Systemic non-Hodgkin's lymphoma presenting as a serpiginous choroidopathy: report of a case and review of the literature

Elevated interleukin-10 levels in patients with ocular toxoplasmosis

In elderly patients, ocular toxoplasmosis is one of the most common etiologies of uveitis, which should be differentially diagnosed from ocular lymphoma, another common pathology of uveitis in older adults. The high level of interleukin (IL)-10 and an IL-10/IL-6 ratio higher than 1 (>1.0) are helpful parameters to diagnose ocular lymphoma. In this study, we used aqueous humor samples to detect 4 cases of ocular toxoplasmosis in patients with high levels of IL-10 and an IL-10/IL-6 ratio higher than 1. Our results show that ocular toxoplasmosis may be associated with increased cytokine levels in aqueous humor.

Multifocal Serpiginoid Choroiditis Due to Mycobacterium Mageritense following Laparoscopic Hysterectomy in an Immunocompetent Host

PURPOSE

To report nontubercular choroiditis, caused by Mycobacterium mageritense isolated using MALDI-TOF MS, following laparoscopic hysterectomy in an immunocompetent patient.

CASE REPORT

A 42-year-old female presented with gradual, painless diminution of vision in the right eye for six weeks. She had undergone laparoscopic hysterectomy two months back. BCVA was 2/60 OD. Clinical presentation and imaging all pointed to a diagnosis of serpiginous-like choroiditis. Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry (MALDI-TOF MS) had led to isolation of Mycobacterium mageritense. Patient was treated with systemic antibiotics. At 3 months follow up, BCVA improved to 6/60; fundus showed healed choroiditis and chorioretinal thinning.

CONCLUSION

Atypical mycobacterial infections associated with laparoscopic surgeries can rarely lead to debilitating systemic bacteremia resulting in profound visual impairment. The importance of timely diagnosis using specific and sophisticated methods such as MALDI-TOF MS as well as maintaining aseptic precautions perioperatively during major surgeries cannot be overemphasized.

Tubercular serpiginous choroiditis

Tubercular association with serpiginous choroiditis, also called ‘serpiginous-like choroiditis’ or ‘multifocal serpiginoid choroiditis’ (MSC) is reported from world over, especially from endemic countries. Though the exact mechanism is not yet clear, a direct or indirect infectious trigger by Mycobacterium tuberculosis (MTB) is believed to cause choroiditis.

The link of immune mechanisms with ocular inflammation caused by MTB is emerging, and has been supported by both experimental and human data. The molecular and histopathological findings of tubercular serpiginous-like choroiditis have been demonstrated in clinicopathological reports, as well as in animal models. Young to middle-aged healthy males are more frequently affected. The choroiditis lesions of tubercular serpiginous-like choroiditis evolve as multifocal lesions, affecting the retinal periphery as well as posterior pole. They begin as discrete lesions, and spread in a serpiginoid pattern to become confluent. Fundus imaging including autofluorescence is extremely helpful in monitoring patients for response to therapy. Its diagnosis is essentially clinical. Corroborative evidence is obtained by a positive tuberculin skin test, or a positive QuantiFERON-TB Gold (Cellestis, Carnegie, Victoria, Australia) test, and/or radiological (chest X-ray or chest CT scan) evidence of TB elsewhere in the body. Systemic corticosteroids are the mainstay of therapy to control active inflammation, while ATT helps to reduce recurrence of inflammatory attacks. Immunosuppressive agents are indicated in cases with relentless progression, paradoxical worsening, or recurrent choroiditis.

BILATERAL SERPIGINOUS-LIKE CHORIORETINITIS ASSOCIATED WITH CILIOCHOROIDAL MELANOMA: A Clinicopathologic Correlation

PURPOSE

To report the clinicopathologic correlation of a case of bilateral serpiginous-like chorioretinitis (SLC) associated with unilateral ciliochoroidal melanoma.

METHODS

A 71-year-old white woman was diagnosed with progressive SLC in both eyes associated with ciliochoroidal melanoma in the right eye. Clinical findings and imaging before and after enucleation in the right eye were correlated to histologic and immunohistochemistry sections.

RESULTS

Examination and imaging identified a peripheral bilobed amelanotic lesion with low reflectivity on B-scan ultrasound with an associated exudative detachment in the right eye. Additionally, multiple areas of new SLC lesions in the macula and peripapillary region in the right eye and along the inferior arcade in the left eye were observed. Oncologic evaluation confirmed a Class 2, ciliochoroidal melanoma, and the eye was enucleated. Autoimmune and infectious laboratory evaluations for the etiology of the SLC lesions were negative. Histopathology of the enucleated eye confirmed the diagnosis of uveal melanoma with lymphocytic inflammation at the edges of the tumor itself and in the areas of discrete SLC lesions. Immunohistochemistry identified similar predominantly CD3 and CD8 T cells and fewer CD20 B cells in both regions.

