Toxoplasmosis (Dr. Michael)

7/28/2019 Toxoplasmosis (Dr. Michael)

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Dr. Michael Indra Lesmana, Sp.M

PID-FK.UKRIDA


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Manifestation of TB-Eye

unilateral - typically affects

children photophobia, lacrimation

blepharospasm delayed hypersensitivity

to tuberculin protein topical steroids /steroid-

ab

Phlyctenulosis


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Intraocular Tuberculosis

Intraocular tuberculosis represents an extrapulmonaryform of the disease and they are seen in more than50% of the patients who have both AIDS andtuberculosis

Jones et al: showed that the risk of extrapulmonary TB

was higher in patients with low CD4 +counts

great mimicker of various uveitis entities


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n ca resen a on n n raocu ar

Tuberculous1.Anterior uveitis:

Granulomatous,nongranulomatous, iris nodules and ciliary bodytuberculoma

2. Intermediate uveitis :

Granulomatous

pars planitis/peripheral uvea

3. Posterior and panuveitis

Choroidal tubercleChoroidal tuberculoma

Subretinal abscess

Serpiginous-like choroiditis

4. Retinitis and retinal

vasculitis

5. Neuroretinitis and opticneuropathy

6. Endophthalmitis andpanophthalmitis

Eales disease

is considered by some to reflecttuberculous infection orhypersensitivity


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Case of patient with Anterior

Uveitis (A) Anterior segmentphotograph showingfibrinous inflammation ina 42-year-old man.His visual acutity was

reduced to counting fingers

(B)Ultrasoundbiomicroscopy showsexudates in pars plana

(C ) MRI shows cavitarylesion

(D) Sputum positive foracid-fast-bacilli.


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Posterior and Panuveitis In tuberculous posterior uveitis, the ocular changes

can be divided into four groups:

1.Choroidal tubercles2.Choroidal tuberculoma

3.Subretinal abscess

4.Serpiginous-like choroiditis


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Choroidal Tubercles

The most common intraocular manifestation

of tubercular posterior uveitis

Right eye of a 24-year-old woman withtubercular meningitisshowing optic diskedema, multiple smallchoroidal tubercles,and a healed choroidaltuberculoma temporalto the fovea with retino-

choroidal anastamosis.


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Choroidal Tuberculoma

(A) There are twogranulomas in the uppertemporal and lower nasal

quadrant in the right eye

In view of a stronglypositive Mantoux test ( >20mm induration) andpositive

chest x-ray, patient wasgiven ATT withconcomitant oralcorticosteoids.

Fundus photofraph RE ofa 45-year old man


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Tubercular Retinal Vasculitis

Patient with systemictuberculosis showing

vasculitis

Polymerase chainreaction from the

vitreous humor was

positive for M.tuberculosis.

Right eye of a 43-year-old man


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Endophthalmitis - Panophthalmitis

Acute onset and shows rapid progression withdestruction of the intraocular tissues

The inflammation may be intense enough to producehypopyon, filling the anterior chamber with purulentmaterial and involving the cornea

In panophthalmitis, the sclera is also involved, whichmay result in globe perforation.


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A case 22 yo,F, Protursion OD

Panophthalmitis ec TB .OD

UTZ


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Post TB drugs treatment

Advised forevisceration


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Diagnosis Clinical indicators

Corroborative evidence

(Purified Protein Derivative, Chest Radiography andComputerized Tomography, Serodiagnosis or ELISA)

Direct evidence

(Acid-Fast, Culture of Intraocular Fluid/Tissue,

Polymerase Chain Reaction)


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Diagnosis QuantiFERON is an approved, antigen specific test

that utilizes synthetic peptides representingMycobacterium tuberculosis proteins

Including latent tuberculosis infection (LTBI) andtuberculosis (TB) disease

This test was approved by the U.S. Food and

Drug Administration (FDA) in 2005.


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QuantiFERON Blood samples are mixed with antigens

The advantages:

> Is not subject to reader bias that can occur withMantoux test

> Is not affected by prior BCG (bacille Calmette-Gurin) vaccination

A positive result suggests thatM. tuberculosis infectionis likely; a negative result suggests that infection isunlikely


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Diagnosis

Level

evidencefor

diagnosisocular TB

Level I

Identification M.Tbin Ocular

fluid/tissueLevel II

Identification M.Tbin Other

fluid/tissue(eg.Lung)

Level III

Suggestive pattern of

intraocularinflammation

+

Suggestive clinical onsystemic exam &

Radiological

Staining,culture, PCR,

histopath


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Treatment

MEDICAL MANAGEMENT

1. Drug Regimens for Treating Intraocular

Tuberculosissimilar to those for pulmonary orextrapulmonary tuberculosis

Comanagement with pulmonologist/internist

2. Duration of Treatment

The initial regimen: RHZE. Pyrazinamide and ethambutolwere stopped after 2 to 3 months and treatment withisoniazid and rifampin was

continued for 9 to 12 months


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3. Concomitant Use of Corticosteroids/Immunosuppressive Agents

Low-dose systemic corticosteroids used for 4 to 6wks,along with multidrug ATT, may limit damage to oculartissues caused from delayed type hypersensitivity


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5. Ocular Side Effects of Anti-Tubercular Drugs

The ethambutol toxicity is rare if the daily dose doesnot exceed

15mg/kg.

