Severe bilateral necrotising retinitis caused by Toxoplasma gondii in a patient with systemic lupus erythematosus and diabetes mellitus (original) (raw)
Severe bilateral necrotising retinitis caused by Toxoplasma gondii in a patient with systemic lupus erythematosus and diabetes mellitus
- J H Yamamoto1,
- D I Boletti1,
- Y Nakashima1,
- C E Hirata1,
- E Olivalves1,
- M M Shinzato2,
- T S Okay3,
- R M Santo4,
- M I S Duarte5,
- J Kalil6
- 1Department of Ophthalmology, University of São Paulo School of Medicine, São Paulo, São Paulo, Brazil
- 2Department of Rheumatology, University of São Paulo School of Medicine, São Paulo, São Paulo, Brazil
- 3Department of Pediatrics, LIM 36,University of São Paulo School of Medicine, São Paulo, São Paulo, Brazil
- 4Departments of Ophthalmology and Pathology, University of São Paulo School of Medicine, São Paulo, São Paulo, Brazil
- 5Department of Pathology, University of São Paulo School of Medicine, São Paulo, São Paulo, Brazil
- 6Department of Allergy and Immunopathology and Laboratory of Immunology, InCor, University of São Paulo School of Medicine, São Paulo, São Paulo, Brazil
- Correspondence to: Joyce Hisae Yamamoto, MD PhD, Av Dr Eneas Carvalho Aguiar 500 3° andar, CEP 05403–000 São Paulo SP Brazil; joycehy{at}uol.com.br
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Ocular toxoplasmosis may be remarkably atypical in situations of evident immunosuppression such as acquired immunodeficiency syndrome, malignancy, and use of chronic immunosuppressive drug therapy.1 Aggressive forms in immunocompetent hosts are very rare.2,3 We present a case of severe, bilateral necrotising retinitis by Toxoplasma gondii initially misdiagnosed as an acute retinal necrosis (ARN) syndrome, in a patient with systemic lupus erythematosus (SLE) and diabetes mellitus type 2, who was taking medium dose prednisone.
Case report
A 47 year old woman reported a 3 month history of rapid visual loss in the right eye followed by a decrease in her left eye vision 2 months later. Twenty days before the onset of ocular symptoms the patient had a seizure. Her medical history showed a SLE,4 with an active lupus central nervous system disease controlled with prednisone (0.5 mg/kg/day), and type 2 diabetes mellitus. At her first visit to our service, visual acuity was hand movements in both eyes. Slit lamp examination showed 3+ aqueous cells and flare, and 2+ anterior vitreous cells in both eyes. The fundus showed a 2+ vitreous haze and almost 360° creamy white necrotising retinitis extending from the ora serrata to the posterior pole, including the macula in both eyes (Fig 1A and B). Thumbprint patches at the border between necrotic and scanty normal retina could be observed, and also diffuse vascular attenuation.
Figure 1
(A) Fundus appearance of …