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7/24/2019 Toxoplasmosis Presentation
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Toxoplasmosis GondiiHelena Wang
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Chief Complaint 67 year old male presents for pressure
check Also complains of oating spots O
starting ! "eek agoOccasional infre#uent photopsias $ut
una$le to determine "hich eye
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Case History %&&' ()!*)!+ at the ,A "ith r- Chini"alla
in Ophthalmology
.OHx' .OAG O/0 Cataracts O/0 1Toxocara2scar O3
4OHx' 5onearried
uit smoking 89 years agorinks :eer and oonshine occasionallyari;uana occasionally :.' !
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.ro$lem %ist Chronic yeloid %eukemia &sophageal =eux &rectile ysfunction Hearing %oss Chronic O$structi>e %ung isease %o"er :ack .ain .T3 History of .olyp of Colon .OAG
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eds .otassium Cl 3ildena?l @matini$ esylate
Arti?cial tears %atanoprost Cosopt :udesonide)4ormoterTiotropium :romideOmepraole Al$uterol Aspirin
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&xam 4indings :C,A' O ac O/ All other structures normal
@O.s' !+0 !8 "ith GAT F !9'99am4&' see photos O/
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O .hotos
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O .hotos
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O3 .hotos
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&xam 4indings ,essels' A, crossing changes O/ .eriphery' 8 circular C= scars 3T to macular
scar os BDholes)tears)detachements O/ ") scleral
depression ED., O3 EDoater O near macula impending .,
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Toxoplasmosis Gondiiost common cause of posterior u>eitisToxoplasmosis Gondii is an o$ligatory
intracellular parasite 4indings common in ne"$orns and
immunocompromised patients 3exual reproduction of the parasite
occurs in the small intestinal epithelialcells of cats 4ecal elimination of oocytes
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Toxoplasmosis GondiiOnce the parasite reaches the retina0 it
proliferates "ithin host cells follo"ed $y
rupture of the host cells and in>adingneigh$oring cells to make primary lesions 3ometimes the restricted parasite $y the host
immunity in the ?rst scar is acti>ated to infectanother lesion near$y the scar
Originally thought that an acti>e ocular toxo isa reacti>ation of a congenital toxo scar
ore recent studies sho" that ac#uiredinfections are much more common thanpre>iously thought
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Toxoplasmosis GondiiTypically asymptomatic in
immunocompetent patients :enign and selfBlimiting
3e>ere in fetus andimmunocompromised patients
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3igns and 3ymptomsild fe>eralaiseuscle and)or;oint painHeadache 3ore throat 3kin rash
4loaters :lurred >ision
4rom macularin>ol>ement or se>ere>itreal inammation
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Acti>e Toxo =etinochoroiditis
=ecurrence in e itWhite and exudati>e "ith illBde?ned
$orders @n>ol>es the macula in a ma;ority of
patientsild to moderate anterior segment
inammation ,itreous inammation is >irtually al"ays
presentay see retinal >asculitis
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Acti>e Toxo =etinochoroiditis
Optic neuritis5euroretinitis .apillitis .seudoretinitisuring healing' =etinochoroidal shunt >essels C5, Gliosis ,itreal tractional $ands
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Acti>e Toxo =etinochoroiditis
@n immunocompromised pts' ay sho" atypical features %arge conuent areas of necrosis :ilateral lesions
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aking the diagnosisainly $y clinical o$ser>ation of a focal necrotiing
retinochoroiditisTest such as serum antiBToxoplasma titers of @g and
@gG can support the dx .C= of a#ueous and >itreous sample ha>e high sensiti>ity
and high speci?city
4luorescein angiography and indoBcyanine greenangiography
5onspeci?c =ecent nonBin>asi>e photography techni#ues @nfrared and autouorescence0 can help determine the
extent of retinochoroiditis
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x 3erpiginous choroiditis C,
H3,0 HI, 4ungal retinitis 3eptic retinitisOcular toxocariasis
3arcoidosis 3yphilisTu$erculosis
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Toxocariasis
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3erpiginous choroiditis
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C,
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4ungal &ndophthalmitis
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Tx ToxoplasmosisGoal is to stop the multiplication of
the parasite during the acti>eperiod of retinochoroiditis and to
minimie further damageCandidates for Tx
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Tx Classic Therapy' .yrimethamine and
3ulfadiaine plus corticosteroids
7+B!99 mg of pyrimethamine daily for t"odays follo"ed $y a
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5e"er Tx intra>itreal in;ection of clindamycin and
dexamethasone
Higher intracellular penetration compared toother A$s like erythromycin and le>ooxacin
3tudies sho" that its ;ust as eJecti>e asolder txs
Gi>en the "idespread use of intra>itreal
dexamethasone0 it has also gainedacceptance as an ad;unct treatment forocular toxoplasmosis
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5e"er Tx Can add clindamycin "ith classic tx %aser photocoagulation and >itrectomy
has also $een used
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Tx in .regnancyuring pregnancy0 acti>e recurrent
lesions usually do not pose a threat tothe fetus
The mother should $e treated $utkeeping in mind the teratogenicpotential of the antimicro$ial agents0especially during the early stages of
pregnancy Com$ined intra>itreal in;ection of
clindamycin and dexamethasone may$e a $etter alternati>e in this case
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Tx in
@mmunocompromised =isk of dissemination and related
complications is high
.yrimethamine has an antagonistic acti>ityagainst idu>udine may $e a>oided or used in lo"er dosage in the
treatment regimen of patients "ith H@,)A@3"ho recei>e HAA=T
%ifetime maintenance therapy includingeither a lo"er dosage of pyrimethaminecom$ined "ith sulfadiaine or clindamycinor trimethoprim)sulfamethoxaole
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=ecurrence =ecurrence rate correlates in>ersely "ith the
period of follo"Bup
Other host factors and the particular strain of T-gondii may also play a roleOne study sho"ed that longBterm intermittent
treatment "ith trimethoprim)sulfamethoxBaolee>ery three days reduced the recurrence rate
@n t"o separate studies0 the recurrence rates"ithin t"o years "ere determined to $e $et"een+-KLB!9-(L
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Conclusions
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=eferences http'))"""-re>ie"ofophthalmology-com)co
ntent)d)retinalMinsider)c)ie"Pid!9-+8!+)apallergy-mode./:=
&A&= http'))"""-aapos-org)terms)conditions)!96
http'))"""-nc$i-nlm-nih-go>)pmc)articles).C(779*6K
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