Of the patients receiving daily dose of 25 mg/kg ormore, 1--2% experience ocular toxicity


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HIV-AIDS Selected Anterior segment manifestation:

Molloscum contagiosum, HZO, Herpes simplex ,Kaposi sarcoma

Most Common Posterior segment manifestation: HIVRetinopathy, CMV retinitis


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Molluscum contagiosum HZO

Molluscum contagiosum, characterized bycutaneous nodules

Painful, dermatoform, clustervesicobullous


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Herpes simplex Kaposi Sarcoma (KS)

Painless, dendritic, decreased of cornealsensibility, recurrent

Nodul, reddish, painless, vascular,eyelid, conj- orbit


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HIV Retinopathy Ocular micro-angiopathic syndrome

Non-infectious microvascular disorder characterisedby cotton wool spots, microaneurysms, retinalhaemorrhages, Roth spots, telangiectatic vascularchanges and areas of capillary non-perfusion


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HIV Retinopathy

Cotton-wool spots (CWS) are the most commonocular micro-angiopathic manifestations of

HIV/AIDS


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CMV-Retinitis

CMV retinitis was afrequentopportunisticinfection amongpatients with AIDStypically occurred in

patients with CD4 Tcells (helper T cells)50 cells/L


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CMV-Retinitis Cytomegalovirus retinitis has been reported to

affect up to 25% to 40% of HIV patients and is themost common cause of visual loss

Highly active antiretroviral therapy (HAART)effectively suppresses HIV replication, resulting in

immune recovery, which, if sufficient, controlsretinitis without anti-CMV therapy.


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CMV-Retinitis Treatment The induction regimen consisted of injection of 2

mg/0.04 ml ofganciclovir twice weekly for 4 weeks

followed by a similar dose weekly for 4 weeks and thena weekly maintenance regimen of 1.0 mg/0.02 mlganciclovir

anti-CMV drugs are virostatic, and treatment has to be

given in a continuous to prevent recurrence of thedisease.


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TOXOPLASMOSIS This is a case of a 20 y.o F with blurring of vision 1 week

ptc.

Associated with eye soreness, mild eye redness, seeingfloaters and half of visual defect.

Pt likes to consume street food satae

No fever nor cough. (-) history of allergic

Had prior consult but gain no relief


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Ophthalmological StatusOD OS

VA : 2/60 (inferior side)

Mild ciliary injection

Clear cornea

-f/-c

+2 vitreous cell

IOP 59 mmHg

Full EOM

+/+RC(-)RAPD

VA : 1.0

No injection

Clear cornea

-f/-c

- vitreous cell

IOP 12 mmHg

Full EOM

+/+RC (-)RAPD


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Fundus Photo pre-treatment


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Ancillary Test

Ro Thorax PA :Mild Infiltrate on left

parahilerAorta Calsification

Ass:BronchopneumoniaDD/ Pulmonary TB


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Hematologi Immunologi

Hb 13.9 g/dl

L 9.2

0/1/2/76/21/0

Ht 43

Tromb 285.000

Blood sugar 126mg/dl

Ig G Toxoplasma

(+) 100 IU/ml


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Diagnosis and Treatment Posterior Uveitis (Retinochoroiditis) ec Toxoplasmosis

OD with secondary glaucoma

Meds: Ab-steroid topical 6x OD

Timolol 0.5% 2x OD

Cotrimoksazol forte 2x 1 tab

Acetazolamide 250mg 3x 1 tab

Methylprednisolone 1 x 48mg pcKalium oral 2x1 tab


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1 week post treatment OD : VAD sc 0.5 ()

BCVA S-1.00 c -0.50 x 160 --- 0.8

(-) ciliary injection(-) vit cell

IOP 10 mmHg ()

OS : VAD sc 1.0

IOP 12 mmHg


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Fundus Photo 2nd wk post tx


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Fundus Photo pre & 3rd wk post tx


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THANK YOU

Toxoplasmosis (Dr. Michael)

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