmic retinochoroiditis. Arch Ophthalmol 1969;81:481–493. The bars identify the ages at which 158 known episodes of toxoplasmic retinochoroiditis occurred in 63 patients. The cross-hatched portion of the bars identify those episodes associated with vision loss. Superimposed on the original figure are narrower solid bars that demonstrate the age at enucleation of all cases with a diagnosis of ocular toxoplasmosis in the records of the Armed Forces Institute of Pathology during the same era. This previously unpublished figure was provided by David L. Knox, MD.

Symptomatic ocular toxoplasmosis among an unscreened, British-born population in four areas of England. Age at presentation for all patients (n = 87) and for patients reporting no previous episode (n = 41). Figure and original legend reprinted with permission from Gilbert RE, Dunn DT, Lightman S, et al. Incidence of symptomatic Toxoplasma eye disease: Aetiology and public health implications. Epidemiol Infect 1999;123:283–289 by Cambridge University Press.

Ocular toxoplasmosis in the Netherlands. Total number of attacks (n = 274) of ocular toxoplasmosis according to age for 60 patients followed for at least 5 years. Figure and original legend reprinted from Bosch-Driessen LE, Berendschot TT, Ongkosuwito JV, Rothova A. Ocular toxoplasmosis: Clinical features and prognosis of 154 patients. Ophthalmology 2002;109:869–878 with permission from the American Academy of Ophthalmology.

The right fundus of a 38-year-old woman with recurrent toxoplasmic retinochoroiditis after receiving a periocular injection of corticosteroid without concurrent antimicrobial therapy. She was originally seen with a satellite lesion (thin black arrow) at the border of a pre-existing retinochoroidal scar (in the area of the thick black arrow). The injection was given during the healing phase of the satellite lesion, and resulted in marked increase in inflammation (shown here) and recrudescence of the retinochoroiditis (area identified by the white arrow). Inflammation gradually subsided over a 6-month period during which she was treated with pyrimethamine, sulfadiazine, and clindamycin.

The same fundus shown in Figure 11, photographed 2 years later. The area of the recrudescent lesion (white arrow) is more deeply excavated than the original scar (the area of scarring farthest from the optic disk) or the site of the satellite lesion from which the recrudescence developed.