CONCLUSION

Serpiginous-like chorioretinitis may present as a paraneoplastic, predominantly T-lymphocyte inflammation associated with intraocular tumor such as uveal melanoma.

Chorioretinal Biopsy-Proven Ocular Sarcoidosis in a Patient with a History of B-Cell Lymphoma

The purpose of this report is to describe biopsy-proven ocular sarcoidosis (OS) in a 67-year-old patient with a history of sarcoidosis and diffuse large B-cell lymphoma (DLBCL). Nonspecific posterior chorioretinal lesions in a patient with prior malignancy necessitated chorioretinal biopsy to rule out metastatic lymphoma. The association between sarcoidosis and malignancy remains unclear and can complicate management of similar patients with nonspecific posterior segment findings. Chorioretinal biopsy may, therefore, be required to rule out malignancy in patients with a leading history.

[Intraocular lymphoma associated with primary malignant lymphoma of the central nervous system: Seven-year experience of a tertiary center]

INTRODUCTION

Primary intraocular lymphoma (PIOL), associated with primary central nervous system lymphoma (PCNSL), is a rare malignancy disease. By way of a seven-year experience of a tertiary center, we discuss the presentation and we review the diagnostic and therapeutic modalities.

OBSERVATIONS

We report six cases of PIOL associated with PCNSL. For all patients, the clinical presentation was a vitreoretinal syndrome. The diagnosis was histologically confirmed by vitreal sample or brain biopsy. Five patients developed a diffuse large B-cell lymphoma. Only one patient developed a T-cell lymphoma. The treatment consisted of conformational radiation therapy, systemic chemotherapy and intravitreal injections of methotrexate. The median survival after the diagnosis was 24 months.

DISCUSSION

PIOL, associated with PCNSL, is the most common type of ocular lymphoma. In most cases, ocular manifestations inaugurate the disease. PIOL is often fatal because of ultimate central nervous system presentation. The role of the ophthalmologist consists in early diagnosis. Typical clinical findings include vitroretinal tumor syndrome but can mascarade other eye pathologies. Diagnosis requires histology. The majority of PIOL is diffused large B-cell lymphoma. Decisions are made through multidisciplinary consultation. PIOL exhibits high responsiveness to methotrexate.

CONCLUSION

Through a literature review and many illustrations, we discuss epidemiological, clinical, histological, radiological and treatment characteristics of PIOL associated with PCNSL.

Primary intraocular lymphoma

Primary intraocular lymphoma (PIOL) is an ocular malignancy that is a subset of primary central system lymphoma (PCNSL). Approximately one-third of PIOL patients will have concurrent PCNSL at presentation, and 42-92% will develop PCNSL within a mean of 8-29 months. Although rare, the incidence has been rising in both immunocompromised and immunocompetent populations. The majority of PIOL is diffuse large B-cell lymphoma, though rare T-cell variants are described. Recently, PIOL has been classified by main site of involvement in the eye, with vitreoretinal lymphoma as the most common type of ocular lymphoma related to PCNSL. Diagnosis remains challenging for ophthalmologists and pathologists. PIOL can masquerade as noninfectious or infectious uveitis, white dot syndromes, or occasionally as other neoplasms such as metastatic cancers. Laboratory diagnosis by cytology has been much aided by the use of immunocytochemistry, flow cytometry, biochemical finding of interleukin changes (IL10:IL6 ratio > 1), and cellular microdissection with polymerase chain reaction amplification for clonality. Use of several tests improves the diagnostic yield. Approaches to treatment have centered on systemic methotrexate-based chemotherapy, often with cytarabine (Ara-C) and radiotherapy. Use of intravitreal chemotherapy with methotrexate (0.4 mg/0.1 mL) is promising in controlling ocular disease, and intravitreal rituximab (anti-CD20 monoclonal antibody) has also been tried. Despite these advances, prognosis remains poor.

