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   Table of Contents      
BRIEF REPORT
Year : 2003  |  Volume : 51  |  Issue : 4  |  Page : 357-359

Presumed ocular toxoplasmosis presenting as papillitis


Department of Ophthalmology, Sultan Qaboos University Hospital, Sultanate of, Oman

Correspondence Address:
R Shenoy
Department of Ophthalmology, Sultan Qaboos University Hospital, Sultanate of
Oman
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Source of Support: None, Conflict of Interest: None


PMID: 14750629

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  Abstract 

Unilateral papillitis is a rare manifestation of ocular toxoplasmosis. However, other causes of papillitis need to be ruled out before concluding the diagnosis

Keywords: Toxoplasmosis, papillitis, chorioretinitis


How to cite this article:
Shenoy R, Al Hinai A. Presumed ocular toxoplasmosis presenting as papillitis. Indian J Ophthalmol 2003;51:357-9

How to cite this URL:
Shenoy R, Al Hinai A. Presumed ocular toxoplasmosis presenting as papillitis. Indian J Ophthalmol [serial online] 2003 [cited 2020 Jun 4];51:357-9. Available from: http://www.ijo.in/text.asp?2003/51/4/357/14644

Toxoplasmosis is a common infection of man and animals. The disease is widespread and has a worldwide distribution.[1], [2] In the eye, the retina is the primary site of infection. It manifests as a necrotizing retinitis with subjacent choroidal inflammation.[2] Optic nerve involvement such as papillitis has been reported before, and can occur due to a lesion at the disc, or secondary to a subjacent retinal lesion.[3], [4]

We report the case of a young woman who presented with sudden loss of vision in her right eye due to papillitis secondary to direct involvement of the optic disc.


  Case report Top


A 32-year-old woman presented to the ophthalmic emergency department with a history of loss of vision in her right eye of 10 days duration. This was preceded a few hours by a right-sided headache that responded to systemic analgesics. There was no associated ocular pain. Her medical history was otherwise non-contributory.

On examination the best-corrected visual acuity in the right eye was 6/36 (-0.50 Dsph/ -0.25Dcyl@125) and 6/6 (-0.25 Dsph) in her left eye. External ocular examination, extraocular muscle movements and slitlamp examination was normal in both eyes. There was an afferent pupillary defect in the right eye. The intraocular pressure (IOP) was 12 mmHg in the right eye, and 14 mm Hg in the left eye. Colour vision (Ishihara'sTests, Kanehara & Co, Ltd, Japan. 38 Plates Edition, 1985) was normal in both eyes. Ophthalmoscopic examination revealed oedema and hyperaemia of the optic disc in the right eye. There was a yellow infiltrate at the upper nasal border of the disc. Healed patches of chorioretinitis were present, close to the temporal arcades in both eyes. In the left eye, a pigment clump was noted in the center of the healed chorio-retinitis patch [Figure - 1]a, b. There was no vitritis in either eye. Visual field (Goldmann Perimeter) was normal in the left eye but showed enlargement of blind spot in the right eye and two relative scotomas to object size I2e and I4e, in the inferior field between the 10 and 20 isopter [Figure - 2]a.

Pattern visually evoked potential was normal in both the eyes. Fundus flourescein angiography revealed hyperfluorescene at the disc in the right eye due to leakage of the dye. There was also hyperfluorescence corresponding to the healed patches of chorioretinitis in both the eyes with blocked fluorescence corresponding to the pigment clump in the left eye [Figure - 2]b.

Laboratory investigations revealed normal blood counts, erythrocyte sedimentation rate, and C reactive protein. Mantoux test was negative. X ray chest and magnetic resonance imaging of the brain and orbit were normal. Serology was negative for syphilis, cytomegalovirus, retrovirus, herpes simplex virus and rubella. Ig G was positive for toxoplasmosis by the ELISA technique (4 IU / ml) (Normal 2- 3 IU/ ml), but Ig M was negative. Rheumatoid factor, Anti-nuclear antibodies, Anti-cardiolipin antibodies, Cytoplasmic antineutrophil antibodies, Anti DNA antibodies and Antibrucella antibodies were negative.

She was diagnosed as having right eye papillitis with healed chorioretinitis in both the eyes due to presumed ocular toxoplasmosis. She was treated with Septran, (960 mg sulfamethoxazole and 160 mg trimethoprim), and was continued on these for 4 weeks. Clinical improvement was noted three days following treatment. The visual acuity improved from 6/36 to 6/12. The visual field changes, disc oedema and the infiltrate in the right eye disc resolved. Systemic corticosteroid was initially withheld pending investigations, and was not initiated later, as clinical improvement was noted with Septran.

At the end of a month, the vision in her right eye was 6/6 and visual field was normal. There was no oedema, hyperaemia or infiltrate at the disc in the right eye [Figure - 3].


  Discussion Top


Ocular toxoplasmosis is the most common cause of posterior uveitis in an immunocompetent individual, accounting for 30-50% cases.[2] The reported incidence of posterior uveitis due to toxoplasma in India is 27.87%. [3] The disease can be congenital or acquired with a variety of manifestations that range from a subclinical course to a generalised infectious disease with a fatal outcome.[3], [4] Unilateral papillitis, is a rare manifestation of ocular toxoplasmosis, but has been reported before. [4],[5],[6] In most reported series, there was past evidence of toxoplasma infection manifested as chorioretinal scars and a positive Ig G. [5],[6]

Our patient presented with sudden diminution of vision, afferent pupillary defect, oedema of the disc, infiltrate at the superior nasal border of the disc, and visual field defect in her right eye. Chorioretinal scars were present in both eyes, with positive Ig G for toxoplasma. However, since a serological response consistent with acute or recent infection does not always occur in recurrent ocular infections, other diseases, like tuberculosis, syphilis, brucellosis, viral infections (Rubella, Herpes Simplex, Cytomegalovirus, Retro virus), vasculitis (Systemic Lupus Erythematosis, and Wegener's Granulomatosis), which can present a similar clinical picture, had to be excluded. Treatment is usually effective, as demonstrated in our patient.

 
  References Top

1.
Morgan CM, Ragouts ES. Branch Retinal artery occlusion associated with recurrent Toxoplasma retinochoroiditis. Arch Ophthalmol 1987;105:130-31.  Back to cited text no. 1
    
2.
Tabbara KF. Ocular Toxoplasmosis. Int Ophthalmol 1990;14:349-51.  Back to cited text no. 2
[PUBMED]    
3.
Biswas J, Narain S, Das D, Ganesh SK. Pattern uveitis in a referral uveitis clinic in India. Int Ophthalmol 1996-97;20:223-28.  Back to cited text no. 3
    
4.
Tandon R, MenonV, Das GK, Verma L. Toxoplasmic papillitis with central retinal artery occlusion. Can J Ophthalmol 1995;30:374-76.  Back to cited text no. 4
    
5.
Durig J, Bernasconi O, Guesx-Crosier Y. Incidence and evolution of parapapillary toxoplasmosis. Invest Ophthalmol Vis Sci 1999;40:787-47.   Back to cited text no. 5
    
6.
Folk JC, Lobes LA. Presumed Toxoplasmic papillitis. Ophthalmology 1984;91:64-67.  Back to cited text no. 6
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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]



 

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