Toxoplasmosis Retinochoroiditis Masquerading as Endogenous Endophthalmitis in a Case of Congenital Long Qt Syndrome

Abstract

Purpose: To describe the diagnostic and treatment challenges of a case of presumed acquired macula-involving toxoplasmosis retinochoroiditis.Methods: Case report of a woman with congenital long QT syndrome presenting with retinochoroiditis after undergoing a cardiac procedure. Laboratory analysis, ocular fluid biopsy, and multimodal imaging were obtained.Results: Ophthalmic examination was significant for decreased vision and a maculainvolving chorioretinal lesion concerning for endogenous endophthalmitis. Multimodal imaging showed a focal, full-thickness necrotizing process associated with vitritis, retinal edema, and choroidal thickening. Analysis of peripheral blood revealed elevated serum toxoplasma Immunoglobulin G titers. Blood cultures and a transesophageal echocardiogram were negative for endocarditis. Aqueous and vitreous specimens were negative for an infectious polymerase chain reaction panel, including toxoplasmosis and negative bacterial and fungal cultures. A diagnosis of presumed acquired toxoplasmosis retinochoroiditis was made and treated with a combination of oral and intravitreal antiparasitic medications resulting in healing of the retinochoroiditis. Conclusion:To the authors' knowledge, this is the first reported case of acquired toxoplasmosis retinochoroiditis in an immunocompetent patient with congenital long QT syndrome masquerading as endogenous endophthalmitis. The association of congenital long QT syndrome and a recent cardiac procedure with a risk for endogenous endophthalmitis complicated the diagnosis, clinical course, and treatment options. Our case emphasizes the importance of a thorough patient history, comprehensive clinical examination, and supportive multimodal imaging that were used to characterize the infectious process and guide empirical treatment. In addition, laboratory analysis, comanagement with other specialists, and evaluating the response to antitoxoplasma therapy were all instrumental in the eventual diagnosis and treatment of ocular toxoplasmosis in this atypical case.

Ocular Toxoplasmosis: No Stranger to the Masquerade Ball

“…Widespread retinal infection with multifocality and large lesions is highly atypical for OT; however, for such a phenotype, OT must be included high in the differential diagnosis as demonstrated by the 2 presented cases. As single, fewer than 2 or 3 DD lesions of retinal whitening are the norm for OT, numerous and/or confluent lesions larger than this may mimic other vision-threatening ophthalmic conditions such as bacterial or fungal endogenous endophthalmitis, 6 and viral retinitis. 7 In a retrospective case series of 154 patients with OT in the Netherlands, 4 of the 18 cases with “extensive” (>3 DD) lesions were initially diagnosed as acute (viral) retinal necrosis based on clinical examination, as was our first case.…”