Serpiginous choroiditis and infectious multifocal serpiginoid choroiditis

Serpiginous choroiditis (SC) is a posterior uveitis displaying a geographic pattern of choroiditis, extending from the juxtapapillary choroid and intermittently spreading centrifugally. The choroiditis involves the overlying retinal pigment epithelium, and the outer retina. This intraocular inflammation typically involves both eyes in otherwise healthy, middle-aged individuals with no familial or ethnic predilection. Pathogenesis is unclear; based on limited histopathologic studies, however, favorable response to immunosuppressive agents, and the absence of association with systemic or local infectious or noninfectious diseases, an organ-specific autoimmune inflammation seems likely to be the underlying process. Patients, particularly from tuberculosis-endemic regions, may present with fundus changes simulating SC, but show evidence of active tuberculosis and/or the presence of mycobacterial DNA in the aqueous humor. This has been referred to as serpiginous-like choroiditis, but we prefer the description multifocal serpiginoid choroiditis (MSC). We present the distinguishing features of SC and infectious multifocal serpiginoid choroiditis simulating SC. The distinction is crucial to avoid unnecessarily treating SC with antimicrobial agents. Advances in diagnostic and imaging modalities can help differentiate SC from MSC. Novel local and systemic treatment approaches improve the outcome and preserve vision in SC.

Clinical Features, Investigations, Management, and Prognosis of Serpiginous Choroiditis

Serpiginous choroiditis is an inflammatory form of posterior uveitis that affects the choroid, retinal pigment epithelium, and choriocapillaries. Known to be recurrent and progressive in nature, this bilateral disease can result in severe visual loss both during the active and healed stages. The age at onset is 40 to 50 years, but it can affect younger Indian population. It can be further classified into 3 types based on its clinical presentation, and they are, namely, peripapillary, macular, and ampiginous. Histological features further qualify the site of inflammation as evidenced by lymphocytic infiltration within the choroid and atrophy of choriocapillaries and retinal pigment epithelium. Despite a multitude of etiologies such as autoimmunity, infection, and degeneration, autoimmune causes remain the mainstay. Laboratory investigations can help rule out infections, whereas angiography can provide further insights into the progression of the disease. Newer investigations such as optical coherence tomography and fundus autofluorescence can help locate the lesion and identify the phase of the disease. Corticosteroids with immunosuppressives are the major management modality. Treatment of complications may require intravitreal injections, laser photocoagulation, or even vitreoretinal surgery.

Indocyanine green angiographic features of systemic non-Hodgkin's lymphoma and bilateral choroidal involvement

A 35-year-old man with systemic non-Hodgkin's lymphoma and bilateral choroidal involvement is described. Indocyanine green angiography depicts choroidal involvement much better than fluorescein angiography and seems to be superior in diagnosing and monitoring patients with systemic non-Hodgkin's lymphoma and choroidal involvement.

Systemic non-Hodgkin's lymphoma masquerading as Vogt-Koyanagi-Harada disease in an HIV-positive patient

A 29-year-old man presented with decreased visual acuity in both eyes secondary to exudative retinal detachment resembling Vogt-Koyanagi-Harada disease. Although fluorescein angiographic pictures supported the clinical findings, there was no choroidal thickening evident with ultrasonography. In 3 days he developed increased disc oedema with peripapillary haemorrhages in both eyes. Further evaluation revealed HIV-positive status and a systemic non-Hodgkin's lymphoma. The patient responded favourably to the treatment for systemic non-Hodgkin's lymphoma confirming our diagnosis of intraocular metastasis. In bilateral exudative detachment, an absence of choroidal thickening on ultrasonography and the presence of peripapillary haemorrhages should prompt a systemic evaluation for causes other than Vogt-Koyanagi-Harada disease, especially in HIV-positive patients.

Bilateral choroidal infiltration from indolent non-Hodgkin's lymphoma: a rapid course with poor prognosis

A 42-year-old-woman, with a 2 year history of non-Hodgkin's lymphoma suffered sudden bilateral visual loss. This unusual patient presented with an unifocal choroidal tumor in the superionasal quadrant in both eyes. Fluorescein angiography revealed early and late intense subretinal fluorescence. Cytological examination of the anterior chamber and vitreous tap material revealed abnormal lymphocytes compatible with NHL. Diffuse choroidal infiltration was diagnosed and treated with radiotherapy. Radiotherapy did not provide local control and preservation of the vision. Non-Hodgkin's lymphoma can infiltrate to the choroid and radiotherapy may not be efffective in every case.

Serpiginous Choroiditis

Serpiginous choroiditis is a rare, usually bilateral, chronic, progressive, recurrent inflammation of the choroid, retinal pigment epithelium, and choriocapillaris of unknown etiology. Based on clinical presentation, it can be classified into 1) peripapillary, 2) macular, and 3) ampiginous types. The clinical course, regardless of the presentation, is progressive with multiple recurrences leading to potentially significant visual loss. Visual outcome is directly related to the involvement of the para-fovea and fovea by the lesions or secondary choroidal neovascularization. The histological findings of the lesions are atrophy of the choriocapillaris, retinal pigment epithelium and photoreceptor cells, and moderate diffuse lymphocytic infiltrates throughout the choroid. Multiple etiologies including autoimmunity, infection, vasculopathy, and degeneration were proposed but none is well supported by clinical and laboratory evidence. Fluorescein and indocyanine green angiography have been useful in the assessment of the extent and the activity of lesions. Due to the insidious and progressive clinical course, an assessment of treatment outcomes needs long term follow-up. Currently, treatment with immunosuppressive and alkylating agents have shown possible efficacy in small case series. Larger clinical studies and interventional trials are required to further our understanding of the pathogenesis, etiology, and for the evaluation of treatment strategies.

Non-Hodgkin lymphoma presenting with uveitis occurring after blunt trauma

We report here an unusual patient suffering from visual loss with refractory uveitis which was occured after a blunt trauma to her left eye. While in the hospital cervical lymph node and anterior chamber aspiration cytology with immunohistochemical staining were performed. The histopathologic diagnosis was highly malignant B-cell non-Hodgkin lymphoma. After the inflammation of the eye was regressed with chemotherapy, pars plana vitrectomy-lensectomy was performed. She was free of inflammation and the best corrected visual acuity was increased. However, she had a refractory inflammatory episode with clumps of cells in the anterior chamber 10 months after the operation. Local radiotherapy to the left eye was applied. Radiotherapy provided local control and preservation of the vision. The present case is presented in order to emphasize the importance of systemic evaluation in uveitis and possible role of trauma leading migration of atypical cells into the eye.

The eye in neurological disease

Neurological disease can involve the eye in many ways. Every structure--the conjunctiva, cornea, anterior chamber, iris, lens, vitreous humour, retina, choroid, and optic nerve--can be affected. In many cases, ocular involvement is the first manifestation of the underlying disease. In such cases, the ability of the physician to recognise the nature and significance of the ocular abnormality can lead to early diagnosis and successful treatment of the underlying condition. In other cases, recognition of the ocular abnormality can prevent permanent visual dysfunction.

Presumed tubercular serpiginouslike choroiditis: clinical presentations and management

PURPOSE

Choroiditis, choroidal tubercles, and tuberculomas are well known ocular manifestations of systemic tuberculosis. The present series aimed to report the occurrence of serpiginouslike choroiditis of presumed tubercular origin.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

Eleven eyes in seven consecutive patients with a diagnosis of choroidal tuberculosis simulating serpiginous choroiditis were studied between 1997 and 2000. TESTING AND INTERVENTION: All patients had their fundus photographs taken at the time of initial presentation as well as during follow-up. All patients underwent a Mantoux skin test and chest radiography. In addition, five patients had their aqueous or vitreous humor subjected to polymerase chain reaction (PCR) for Mycobacterium tuberculosis. Sputum examination, biopsy, or both were carried out whenever recommended by the pulmonologist. Systemic antituberculosis chemotherapy was instituted in combination with treatment for ocular inflammation.

MAIN OUTCOME MEASURE

Therapeutic response and visual improvement.

RESULTS

There were five men and two women ranging in age from 17 to 32 years. Clinical presentations included three morphologic variants; multifocal progressive choroiditis showing wavelike progression to confluent, diffuse lesions resembling serpiginous choroiditis (three eyes); diffuse choroiditis characterized by diffuse plaquelike choroiditis with an amoeboid pattern suggestive of serpiginous choroiditis at initial presentation (four eyes); and mixed variety where opposite eyes had mixed features (four eyes). All patients had strongly positive Mantoux skin test results and positive chest radiograph results. The PCR results from aqueous and vitreous humor in four samples was positive for Mycobacterium tuberculosis; one had sputum positive for acid-fast bacilli, whereas two had histopathologic evidence of tuberculosis from cervical or parahilar lymph nodes. Treatment was associated with resolution of choroidal lesions and visual improvement. Final visual acuity of 20/30 or better was achieved in five eyes.

CONCLUSIONS

Choroidal tuberculosis may present as multifocal progressive or diffuse choroiditis resembling serpiginous choroiditis. It is important to recognize these presentations because these eyes show good response to systemic antituberculosis chemotherapy.